Form CFL10 Claim for Loss

IA Form CFL10 OMB Control No. 1076-0020

Revised March 2010 Expires: ________

Claim for Loss

Department of the Interior

Loan Guarantee, Insurance and Interest Subsidy Program

(Note: do NOT use this form for Bond Guarantee claims)

Date: ____________

• Department Loan Guarantee Certificate Number ____________

• Department Loan Insurance under Loan Insurance Agreement Number _____________

Lender:_______________________________________

Address:______________________________________

______________________________________

______________________________________

______________________________________

Borrower:_____________________________________

Address:______________________________________

______________________________________

______________________________________

______________________________________

Guarantee or Insurance Percentage: _______%

Original Loan Principal Amount: $________________________

(Exclusive of amounts potentially added pursuant to 25 CFR §§ 103.8, 103.34, or 103.36.)

Lender’s Internal Loan Number: _________________________

Interest Subsidy awarded on loan? Yes  No 

Indicate the earliest date of default, as defined by 25 CFR § 103.44: _______________________, 20______

List all bases for default: ___________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I. The Unpaid Debt

Please list the following:

34640. The amount of past due principal: ________________

34641. The amount of past due interest: ________________

34642. The amount of any late fees: ________________

34643. The amount of any precautionary advances: ________________

34644. Any other amounts the Lender claims: _______________

(Identify authority in space provided below.)

Total: ________________

34645. The date through which interest has been calculated: ______________________, 20____

II. Liquidation Efforts

If the Lender liquidated loan collateral prior to submitting this Claim for Loss (this is mandatory before submitting a Claim for Loss under an Insurance Agreement), please list the following:

1. Total proceeds from collateral liquidation: $________________

(Please attach a detailed breakdown showing what

assets were sold, how and where they were sold, the

proceeds attributable to each asset, and the date(s) of sale.)

2. Administrative expenses of liquidating collateral: $________________

(Please attach receipts and a detailed breakdown showing

the nature and date of each expense.)

3. Liquidation proceeds applied to debt: $________________

(Please attach a description of how liquidation

proceeds were allocated to principal, interest and

other fees, and the dates posted.)

4. Does the unpaid debt listed in Section I reflect the amount of the lender’s loss after applying liquidation proceeds to the debt? Yes  No 

(If not, please provide an explanation.)

III. Claim Amount

For guaranteed loans, the claim amount should equal the Department’s guarantee percentage rate multiplied by the total unpaid debt listed in Part I, after deducting any recovery from liquidation proceeds reflected in Part II.

For insured loans, the claim amount should equal the Department’s insurance percentage rate multiplied by the total unpaid debt listed in Part I, after deducting any recovery from liquidation proceeds reflected in Part II, unless, as of the date of this Claim for Loss, the amount claimed would exceed 15% of the aggregate outstanding principal amount of all loans – including this one – that the lender has insured under the Program (“15% cap”). If so, then the claim amount should equal the 15% cap.

The Lender’s claim: $_________________________

If this is an insurance claim, please list the

15% cap as of the date of this

Claim for Loss: $_________________________

Lender:______________________________

ABA No.: _______________

By:__________________________________

Its:__________________________________

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to establish the nature and amount of a claim the respondent can make against the Federal government. The information is provided by respondents to obtain or retain a benefit. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and an expiration date. The number and expiration date are at the top right corner of the form. An agency may not sponsor or conduct, and a person is not required to respond to, a request for information collection unless it displays a currently valid OMB Control Number. The public reporting burden is estimated to average 2 hours per respondent. This includes the time needed to understand the requirements, gather the information, complete the form, and submit it to the Department. Comments regarding the burden or other aspects of the form may be directed to the Indian Affairs Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.

Privacy Act Statement (5 U.S.C. 552(a)): The authority for collecting this information is 25 U.S.C. 1511. The information will be used to administer the Loan Guarantee, Insurance and Interest Subsidy Program, 25 U.S.C. 1481 et seq. Disclosures of this information may be made to track and record payments and unpaid balances and provide information on payments made for paying interest subsidy, credits obtained, service loans made, and premiums paid by

Lenders, and for the other routine uses described by system of record notice, BIA-13, Loan Management and Accounting System.

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