Form EIB 10-04 EIB 10-04 Notice of Claim and Proof of Loss, Working Capital Guara

OMB 3048-XXXX
Expires XX/XX/XXXX

Claim Control No:

Working Capital Guarantee
Section A - Names and Addresses

( * An asterisk denotes that a field is a required entry)

Guaranteed Lender Making Demand for Payment
Master Guarantee Agreement (MGA)
Number:
Ex-Im Bank Transaction No.
( AP No.):
Name:

*
*
*

Address Line 1:

*

Address Line 2:

*

Address Line 3:

*

City:

*

State:

*

Zip Code:

*

Contact Name:

*

Phone:

*

Fax:

*

E-Mail:

*

Current Holder of Original Note

Who is the current holder of the original
note?

Borrower

*

Same as the Guaranteed Lender
PEFCO

Name:

*

Address Line 1:

*

Address Line 2:

*

Address Line 3:

*

City:

*

State:
Zip Code:
Country

EIB 10-04
Revised 11/10

*United States of America

Contact Name:

*

Phone:

*

OMB 3048-XXXX
Expires XX/XX/XXXX

Fax:

*

E-Mail:

*

First Guarantor

Click here if not applicable

Not Applicable

Name:
Address Line 1:
Address Line 2:

*

Address Line 3:

*

City:
State:
Zip Code:
Country
Federal Tax ID or SSN:
Contact Name:

*

Phone:

*

Fax:

*

E-Mail:

Second Guarantor

Click here if not applicable

Not Applicable

Name:
Address Line 1:
Address Line 2:

*

Address Line 3:

*

City:
State:
Zip Code:
Country
Federal Tax ID or SSN:
Contact Name:

*

Phone:

*

Fax:

*

E-Mail:

*

Third Guarantor

Click here if not applicable
Name:

EIB 10-04
Revised 11/10

Not Applicable

OMB 3048-XXXX
Expires XX/XX/XXXX

Address Line 1:
Address Line 2:

*

Address Line 3:

*

City:
State:
Zip Code:
Country
Federal Tax ID or SSN:
Contact Name:

*

Phone:

*

Fax:

*

E-Mail:

*

Fourth Guarantor

Click here if not applicable

Not Applicable

Name:
Address Line 1:
Address Line 2:

*

Address Line 3:

*

City:
State:
Zip Code:
Country
Federal Tax ID or SSN:
Contact Name:

*

Phone:

*

Fax:

*

E-Mail:

*

Fifth Guarantor

Click here if not applicable

Not Applicable

Name:
Address Line 1:
Address Line 2:

*

Address Line 3:

*

City:

EIB 10-04
Revised 11/10

OMB 3048-XXXX
Expires XX/XX/XXXX

State:
Zip Code:
Country
Federal Tax ID or SSN:
Contact Name:

*

Phone:

*

Fax:

*

E-Mail:

*

Note: If there are more than five guarantors for this transaction, please mail the name, address, and
contact information on these additional guarantors to Ex-Im Bank along with the other required
documentation at the following address:
Working Capital Claims
Asset Management Division
Export-Import Bank of the U.S.
811 Vermont Avenue, NW
Washington, DC 20571

To speed your claim, we recommend sending this via overnight mail.

EIB 10-04
Revised 11/10

OMB 3048-XXXX
Expires XX/XX/XXXX

Claim Control No:

Working Capital Guarantee
Section B - Loan Information

( * An asterisk denotes that a field is a required entry)

General Information

What is the reason for the claim?

* Bankruptcy

If Other, please explain.

Was this guarantee approved under lender's
delegated authority?
Is there a PEFCO assignment?

* Yes

No

* Yes

No

Loan Dates

What is the default date?

* Month

Day

, Year

Date Loan Approved (aka Note date)?

* Month

Day

, Year

Loan amount approved?

*

Last Date Allowed to Disburse?

* Month

Day

, Year

Actual Date of Last Disbursement to
Borrower?
Renewal Date?

* Month

Day

, Year

Not Applicable
Month
Day

, Year

If past the claim filing deadline, did Ex-Im
Bank authorize an extension?

* Yes

No

Revolving Lines, Domestic Lines and Collaterlatization
Is this a revolving line?

* Yes

No

Is there a domestic line?
If 'Yes', give the amount

* Yes

No

What is the current outstanding amount of
the domestic line?
Is the domestic line current?

Yes

No

N/A

Is the domestic line collateralized?

Yes

No

N/A

Is there cross collateralization?

Yes

No

N/A

What is the approved collateral?
*
What is the advance rate of collateral?

