RD 4280-1 Survey of Recipients of Rural Development Loan and Grant

Form RD 4280-1
(12-06)

UNITED STATES DEPARTMENT OFAGRICULTURE
RURAL DEVELOPMENT

FORM APPROVED
OMB NO. 0570-0035

SURVEY OF RECIPIENTS OF RURAL DEVELOPMENT
LOAN AND GRANT PROGRAM
1. Name of RUS Utility and Intermediary ID Number

6. Name of Loan Recipent:

2. Address

7. Address

3. City/StateZIP:

8. City/State/ZIP:

4. Contact Person & Title

9. Contact Person & Title

5. Telephone Number:
11. Loan Amount:

10. Telephone Number:
12. Date of Loan Agreement

13. Repayment Terms (Monthly payment, maturity date, and for revolving loan funds, the interest rate):
14. Briefly describe the funded project (including its location):

15. Which of the following best describes the project:
a. Business expansion
b. Business startup
c. Business incubator
d. Community development

e.
f.
g.
h.

Infrastructure (Water, waste water disposal, etc.)
Speculative building/land available for new businesses
Medical care
Education/Training

16. Was the project completed or implemented as proposed in the application? _____ YES _____ NO
If answer is YES, insert the start and completion dates below:
Project start date(Month/Year): _____/_____
Project completion date (Month/Year): _____/_____
If project was not completed, please explain the reason:
Is the project still in operation? _____ YES _____ NO If answer is NO, please explain:
17. Actual number of new jobs created: _______

18. Number of jobs retained/saved as a result of project:____

19. Briefly describe any secondary positive or negative impacts of the project on the community. Consider economic,
social, and/or environmental impacts:

20. Grant recipients only-If the loan was made from a revolving loan fund, the total dollar amount that has been loaned,including
this loan, from 1.) initial grant funds $ ___________and 2.) the Intermediary’s contribution $___________.
Mark one - this loan was made from: ____the intital grant & RUS borrower’s contribution, or ___repayments from initial loans.

Signature of Authorized Official of Intermediary

Date
Form RD 4280-1

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0575-0035. The time required to complete this informatiopn collection is estimated to average 1 hour per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completeting and reviewing the collection of information.