Dot F 2304-1 Short Term Lending Program Bank Acknowledgement Loan Clo

OMB NO.: 2105-0555

EXPIRATION DATE: MM/DD/YYYY

Office of Small and Disadvantaged Business Utilization SHORT TERM LENDING PROGRAM BANK ACKNOWLEDGEMENT LOAN CLOSE-OUT FORM
Participating Lender
Borrower
City ______________________________ State ______________	Bank Loan Identification Number ___________________________
Loan Amount $ _________________	Loan Activation Date ________________
DOT Guarantee Amount	$ _________________
Loan Close-Out Date:	_________________
Bank Representative (print)	_______________________________
Signature	_______________________________
Do Not Write Below - For Internal Use Only
STLP Loan Number ________________ Cohort _______ Subsidy Rate ______	Expected STLP __________ Graduation Date
Date Received __________________	Program Manager _____________________

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT

A Federal agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. The OMB Control No. for this information collection is 2105-0555. The information requested on this form is being collected and disseminated by the U.S. Department of Transportation, Office of the Secretary as a courtesy to the public. Public burden reporting for this collection of information is estimated to be 30 minutes per response, including time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection are mandatory. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Office, US Department of Transportation, Office so Small and Disadvantaged Business Utilization, Financial Assistance Division, 1200 New Jersey Ave., S.E., 5^th Floor, W56-497, Washington, DC 20590.

PRIVACY ACT STATEMENT

The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this application is solicited under the authority of Title 49 U.S.C. 332(b)(3)(4)(5) which authorizes DOT OSDBU to assist Disadvantage Business Enterprises and Small and Disadvantaged Business in acquiring access to working capital and to debt financing, in order to obtain transportation related contracts wholly or partially funded by DOT. Your request cannot be processed unless the data is complete. Disclosures of name and other personal identifiers are required for a benefit, as DOT requires an individual seeking assistance from DOT to provide with sufficient information for it to evaluate the risk of a loan application. In making loan guarantees pursuant to Title 49 U.S.C. 332(b)(3)(4)(5), DOT is required to have reasonable assurance that the loan is of sound value and will be repaid or that is in the best interest of the Government to grant the assistance required. Routine uses of records maintained in the system include: processing, review, and final approval of your loan by authorized Office of Small and Disadvantaged Business Utilization (OSDBU) personnel; internal loan review and independent financial analyst provided by a financial expert contractor working for OSDBU; the loan referral to a Participating Lender involved in the underwriting, loan approval, and loan servicing of the loan guarantee; and recording in the Grant Information System. Disclosure of your Social Security Number (SSN) and/or date of birth (DOB) are optional. Refusal to furnish your SSN and/or DOB will not result in the denial of any right, benefit or privilege provided by law; however, failure to provide SSN and/or DOB may result in the delay of a response of the processing of your loan application or its rejection. Routine uses of your social security number include: processing, review, and final approval of your loan by authorized Office of Small and Disadvantaged Business Utilization (OSDBU) personnel; internal loan review and independent financial analysis provided by a financial expert contractor working for OSDBU; and the loan referral to a Participating Lender involved in the underwriting, loan approval, and loan servicing of the loan guarantee.

DOT F 2304-1