EIB 10-04
Revised 11/10

*(

)% of Inventory

*(

)% of Receivables

OMB 3048-XXXX
Expires XX/XX/XXXX

What is the estimated net market value of
the remaining collateral?

*

Transaction-Specific Loans
Is this transaction-specific?

* Yes

No

Is this transaction under the City State
Program?
Has this transaction been rescheduled?

Yes

No

Yes

No

Did Ex-Im Bank approve the rescheduling?

Yes

No

N/A

Loan Insurance

Is there a related insurance policy from ExIm Bank? If 'Yes', give policy number.

*

Yes No

Is there a related insurance policy from
Yes No
*
another Insuror?
If 'Yes', give insuror name, policy number and contact address for Other Insuror.
Insuror Policy Number:
Name:
Street:
City:
State:
Zip:

EIB 10-04
Revised 11/10

Contact Name:

*

Phone:

*

Fax:

*

E-Mail:

*

OMB 3048-XXXX
Expires XX/XX/XXXX

Working Capital Guarantee
Section C - Business Structure Information

Claim Control No:

( * An asterisk denotes that a field is a required entry)
What is the business structure of the
borrower?
What are the products provided by the
borrower?

* Proprietorship

*
Borrower's type of business

* Wholesale

Status of borrower's operation

* Still Operating

NAICS Code

*

EIB 10-04
Revised 11/10

Select NAICS Code

OMB 3048-XXXX
Expires XX/XX/XXXX

Claim Control No.:

Working Capital Guarantee
Section D - Supporting Documentation

( * An asterisk denotes that a field is a required entry)
Demand Letter to Borrower:

*

Have in possession
Do not have
N/A
Date of
Demand Letter:

Demand Letter to Guarantor(s):

*

Month

Day

, Year

Day

, Year

Have in possession
Do not have
N/A
Date of
Demand Letter:

Month

Promissory Note(s)

*

Have in possession

Do not have

N/A

Evidence of Payment of the facility fee

*

Have in possession

Do not have

N/A

Master Guarantee Agreement

*

Have in possession

Do not have

N/A

*

Have in possession

Do not have

N/A

Loan Authorization Notice
(Annex A-2 Under /DA)

*

Have in possession

Do not have

N/A

Executed copy of Borrower's Agreement

*

Have in possession

Do not have

N/A

Delegated Authority Letter Agreement

*

Have in possession

Do not have

N/A

Loan agreement

*

Have in possession

Do not have

N/A

Security agreement

*

Have in possession

Do not have

N/A

Copies of all filed UCC financing
statements

*

Have in possession

Do not have

N/A

*

Have in possession

Do not have

N/A

Subordination agreement

*

Have in possession

Do not have

N/A

Copies of all reports of inspection of the
collateral

*

Have in possession

Do not have

N/A

*

Have in possession

Do not have

N/A

Executed copy of Loan Authorization
Agreement
(Annex A-1)

Evidence of a lien search of UCC records
which indicates a perfected security
interest

Copies of last 3 sets received by lender of
the inventory schedules and accounts
receivable aging reports.

EIB 10-04
Revised 11/10

OMB 3048-XXXX
Expires XX/XX/XXXX

Copies of all export orders or summaries of
export orders

*

Have in possession

Do not have

N/A

*

Have in possession

Do not have

N/A

*

Have in possession

Do not have

N/A

Executed copy of PEFCO assignment
(for PEFCO transactions only)

*

Have in possession

Do not have

N/A

Assignment of Ex-Im Bank or other
insurance policy (If insurance is used)

*

Have in possession

Do not have

N/A

Copies of any Ex-Im Bank correspondence
concerning waivers or filing extensions

*

Have in possession

Do not have

N/A

Copies of all borrowing base certificate(s)
for each disbursement request
(Provided by lender and executed by
borrower)
Copies of the lender's records regarding
disbursements and application of payments
to the loan.

EIB 10-04
Revised 11/10

OMB 3048-XXXX
Expires XX/XX/XXXX

Working Capital Guarantee
Section E - Lender's Checklist and Certification of
Action Items

Claim Control No:

( * An asterisk denotes that a field is a required entry)

1. Disbursements were made after receipt of
a borrowing base certificate and a copy of
the export orders or for revolving loans a
quarterly written summary of the export
orders.
2. Disbursements were made prior to the
final disbursement date.

