Form EIB 10-01A EIB 10-01A Long Term Transaction Questionnaire

Export-Import Bank

of the United States

___________________________________________________________________________

EIB10-01A

OMB 3048-xxxx

Expires:

The Export-Import Bank of the United States (“Ex-Im Bank”) requires your company to complete and return this Questionnaire to Ex-Im Bank within ten days. In addition, Ex-Im Bank reserves the right to ask further questions as necessary.

Part A: General Information

1. Company Information:

Company Name: ____________________

Address: ____________________

____________________

____________________

Contact:

Name and Title: ____________________

Telephone: ____________________

Email: ____________________

2. Does the company produce, refine, or sell petroleum, refined petroleum products, oil, or natural gas?

 Yes

 No

3. Is the company a direct or indirect subsidiary of another company that produces, refines, or sells petroleum, refined petroleum products, oil or natural gas?

 Yes

 No

If you answered yes, list each company’s name, together with the address of its main or head office(s) and contact information:

Company: ____________________

Address: ____________________

____________________

____________________

Contact:

Name and Title: ____________________

Telephone: ____________________

Email: ____________________

Part B: Certification

Certification. The submitter of this questionnaire (“Submitter”) certifies that the facts stated and the representations made above and in any attachments to this Questionnaire are true, to the best of the Submitter’s knowledge and belief after due diligence, and that the Submitter has not misrepresented or omitted any material facts. The Submitter further understands that this is an official submission to the United States Government and this Certification is subject to the penalties for fraud against the U.S. Government (18 U.S.C. § 1001, et. seq.). The Submitter further certifies that it will provide additional information with respect to any of the matters covered in this Questionnaire upon Ex-Im Bank’s request. The authorized officer or employee signing below is fully authorized to certify the answers in this Questionnaire on behalf of the Submitter.

Company Name: ___________________________

By: ___________________________

(Authorized Officer or Employee)

Name:

Title:

Date: ___________________________

Public Burden Statement - Reporting for this collection of information is estimated to average xx hours per response, including reviewing instructions, searching data sources, gathering information, and 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-XXXX, Washington, D.C. 20503.

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811 Vermont Avenue, N.W. Washington, D.C. 20571