Form EIB 92-34 EIB 92-34 Application for Letter of Credit Insurance Policy

Print Form

Export-Import Bank of the United States

OMB No. 3048-0009
Expires 07/31/2010

APPLICATION FOR LETTER OF CREDIT INSURANCE POLICY
This application is to be completed by a finan cial institution (or a b roker acting on its b ehalf) in order to obtain a sh ort-term
letter o f cred it in surance po licy. An online v ersion of t his application is avai lable on Ex-Im B ank’s web si te. E x-Im B ank
encourages customers to apply o n line, as it will facilitate our review and allow cu stomers 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 pd f and fax ed applicatio ns. Ex -Im Ban k will n ot req uire the orig inals of these ap plications to be m ailed. Th e
application must be PDF s cans of ori ginal applications and all r equired attach ments. ( Fax nu mber 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:

No
If yes, indicate the name of the rating agency, rating, and the
Does the applicant have a market rating?
Yes
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
01/07

OMB No. 3048-0009
Expires 07/31/2010

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
Insurance

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

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?
______________________________

EIB-92-34
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EXPORT-IMPORT BANK OF THE UNITED STATES
APPLICATION FOR LETTER OF CREDIT INSURANCE POLICY
•

OMB No. 3048-0009
Expires 07/31/2010

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 app licant certifies th at neither it, nor its Pri ncipals, have within t he past 3 y ears been a) debarred, s uspended, decl ared
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 t he date of e xecution of t his applica tion; or e ) the unde rsigned ha s receive d a written state ment of
exception from Ex-Im Bank attached t o this certificatio n, p ermitting p articipation in th is Cov ered Tran saction 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: 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 th at the representation made and the facts stated in this docum ent and any attachments are tru e,
to t he best o f i ts kno wledge and belief, and i t has not misrepresented o r om itted any m aterial f acts, and i f a ny of t he
certifications made h erein become u ntrue, Ex -Im Ban k will b e pr omptly in formed of su ch ch anges. Th e app licant fu rther
understands that these certifications are subject to the penalties for fraud against the U.S. Government (18 USC 1001, et seq.).
EIB-92-34
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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 resu lt i n Ex -Im Ban k being un able to determine elig ibility fo r supp ort. Th e in formation provided will b e
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 Bu rden State ment: Rep orting fo r th is co llection of in formation is esti mated to av erage 1 hour per response, including
reviewing i nstructions, sea rching dat a so urces, gat hering i nformation, co mpleting, an d reviewing th e ap plication. Send
comments reg arding t he burden est imate, i ncluding s uggestions f or reducing i t, t o Of fice of M anagement an d B udget,
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: ________________________________________________________________________________________

EIB-92-34
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