Form EIB-92-34 Export-import Bank of the United States Application for

Export-Import Bank of the United States

OMB No. 3048-0009
Expires 04/30/07

APPLICATION FOR LETTER OF CREDIT INSURANCE POLICY

This application is to be completed by a financial institution (or a broker acting on its behalf) in order to obtain a short-term
letter of credit insurance policy. An online version of this application is available on Ex-Im Bank’s web site. Ex-Im Bank
encourages customers to apply on line, as it will facilitate our review and allow customers a faster response time. Additional
information on how to apply for Ex-Im Bank insurance can be found at Ex-Im’s web site http://www.exim.gov.
Send this completed application to Ex-Im Bank, 811 Vermont Ave NW, Washington, D.C. 20571. Ex-Im Bank will also accept
e-mailed pdf and faxed applications. Ex-Im Bank will not require the originals of these applications to be mailed. The
application must be PDF scans of original applications and all required attachments. (Fax number 202.565.3675, e-mail
[email protected])
____________________________________________________________________________________________________

APPLICATION FORM
Applicant:
Applicant legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street address:

Phone:

City:

Postal code:

Fax:

Does the applicant have a market rating?
Yes
No
If yes, indicate the name of the rating agency, rating, and the
date of the rating. ______________________________________________________________________________________
Please provide the following information from the applicant’s most recent audited financial statements.
Statement period (fiscal or interim):

Are the financial statements combined or consolidated?

Financial Statement Dates:
Auditor:

Opinion:

Net Income:

Net Loans:

Total Assets::

Equity:

Broker (if applicable):
Name of Broker:
Ex-Im Bank Broker #:
Contact person:
Phone number:
Fax:
E-mail:
EIB-92-34
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OMB No. 3048-0009
Expires 04/30/07

EXPORT-IMPORT BANK OF THE UNITED STATES
APPLICATION FOR LETTER OF CREDIT INSURANCE POLICY

Affiliate(s) (if applicable)
Please provide the following information for any subsidiaries, branches, or affiliates that the applicant would like us to consider
adding as Additional Named Insureds under the policy.
Legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street address:

Phone:

City:

Postal code:

Fax:

1. General Questions
A. Indicate the Ex-Im Bank programs the applicant has used.
B. What type of charter does the applicant hold?

Insurance

State

Working Capital

Loan Guarantee

National

C. Indicate the name of the applicant’s regulatory authority. _________________________________________________
D. Does the applicant have any foreign government ownership?
Yes

No

If yes, please indicate the country and the percentage owned: _________________________________________
E. Letter of Credit Experience
•

In what year did the applicant’s letter of credit business begin? ________________________________________

•

What was the total amount of letter of credit transactions in the last 12 months? ___________________________

•

What was the total number of letter of credit transactions in the last 12 months? ___________________________

•

Please provide the following information on the individuals responsible for administering the letter of credit policy:

Name

Title

Years of Trade
Finance
Experience

Years of Letter
of Credit
Experience

2. Letter of Credit Portfolio
•

What is the expected maximum value of letters of credit outstanding at any time over the next 12 months?
______________________________

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EXPORT-IMPORT BANK OF THE UNITED STATES
APPLICATION FOR LETTER OF CREDIT INSURANCE POLICY
•

OMB No. 3048-0009
Expires 04/30/07

Please provide the following details regarding projected transactions to be insured over the next 12 months.

Country

Number of
Issuing Banks

Total Letters of Credit
$
$
$
$
$

Total Letters
of Credit (#)

3. Attachments
•

Please provide any information (e.g., the applicant’s most recent annual report) that would be helpful in evaluating this
application.

4. Certifications
The applicant certifies that neither it, nor its Principals, have within the past 3 years been a) debarred, suspended, declared
ineligible from participating in, or voluntarily excluded from participation in, a Covered Transaction, b) formally proposed for
debarment, with a final determination still pending, c) indicted, convicted or had a civil judgment rendered against it for any of
the offenses listed in the Regulations, d) delinquent on any substantial debts owed to the U.S. Government or its agencies or
instrumentalities as of the date of execution of this application; or e) the undersigned has received a written statement of
exception from Ex-Im Bank attached to this certification, permitting participation in this Covered Transaction despite an
inability to make certifications a) through d) in this paragraph.
The applicant further certifies that it has not and will not knowingly enter into any agreements in connection with the Goods
and Services with any individual or entity that has been debarred, suspended, declared ineligible from participating in, or
voluntarily excluded from participation in a Covered Transaction. All capitalized terms not defined herein shall have the
meanings set forth in the Ex-Im Bank Suspension and Debarment Regulations at 12 C.F.R. Part 413 (Regulations). The
applicant is not listed on any of the publicly available debarment lists of the following international financial institutions:
World Bank Group, African Development Bank, Asian Development Bank, European Bank for Reconstruction and
Development and the Inter-American Development Bank.
In addition, the applicant certifies that neither the applicant nor anyone acting on its behalf, such as agents, has engaged, or will
engage, in any activity in connection with this transaction that is a violation of the Foreign Corrupt Practices Act of 1977, 15
U.S.C. 78dd-1 et seq. (which provides for civil and criminal penalties against companies and individuals who directly or
indirectly make or facilitate corrupt payments to foreign officials to obtain or keep business). Further, the applicant has not
engaged, and will not engage, in any activity in connection with this transaction that is a violation of the Arms Export Control
Act, 22 U.S.C. 2751 et seq., the International Emergency Economic Powers Act, 50 U.S.C. 1701 et seq., or the Export
Administration Act of 1979, 50 U.S.C. 2401 et seq. The applicant has not been found by a court of the United States to be in
violation of any of these statutes within the preceding 12 months, and to the best of its knowledge, the performance by the
parties to this transaction of their respective obligations does not violate any other applicable law.
The applicant certifies that neither the applicant nor anyone acting on its behalf in connection with this transaction is currently
under charge or has been, within the past 5 years, convicted in any court or subject to national administrative measures of any
country for bribery of foreign public officials.
Further, the applicant certifies that the representation made and the facts stated in this document and any attachments are true,
to the best of its knowledge and belief, and it has not misrepresented or omitted any material facts, and if any of the
certifications made herein become untrue, Ex-Im Bank will be promptly informed of such changes. The applicant further
understands that these certifications are subject to the penalties for fraud against the U.S. Government (18 USC 1001, et seq.).

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EXPORT-IMPORT BANK OF THE UNITED STATES
APPLICATION FOR LETTER OF CREDIT INSURANCE POLICY

Notices
The applicant is hereby notified that information requested by this application is done so under authority of the Export-Import
BankEIB-92-64 (07/06)
Act of 1945, as amended (12 USC 635 et seq.); provision of this information is mandatory and failure to provide the requested
information may result in Ex-Im Bank being unable to determine eligibility for support. The information provided will be
reviewed to determine the participants’ ability to perform and pay under the transaction referenced in this application. Ex-Im
Bank may not require the information and applicants are not required to provide information requested in this application unless
a currently valid OMB control number is displayed on this form (see upper right of each page).
Public Burden Statement: Reporting for this collection of information is estimated to average 1 hour per response, including
reviewing instructions, searching data sources, gathering information, completing, and reviewing the application. Send
comments regarding the burden estimate, including suggestions for reducing it, to Office of Management and Budget,
Paperwork Reduction Project OMB# 3048-0009, Washington, D.C. 20503.

Applicant (Financial Institution) Name: ____________________________________________________________
Name and title of authorized officer: _______________________________________________________________
Signature of authorized officer: ___________________________________________________________________
Date: ________________________________________________________________________________________

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