Form EIB92-41 Application for Financial Institution Short-Term Single

Print Form

Export-Import Bank of the United States

OMB #3048-0019
Expires 07/31/09

APPLICATION FOR FINANCIAL INSTITUTION
SHORT-TERM, SINGLE-BUYER INSURANCE
This application is to be completed by a financial institution (or a broker acting on its behalf) in order to obtain a short-term
insurance policy covering transactions to a single foreign buyer. Repayment terms can be up to 360 days.
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 ExIm 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 202.565.3380, e-mail
[email protected])
____________________________________________________________________________________________________

APPLICATION FORM
Applicant/Lender
The applicant is the financial institution that extends the Ex-Im Bank insured loan to the buyer.
Applicant legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:
Fax:

City:

Postal Code:

Broker (if applicable):

Name of Broker:
Ex-Im Bank Broker #:
Contact Person:
Phone number:
Fax:
E-mail:

1. GENERAL QUESTIONS
A. Coverage Types Requested
Risk coverage
Comprehensive Risk
Political Risk

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Type of credit
Buyer credit (based on applicant’s relationship with the buyer or guarantor)
Supplier credit (based on the applicant’s relationship with the exporter or supplier)
Is this a resubmission of a previously withdrawn, returned or denied application, or a renewal for an existing policy?
Yes
No
If yes, indicate previous transaction number: _________________
B. Primary Reason for applying for this policy
Risk Mitigation
Financing
To offer more competitive terms
C. Primary point of contact for this applicant/application
Lender
Broker
2. SPECIAL COVERAGES
Check the boxes for the special coverages that apply to this transaction. Complete and attach the requested forms,
where applicable.
Shipment to address in the U.S.

Foreign Currency Coverage
-indicate currency ________
- currency of supply contract
US dollar
foreign currency
Warehouse – Attachment IV
Required

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Services

Additional Named Insured
Attachment III - ANI required

Bulk Agriculture

Documentary Cover (question
applicable only to supplier credits)
Attachment II required

Other

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3. PARTICIPANTS
Provide information on the additional participants to the transaction.
Exporter
The exporter is the U.S. entity that contracts with the buyer for the sale of the U.S. goods and services.
Applicant legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

Supplier
if the
The supplier is the U.S. entity that manufactures the goods and/or performs the services to be exported. Check
exporter is the supplier and there are no additional suppliers. Enter any additional suppliers, or check
various:
Supplier legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

Buyer The buyer is the entity that contracts with the exporter for the purchase of U.S. goods and services.

Buyer legal name:

Postal Code :

Contact person:

Country: Albania

Position title:

E-mail:

Street Address:

Phone:

City:

Fax:

Guarantor
The guarantor is the person or entity that agrees to repay the credit if the buyer does not. Refer to the short-term credit
standards to determine in what circumstances personal or corporate guarantors are required.
No
Is a guarantor involved in this transaction? Yes

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APPLICATION FOR FINANCIAL INSTITUTION, SHORT-TERM SINGLE-BUYER INSURANCE
If yes, is the guarantor

an individual or

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a company?

Guarantor legal name:
Contact person:

Country:
E-mail:

Position title:
Phone:
Street Address:
Fax:
City:

Postal Code:

End-user
The end-user is the foreign entity that uses the U.S. goods and services:
Check if the end-user is also the buyer.

End-user legal name:

Province :

Contact person:

Country:
E-mail:

Position title:
Phone:
Street Address:
Fax:
City:

Postal Code:

Agent:
An agent is a business entity or individual located in the country of the borrower or buyer who has assisted in the sourcing,
packaging, and/or preparation of a request for support from Ex-Im Bank, and which will receive compensation in some form for
their services.
Is an agent involved in this transaction? yes
If yes, add the agent information below:

no

Agent legal name:

Province :

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

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Fax:

Postal Code:

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Related Parties
Describe any direct or indirect ownership or family relationship that exists between any of the participants. If none, so indicate:
None.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Primary Source of Repayment (PSOR)
The PSOR is the entity whose financial statements form the basis of Ex-Im Bank’s evaluation of reasonable assurance of
repayment, i.e. the entity whose financial statements Ex-Im Bank uses to supply calculate the ratios for short-term credit
standards compliance. For this transaction, indicate whether the PSOR is:
the buyer,
the corporate guarantor, or
business combination, (e.g. the consolidated or combined financial statements of the buyer and one or more corporate
guarantors.). If business combination, indicate which entities comprise the
combination____________________________________________________________________________________________
No

Is the PSOR a financial institution?

