Dot F 2312-1 Stlp Application Checklist For Continued Participation

OMB NO.: 2105-0555

EXPIRATION DATE: MM/DD/YYYY

STLP Application Checklist for Continued Participation

Note to Participating Lenders and Applicants: If the PL has received a previous DOT loan guarantee for the Borrower who is now applying for a subsequent year of participation in the DOT OSDBU Short Term Lending Program, the following Application Checklist should be used.

1. ­­­_____ An updated DOT OSDBU Short Term Lending Program Application, signed and dated.

2. ______Does the business meet the eligibility requirements: DOT Federally Funded Transportation related contract- i.e., maintenance, rehabilitation, restructuring, improvement, or revitalization of any local, State or Federal transportation system. In addition, the source of contract dollars defines whether it is considered transportation related.

3. _____ Business Financial Statements for the most recent fiscal year.* These statements should be prepared by an independent CPA firm and include the accountant’s cover letter, the Balance Sheet, the Profit & Loss or Income Statement, any and all additional statements and schedules, and any and all accompanying CPA notes. If the STLP Loan guarantee request is for $500,000 or greater, the business financial statements must be CPA reviewed.

4. _____ If the business’ last fiscal year has ended longer than 90 days at the time of application, the business must also submit Interim Business Financial Statements to include Balance Sheet, P&L, and Aging Reports of both Receivables and Payables.

5. _____ A Current Work in Progress Schedule or Statement to include all jobs currently under contract. Contract owner, project name, contract amount, starts date, percentage completed and billed amounts, collected amounts, and estimated completion date should be included in this document, at a minimum.

6. _____ Current Aging Reports of both Receivables and Payables, if not included with the Interim Statements (item 3. above).

7. _____ An updated Business Cash Flow Projection covering the term of the requested loan must be submitted. This report should show, on a monthly basis, total revenues from both transportation and non-transportation related contracts in progress, the associated cost of goods and services, general and administrative operating costs, net monthly cash flow, and anticipated advances and repayment on the proposed line of credit.

8. _____ Business federal tax returns for the most recent fiscal year.

9. _____ Evidence of current DBE certification and/or other eligible SBA certification (8a, HUBZone, SDB, DSV). Include a copy of the original state or SBA certification letter and the most current annual affidavit attesting to continued program eligibility that was filed and approved by the issuing agency.

10. _____ A job performance reference letter from either the Prime Contractor or the Owner of a transportation-related project completed within the past 12 months.

11. _____ For each principal owner of the applicant business (an individual owning 20% or more of the company), submit the following information: Personal Financial Statement (dated with 90 days of application); Recent year federal tax returns; For any other guarantor that is not an owner of the business, submit only the PFS and tax returns.

12. _____ A complete copy of all new transportation-related contracts, subcontracts, and/or purchase orders that will be assigned to the proposed loan.

13. _____ If any of the principal owners of the applicant business also own a majority interest in other business concern, he/she must submit the most recent fiscal year of financial statements and/or federal tax returns for the each affiliated business.*

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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 reporting for this collection of information is estimated to be120 minutes per response, including time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection of information 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 Officer, Office of the Secretary, Office of 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.

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DOT F 2312-1