* Yes

No

(Add comments below)

* Yes

No

(Add comments below)

3. The borrower was current under the
Working Capital line at time of
disbursement(s)

* Yes

No

(Add comments below)

4. All disbursements under the Working
Capital line were less than or equal to the
borrowing base (net of reserves for letters of
credit, or allowed over advances, unless as
allowed in the Master Guarantee
Agreement).
5. Disbursements were made in agreement
with the conditions and prohibitions stated
in both the Loan Authorization Agreement,
the Borrower Agreement, and the Master
Guarantee Agreement.
6. Items financed are those identified in the
Loan Authorization Agreement.

* Yes

No

(Add comments below)

* Yes

No

(Add comments below)

* Yes

No

(Add comments below)

7. Loan Amount, disbursement terms and
conditions and disbursement rates are
consistent with those approved in the Loan
Authorization Agreement.

* Yes

No

(Add comments below)

8. Transaction is in compliance with all
special conditions.

* Yes

No

(Add comments below)

9. Transaction is in compliance with
requirements of the Country Limitation
Schedule in force at time of approval.

* Yes

No

(Add comments below)

10. Loan Authorization Agreement or notice
EIB 10-04
Revised 11/10

OMB 3048-XXXX
Expires XX/XX/XXXX

is signed by an authorized officer of lender
or affiliate and Ex-Im Bank.

* Yes

No

11. The Borrower Agreement is signed by
all relevant parties.

* Yes

No

(Add comments below)

12. To the best of the borrower's knowledge,
all terms and conditions of the Borrower
Agreement have been met.

* Yes

No

(Add comments below)

13. The loan documents are free of any
binding alternative dispute resolution
provisions.

* Yes

No

(Add comments below)

14. The borrower has provided financial
statements to the lender as required under
the Borrower Agreement and the special
conditions (if applicable).

* Yes

No

(Add comments below)

15. This delinquency on the part of the
borrower and guarantors was reported to
credit agencies.

* Yes

No

(Add comments below)

(Add comments below)

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EIB 10-04
Revised 11/10

OMB 3048-XXXX
Expires XX/XX/XXXX

Working Capital Guarantee
Section F - Claim Payment Calculation

Claim Control No:

( * An asterisk denotes that a field is a required entry)

1) Date of Promissory Note

* Month

Day

2) Original Promissory Note
Amount

, Year

*

3) Principal Claimed
(Total Disbursements - Payments)
(a) Total Outstanding
(b) Less Amount Paid

*
(--) *

(c) Principal Claimed

(=)

Interest
4) Interest Paid To

* Month

Day

, Year

5) Last Payment Date

* Month

Day

, Year

6) Interest Claimed

First Date Interest
EIB 10-04
Revised 11/10

List below how the interest you are claiming was calculated.
(a) In the first column, first date of interest rate, list the date when the interest rate
became effective.
(b) in the second column, last date of interest rate, list the last date that the interest
rate applied. This date will not be included in the total days. For ex. if the first date is
1/1/2002 and the last date is 1/2/2002, only 1 day will be used to calculate the interest.
(c) in the third column, list the remaining principal amount that applied at that point in
time.
(d) in the fourth column, list the interest rate that applied at that point in time.
(e) in the fifth column, the number of days that interest rate was effective will appear
automatically.
(f) in the sixth column, list the amount of accrued interest in US dollars using the
formula
(Rate of Interest) X (Amount in Arrears) X (# of Days Interest Applies)/(Days In
Year) = (Interest Claimed)
You must use 360 days/year for any calculations.
Last Date Interest
Remaining
Rate of
# of Days
Interest Claimed

OMB 3048-XXXX
Expires XX/XX/XXXX

Rate Effective

Rate Effective

Principal

Interest
(X)

Interest
Applies

(=)

(X)

(=)

(X)

(=)

(X)

(=)

(X)

(=)

(X)

(=)

(X)

(=)

(X)

(=)

(X)

(=)

(X)

(=)

Sub-Total ===========> *
7) Per diem Interest

*

Other Eligible Costs
8) Enforcement Costs Claimed Eligible Enforcement Costs

*

9) Collateral Protection Costs
Claimed

*

Total

Total claimed at date of filing

Eligible Collateral Protection
Costs

===========>

Note: Interest to Date of Claim Payment will be calculated by Ex-Im Bank

EIB 10-04
Revised 11/10

OMB 3048-XXXX
Expires XX/XX/XXXX

Claim Control No.:

Working Capital Guarantee
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Section
G - Wire Instructions

( * An asterisk denotes that a field is a required entry)


Routing Bank Name

*

Recipient Bank Name

*

ABA #

*

Account Name

*

Account #

*

Attention:

*

Borrower:

*

Submit Claim










EIB 10-04
Revised 11/10