Yes

Select the risk category:

Private sector

Does the PSOR have a bond rating?

Yes

Public sector

No

If yes, indicate the name of the rating agency, rating, and the date of the rating.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4. TRANSACTION DESCRIPTION AND ELIGIBILITY
Provide a description of the products or service, including their NAICs code, if known:
______________________________________________________________________________________________________
Answer the following questions about the products or services.
Is each product produced or manufactured in the United States?
yes no
Has at least one-half of the value, exclusive of mark-up, been added by labor or material exclusively of United States origin?
yes no
Are these products on the munitions control list?

yes

Are the products new or used?

new

no
used

Are the products capital goods that will be used to produce exportable products? yes

no

Will any value be added to the product after export from the U.S.?

no

yes

If yes, provide an explanation: ____________________________________________________________________________
Has this transaction been considered by any other export credit insurer?

yes

no

If yes, provide an explanation: ___________________________________________________________________________

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5. FINANCED AMOUNTS AND STRUCTURE
Enter the %s for each payment term the exporter will extend to the buyer
Payment terms requested
Payment
Sight
type
Cash
Against
Documents
Sight Draft
Documents
Against
Payment
Sight Draft
Documents
Against
Acceptance
Open Acct.
Prom Note

Up to 30

Up to 60

(number of days)
Up to 90
Up to 120

Up to 180

Up to 270

Up to 360

Enter the details of the transaction below:
Single financing
Revolving line
the transaction is still being negotiated
Indicate whether:
the financing mandate has been received
Credit Limit requested: $ _______________________________________________________________________________

This application is for:

Requested effective date: _______________________________________________________________________________

6. CREDIT INFORMATION ON THE PSOR
The information requested in Attachment I: Credit Information is attached.
7. NOTICES AND CERTIFICATIONS
Anti-Lobbying Disclosure Form
Please sign the Anti-Lobbying Statement (Attachment V) and, if applicable, the Disclosure Form available at
www.exim.gov/pub/ins/pdf/lll.pdf and include a copy of the signed form(s) with your application.
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 capitalization terms not defined herein shall have the
meanings set forth in (1) the Export-Import Bank’s Non-procurement Debarment and Suspension regulations, 2 C.F.R. Part
3513, adopting by reference, the OMB Guidelines to Agencies on Government wide Debarment and Suspension (Non-procurement),
2 C.F.R. Part 180; and (2) the Debarment, Suspension, and Ineligibility provisions of the Federal Acquisition Regulation, 48, C.F.R.
Subpart 9.4. The applicant is not listed on any of the publicly available debarment lists of the following international financial institutions:

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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.).

Notices: The applicant is hereby notified that information requested by this application is done so under authority of the
Export-Import Bank 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# 3048-0019, Washington, D.C. 20503.

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

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Attachment I: Credit Information Requirements
Directions: The required credit information depends on the type of PSOR (non-financial institution or a financial institution)
and on the amount of credit support requested. Check the boxes that are applicable to your transaction.
1.

