Form 5-4754a Notice of Insured Loan

BIA Form 5-4754a OMB Control No. 1076-0020

Revised 4/17/01 Expires: 12/31/06

Notice of Insured Loan

(Using this form is optional, but it complies with 25 CFR § 103.18(b).

Lender: ______________________________________

Address: ______________________________________

______________________________________

______________________________________

______________________________________

Borrower: ______________________________________

Address: ______________________________________

______________________________________

______________________________________

______________________________________

The Lender hereby notifies the United States Department of the Interior, Bureau of Indian Affairs ("BIA”) that the Lender has extended a loan to the Borrower pursuant to BIA Loan Insurance Agree1Ilent number ________ (the "Agreement"), and 25 U.S.C. §§ 1481 et seq. and 1511 et seq., and 25 CFR Part 103, the Loan Guaranty, Insurance, and Interest Subsidy Program (the "Program"). The Lender intends for BIA to insure the loan in accordance with the Agreement and the Program, and provides the following information to comply with Agreement and Program requirements:

Original loan principal amount: $ _

(Exclusive of amounts potentially added pursuant to 25 CFR §§ 103.8, 103.34, or 103.36.)

Lender's internal loan number: __________________________________

Interest rate: q Fixed at %

q Variable at % over the prime rate announced by________________________________

___________ from time to time.

Loan term (the period over which the loan is to be repaid):___

Payment schedule (specify number of payments, due dates, maturity, and any special terms such as

periods of interest only payment or periodic pay down requirements for a revolving

loan): _

.

Date on which the loan closed: 20

If the loan was not fully funded on the date it closed, please explain here:

_________________________________________________________________________________

_________________________________________________________________________________

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BIA Form -4754a OMB Control No. 1076-0200

Revised 4/17/01 Expires12/31/06

The Borrower is a(n):

q individual Indian

q partnership under ___________________________ law

q limited partnership under _____________________law

q corporation under law

q limited liability company under law

q Indian tribe

q Indian tribal enterprise (name tribe and reference organizational resolutions or other

source of authority for enterprise)

q other (specify kind of organizational structure and source of legal authority) _______________ ________________________________________________________________________________

Premium due (1% of original loan principal amount): $________________________________________ _

Is the BIA loan insurance premium payment enclosed?-

q Yes

q No (please explain):

Lender: ________________________________

ABA No.: _________________ _

By: __________________ Its: : __________________

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to establish the respective rights and responsibilities of the respondent and the Federal government. The information is provided by respondents to obtain or retain a benefit. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and an expiration date. The number and expiration date are at the top right corner of the form. An agency-may not sponsor or conduct, and a person is not required to respond to, a request for information collection unless it displays a currently valid OMB Control Number.

Burden Estimate: The public reporting burden is estimated to average 10 minutes per respondent. to understand the requirements, gather the information, complete the form, and submit it to BIA. Comments regarding the burden or other aspects of the form may be directed to the Information Collection Clearance Officer, Bureau of Indian Affairs, 625 Herndon Parkway -2079, Herndon, Virginia 20170 Note: comments, names and This includes the time needed addresses of commentators are available for public review during regular business hours. If you wish us to withhold this information, you must state that prominently at the beginning of your comment. We will honor your request to the extent allowable by law.

Privacy Act Statement (5 U.S.C. 552(a)): The authority for collecting this information is 25 U.S.C. 1511. The information will be used to administer the interest subsidy provisions relating to the Loan Guaranty and Insurance Program, 25 U.S.C. 1481 et seq. Disclosures of this information may be made to consumer reporting agencies; Federal, State, or local governments; law enforcement personnel responsible for investigating or prosecuting violations of, or for enforcing or implementing, statutes, rules, regulations, orders, or licenses; the U.S. Department of Justice; courts of law or adjudicative bodies; Members of Congress; the U.S. Department of the Treasury; and other Federal agencies responsible for collecting debts or detecting and eliminating fraud.

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