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pdfForm 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.
File Type | application/pdf |
File Title | 4280-01.pmd |
Author | jeanne.jacobs |
File Modified | 2006-12-15 |
File Created | 2006-12-15 |