Dot F 2301-1 (rev. Stlp Application For A New Loan Guarantee

U.S. Department of Transportation Office of Small and Disadvantaged Business Utilization Short Term Loan Program APPLICATION FOR NEW LOAN GUARANTEE

OMB Approval Number: 2105-0555 Expiration Date: MM/DD/YYYY Form DOT 2301-1(REV.1)

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 be 60 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 Officer, U.S. Department of Transportation, OSDBU, Financial Assistance Division, 1200 New Jersey Ave., S.E., 5th Floor, W56-497, Washington, DC 20590.

Full Legal Name of Company:

TIN (Federal Tax ID No):

Primary Contact Name and telephone:

Legal Structure of Applicant: a. Sole Proprietorship b. LLC c. LLP d. General Partnership e. Corp. f. S. Corp g. Other Date Business Established:

Participating Lender Name:

Applicant ‘s email Address and website:

Full Street Address of Primary Business Location:

15. a. D&B#: ___________________ b. NAICS Code: ______________

City:

State:

Zip Code:

Primary Contact telephone:

Number of Employees: (Including subsidiaries and affiliates)

16a. At Time of Application: ___________

16b. If STLP Loan is Approved:__________

County:

Fax Number:

16c. Subsidiaries or Affiliates: (Separate for above)____________

16d. Total: __________________

Bank of Business Account:

Bank Officer’s telephone:

Bank Officer’s fax/email:

Bank Officer’s Name:

Bank Officer’s E-Mail Address:

Business Account Bank Address:

PART B- TRANSPORTATION-RELATED CONTRACTS TO BE FINANCED WITH LINE OF CREDIT

24. Transportation-Related contracts to be financed with line of credit

The Transportation related contract(s) supporting the line of credit application will be the first source of collateral and repayment: Describe the Transportation-related contract by contract number and amount (Discount any retainage held by agency or prime).

Other

Contract Amount:

$

Total LINE OF CREDIT Requested:

$

PART C - LIST OTHER COLLATERAL USE ADDITIONAL PAGES, IF NECESSARY, AND LABEL AS EXHIBITS ALL EXHIBITS MUST BE SIGNED AND DATED BY PERSON SIGNING THIS FORM

SECTION I – Other Collateral

25. LIST OF OTHER COLLATERAL (if applicable)

Attach a copy of the deed(s) containing a full legal description of the land and show the location (street address) and city where the deed(s) is recorded. Following the address below, give a brief description of the improvements, such as size, type of construction, use, number of stories, and present condition (use additional sheet if more space is required).

Address

Year Acquired

Original Cost

Market Value

Amount of Lien

Name of Lien Holder

A

$

$

$

B

$

$

$

C

$

$

$

D

$

$

$

PART D – Business Debt Schedule
26. LIST OUTSTANDING DEBT
NAME OF CREDITOR		Original Date (mm/dd/yy)		Original Amount	Present Balance	Maturity Date (mm/dd/yy)	Monthly Payment
1		$				$
2		$				$
3		$				$
4		$				$
5		$				$
6		$				$
7		$				$
8		$				$
9		$				$
10		$				$
Grand Total		$				$	$
GOVERNMENT: Describe any debt owed to any governmental authority, including Federal, State, or local taxes, if any.
Outstanding Debt Item		Original Amount	Agency		Settlement/Workout Plan - Date Approved	Balance Due	Current or Past Due
1		$				$
2		$				$
3		$				$