The PSOR is not a financial institution
a) Provide details of the applicant’s experience with the buyer
yes
Does the applicant have any experience with the buyer?

no

If yes, provide the following information:
Date of first transaction with the buyer: _______________________________________________________________
Date of first credit transaction with the buyer: __________________________________________________________
Has the applicant visited the buyer?

yes

no

If yes, indicate the date of the last visit and provide a call report.___________________________________________
Describe the credit facilities extended to the buyer:

short-term
medium-term
long-term
security
none

Total credit limit available to the buyer/corporate guarantor ________________________________________________
Total outstanding short-term balances ________________________________________________________________
Total outstanding medium-term or long-term balances ___________________________________________________
Credit performance

satisfactory

unsatisfactory

Has the applicant ever had credit insurance for the buyer or corporate guarantor before?

yes

no

If yes, enter the name of the insurer, and coverage dates and amounts _______________________________________
_______________________________________________________________________________________________
b) Provide the applicable supporting financial information on the PSOR.
Check the box that applies to your transaction and provide the information noted below the box
The transaction is for an amount up to $1 million:
• A credit report on the PSOR dated within six months of the application
• Two trade references on the PSOR of similar amounts and payment terms and dated within six months of the
application
• the applicant’s credit memorandum on the PSOR
• the applicant’s call report on the PSOR (if applicable)
• audited or signed unaudited financial statements with notes for the last 2 fiscal years which adequately
disclose financial condition and afford a reasonable basis for reliance on the information provided
The transaction is over $1 million
• A bank reference on the PSOR not older than 6 months from the date of application
• A credit report on the PSOR dated within six months of the application
• Two trade references on the PSOR of similar amounts and payment terms and dated within six months of the
application
• The applicant’s credit memorandum on the PSOR
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• The applicant’s call report on the PSOR (if applicable)
•

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Three fiscal year end audited financial statements with notes and the most recent interim statements with
notes if the last fiscal year end is more than nine months prior to application

PSOR is a financial institution

2.

a) Provide details of the applicant’s experience with the financial institution guarantor. Include dates and amounts of
none
previous transactions with the PSOR or indicate
_____________________________________________________________________________________________
b) Provide the applicable supporting financial information on the PSOR:
Check the box that applies to your transaction and provide the information noted below the box
The transaction is for an amount up to $1 million:
• One short-term debt rating of the PSOR from S&P, Moody’s or Fitch. Rating must be B, P-3 or F3 or better.
The transaction is for between $1,000,001 and $10,000,000
• One short-term debt rating of the PSOR from S&P, Moody’s or Fitch. Rating must be B, P-3 orF3 or better.
•

If the PSOR does not have an acceptable current market rating, provide most recently published audited financial
statements that adequately disclose financial condition and were prepared in accordance with accounting principles
that afford a reasonable basis for reliance on the information provided.

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Attachment II. Documentary Cover Attachment
If the credit is a supplier credit, and documentary cover is requested, provide the following:
• A bank reference on the exporter dated within six months of the application
• Two trade references on the exporter dated six months of the application
• Financial statements on the exporter as follows
$500,000 or less signed by an authorized office for the exporter
$500,001 - $999,999 reviewed by a CPA with notes attached
$1,000,000 or more audited by a CPA with opinion and notes attached
Note that typically documentary cover is only provided for a supplier credit when the exporter/supplier is a small
business. Call Ex-Im Bank’s Trade Finance and Insurance Division at 202-565-3600 with further questions.

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Attachment III: Additional Named Insured Questionnaire
Indicate the name of the additional named insured as follows:
Legal Name:________________________________________________________________________________
Address: ___________________________________________________________________________________
City: ______________________________________________________________________________________
State: ______________________________________________________________________________________
Country: ___________________________________________________________________________________
Zip/ Postal Code: ____________________________________________________________________________
Relationship to Applicant: ______________________________________________________________________
Role in the transaction: ________________________________________________________________________
Contact: ___________________________________________________________________________________

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Attachment IV – Warehouse Information
If you requested the Special Coverage – Warehouse, answer the following questions about the warehouse
Warehouse Type:

Owned or controlled by exporter
Bonded warehouse
Neither, provide details

Warehouse Location:
City ___________________________
State/Province __________________
Country________________________

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Attachment V
Anti-Lobbying Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or
employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member
of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the
undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,'' (available at
www.exim.gov/pub/ins/pdf/lll.pdf) in accordance with its instructions. Submission of this statement is a prerequisite
for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to
file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for
each such failure.

Signature

Title

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