PART E – MANAGEMENT/OWNERSHIP INTEREST
28. MANAGEMENT: (This section should be completed by all Proprietors, partners, members and by all officers, directors, and/or stockholders of corporation having 20% or more ownership interest in the business applicant). Use separate sheet if necessary.
Name and Social Security Number and Position Title	Complete Address		% Owned		Annual Compensation Amount
Are there any affiliated businesses? (Businesses that share common ownership with the applicant) If yes, please provide the business name(s) and current financial statements (dated within 90 days of application):
Yes No
Are you now (or have you ever been) subjected to any claim for additional taxes? If yes, please explain:
Yes No
Are any federal, state or local taxes now past due? (If so, DOT cannot accept this application until paid in full and proof is provided.
Yes No
Are any liabilities other than taxes now past due? If yes, explain: (If so, DOT cannot accept this application until paid in full and proof is provided).
Yes No
Are there currently any bankruptcy, insolvency proceedings, or pending lawsuits?
Yes No
f. Are you current on any obligation to pay child support arising by an administrative order; a court order; a repayment agreement; or a repayment agreement from a State agency with child support enforcement services?
Yes No If no how many months delinquent: _______________
29. CONTINGENT LIABILITIES: (Identify and provide documents)
a. As Guarantor, Endorser, or Co-Maker:		Org. Amount $ _________		Bal. Amount: $ ____________		As of Date: _____________
______________________________________ b. Other Contingent Debts: (contracts, leases, etc.): ______________________________________		Org. Amount $ _________		Bal. Amount: $ ____________		As of Date: _____________

PART F – CERTIFICATION
The definition of a Disadvantaged Business Enterprise (DBE), which includes women-owned businesses and minority owned businesses, are set forth in 49 Code of Federal Regulations Parts 23.
The applicant, _______________________________________________ certifies that it is a Disadvantaged Business Enterprise and that the contract or contracts to be financed are transportation-related contracts. The applicant understands that this is a Revolving Line of Credit loan guaranty application for Accounts Receivable financing. For the purposes of this application, an accounts receivable is money which is owed to a company for products and services provided on credit by means of a written contract or purchase order for eligible transportation-related contracts only and is treated as a current asset on a balance sheet.
30. BASIS FOR DBE STATUS: (Check as appropriate) a. Female b. Asian c. Black d. Hispanic e. Indian/Alaskan f. Other:
Name of Agency which Certified your Business as a DBE: _________________________________________________________ State: _____________________________ Certification Expiration/Renewal Date:_____________________________________ Affidavit Date: ___________________ Enclose a copy of your affidavit with your application and supporting documentation.
31. OTHER FEDERAL GOVERNMENT CERTIFICATION:
a. Section 8(a)	YES	NO
b. Small Disadvantaged Business (SDB)	YES	NO
c. HUBZone	YES	NO
d. Disabled Service Veteran (DSV)	YES	NO

PART G – CERTIFICATION AND SIGNATURE OF APPLICANT
32. CERTIFICATION
In submitting the foregoing application, the undersigned guarantees its accuracy with the intent that it be relied upon by the PL Bank and the U.S. Department of Transportation in extending credit to undersigned and warrants that the undersigned has not, knowingly, withheld any information that may affect its credit risk, and the undersigned expressly agrees to immediately notify said bank and the U.S. Department of Transportation, in writing, of any material change in its financial condition.
Signature of Preparer: (If other than applicant):	Type Name of Preparer:
Address of Preparer:
If applicant is a proprietorship or partnership, sign below: Name: _________________________________ Title: ______________________________ Date: _______________
If applicant is a corporation or limited liability company, sign below ( Include copy of resolution authorizing you to act on its behalf with regard to this STLP Loan Guarantee application) Name: _________________________________ Title: ______________________________ Date: ______________ (Corporate Seal)
33. Business References
a. ATTORNEY’S NAME: TEL: E-MAIL: b. ACCOUNTANT’S NAME: TEL: E-MAIL: c. INSURANCE COMPANY NAME: TEL: E-MAIL: d. INSURANCE AGENT’S NAME: TEL: E-MAIL: e. BOND AGENT TEL: E-MAIL:

THE FOLLOWING APPLICATION EXHIBITS MUST BE COMPLETED BY THE APPLICANTS ALONG WITH A $150.00 APPLICATION FEE.

SHORT TERM LENDING (STLP) CHECKLIST FOR NEW APPLICANTS

1. _____ Completed DOT OSDBU STLP application signed and dated.

2. _____ Financial Records for business:

_____Three years of business financial statements

Note: Business financial statements should be prepared by an independent CPA firm and to include the accountant's cover letter, balance sheet, operating statement, any additional statements and schedules, and any accompanying notes. If the latest financial statements are more than 90 days old, interim financial statements are to be furnished which may be management prepared.

_____Three years of business federal tax returns

3. _____ Financial Records personal: (for each proposed guarantor and individual owning 20% or more of the company)

_____Current personal financial statement (dated and signed)

_____Three years of personal income tax returns

4. _____ Current Work in Progress (WIP) Schedule or statement to include all jobs currently under contract. (Contract owner, project name, contract amount, start date, percentage completed and billed amounts, collected amounts, and estimated completion date should be included)

5. _____ Current Aging Reports of both Receivables and Payables (should be 90 days current)

6. _____ Cash Flow Projection covering the term of the 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.

7. _____ Current DBE Certification and/or other eligible SBA certification (8a, HUBZone, SDB, DSV). This is to include updated an annual affidavit as part of the certification requirements and evidenced of acceptance by the DOT by your home state or your Business Opportunity Specialist (BOS) if it is a SBA certification.

8. _____ Business formation documents (Articles of Incorporation, or Partnership Agreement, or Articles of Organization) and evidence of proper business registration.

9. _____ Company history and a statement of the expected benefits of the loan.

9. _____ List of completed contracts during the past 12 month period.

9. _____ 2 Reference letters relating to the applicant’s contract performance and one other reference letter relating to either financial or professional performance. These letters should be dated within the past six months of the date of application.

9. _____ Resume of key management

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

9. _____ Bonding information, if applicable

9. _____ If any of the principal owners of the applicant business also own a majority interest in other business concern, he/she must submit the past three fiscal years of financial statements and/or federal tax returns for the each affiliated business.

AGREEMENTS AND CERTIFICATIONS

I authorize the DOT to have its agent, the PL or Surety Company, to conduct such credit and personal history report and information checks about me as may be needed in order for the DOT to carryout its fiduciary responsibilities and such other due diligence as may be necessary for the purpose of determining my eligibility for the programs authorized by the DOT and its OSDBU under 49 U.S.C. 332.

CAUTION: Knowingly making a false statement on this form is a violation of Federal Law and could result in criminal prosecution, significant civil penalties, and a denial or your DOT loan guarantee or surety bond guarantee, as well as other DOT program participation. A false statement is punishable under 18 USC§ 1001 by imprisonment of not more than five years and/or a fine or not more than $10,000.

CERTIFICATION: Agreements of non-employment of DOT personnel: I agree that if DOT approves this loan application I will not, for at least two years, hire as an employee or consultant, anyone that was employed by DOT during the one year period prior to the disbursement of the loan.

I certify:

(a) I have not paid anyone connected with the Federal Government for help in getting this loan. I also agree to report to the DOT Office of the Inspector General, Washington, DC 20590 any Federal Government employee who offers, in return for any type of compensation, to help get this loan approved.

(b) All information in this application and the exhibits are true and complete to the best of my knowledge and are submitted to DOT for credit underwriting, whereby DOT guarantees the loan up to 75%. I agree to pay for or reimburse the bank for the cost of any surveys, title or mortgage examinations, appraisals, credit reports, etc., performed by bank personnel.

(c) The prospective borrower certifies, by submission of this application, that neither it nor its principals are presently debarred, suspended, proposed for disbarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

By: ______________________________________________________________________________

_____________________________­_________________________________________________

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.

APPLICANT’S CERTIFICATION

By my signature, I certify that I have read and received a copy of the “STATEMENTS REQUIRED BY LAW AND EXECUTIVE ORDER,” which was attached to this application. My signature represents an agreement to comply with the approval of this loan request and to comply, whenever applicable.

Each proprietor, each General Partner, each Limited Partner or Stockholder owning 20 percent or more, each Guarantor and the spouse of each Guarantor must sign. Each person should sign only once.

Business Name: _____________________________________________________________

By: _______________________________________________________________________
Signature and Title

34. GUARANTORS:
Signature and Title		Date
Signature and Title		Date
Signature and Title		Date

Form DOT 2301-1 OMB Approval Number: 2105-0555 Expiration Date: MM/DD/YYYY - 9 -