Form EIB 10-05 EIB 10-05 Notice of Claim and Proof of Loss, Medium Term Insurance

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Claim Control No.:

Medium Term Bank 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?

Same as the Guaranteed Lender
PEFCO

Other
If you select "other" fill in the following information:
Other Name:
Address Line 1:
Address Line 2: *
Address Line 3: *
City:
State:
Zip Code:
Contact Name: *
Phone: *
Fax: *
EIB 10-05
Revised 11/10

OMB No. 3048-XXXX
Expires XX/XX/XXXX

E-Mail: *

Borrower

Name: *
Address Line 1: *
Address Line 2: *
Address Line 3: *
City: *
Country *
Contact Name: *
Phone: *
Fax: *
E-Mail: *

First Guarantor

Click here if not applicable

Not Applicable
Name:
Address Line 1:
Address Line 2: *
Address Line 3: *
City:
Country
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:
Country
Contact Name: *
Phone: *
Fax:

EIB 10-05
Revised 11/10

OMB No. 3048-XXXX
Expires XX/XX/XXXX

*
E-Mail: *

Note: If there are more than two 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.

EIB 10-05
Revised 11/10

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Medium Term Bank Guarantee
Section B - Guarantee Information

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

What are the goods and/or services?
*
What is the U.S. content percentage?

*

What is the total contract price?

*

What is the amount of the cash payment?

*

EIB 10-05
Revised 11/10

Claim Control No.:

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Medium Term Bank Guarantee
Section C - Claim Information

Claim Control No.:

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

When were the disbursements?

What is the first default date?
What is your claim filing deadline?

First Disbursement:
Day
* Month
Second Disbursement:
Day
_ Month
Third Disbursement:
Day
_ Month
Fourth Disbursement
Day
_ Month
Fifth Disbursement
Day
_ Month
Sixth Disbursement
Day
_ Month
*
Day
* Month

What is the reason for the claim?

* Month
* Bankruptcy

Type of foreign buyer.

* Proprietorship

Type of buyer's business.

* Wholesale

EIB 10-05
Revised 11/10

Day

, Year
, Year
, Year
, Year
, Year
, Year
, Year
, Year

**

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Claim Control No.:

Medium Term Bank Guarantee
Section D - Supporting Documentation

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

Demand Letter to Borrower:

*

Have in possession
Not required per MGA Sec 8.02 (b)
Date of
Demand Letter:

Demand Letter to Guarantor(s):

* Have

* Have

Month

in possession Not

Date:
Annex B:

Month

in possession Not

Annex B Date: Month

EIB 10-05
Revised 11/10

Day

, Year

Day

, Year

in possession
* Have
Not required per MGA Sec 8.02 (b)
Date of
Demand Letter:

Lender Credit Agreement:

Month

required
Day

, Year

required
Day

, Year

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Claim Control No.:

Medium Term Bank Guarantee
Section E - Promissory Note 2QH

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

Click here if not applicable

* Not

Applicable

Note Information

Have in Possession: * Yes No
Date of Promissory Note: Month

Day

, Year

Total Principal Amount: *
Number of Installments: * Principal Installments:
* Interest Installments:
First Due Dates *Date 1st Principal Due: Month
*Date 1st Interest Due: Month
Frequency of Payment: * Monthly
Interest Rate: *
Fixed

Day
Day

, Year
, Year

Floating

Rate:
* Method of Calculation
360/360 Days
365/365 Days
Date Ordinary Interest Paid _ Month
Through

Day

, Year

Installment Information
*
Installment
Number(s)

EIB 10-05
Revised 11/10

*
Due
Date(s)
00/00/0000

*
Declining
Outstanding
Balance

*
Principal
Due

*
Principal
Paid

*
Outstanding
Principal

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Installment -- Additional Comments

EIB 10-05
Revised 11/10

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Claim Control No.:

Medium Term Bank Guarantee
Section E - Promissory Note TZR

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

Click here if not applicable

* Not

Applicable

Note Information

Have in Possession: * Yes No
Date of Promissory Note: Month

Day

, Year

Total Principal Amount: *
Number of Installments: * Principal Installments:
* Interest Installments:
First Due Dates *Date 1st Principal Due: Month
*Date 1st Interest Due: Month
Frequency of Payment: * Monthly
Interest Rate: *
Fixed

Day
Day

, Year
, Year

Floating

Rate:
* Method of Calculation
360/360 Days
365/365 Days
Date Ordinary Interest Paid _ Month
Through

Day

, Year

Installment Information
*
Installment
Number(s)

EIB 10-05
Revised 11/10

*
Due
Date(s)
00/00/0000

*
Declining
Outstanding
Balance

*
Principal
Due

*
Principal
Paid

*
Outstanding
Principal

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Installment -- Additional Comments

EIB 10-05
Revised 11/10

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Medium Term Bank Guarantee
Section G - Wire Instructions

Claim Control No.:

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

Routing Bank Name

*

Recipient Bank Name

*

ABA #

*

Account Name

*

Account #

*

RE: Ex-Im # (from Section A):

*

Attention:

*

Borrower:

*

EIB 10-05
Revised 11/10

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Medium Term Bank Guarantee
Section F - Claim Calculator

Claim Control No.:

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

Claim Payment (not including Post Maturity Interest)
a) Total face value of Note(s) from Section E1 through E2.

(+)

b) Total borrower principal payment(s).

(-)

e) Total Claim Payment
(not including post maturity interest)

EIB 10-05
Revised 11/10

*
*

c) Loss (not including interest)
d) % of Guarantee Coverage

*

(%)

*
*

OMB No. 3048-XXXX
Expires XX/XX/XXXX

Medium-Term Bank Guarantee
Section G - Certification and Notices

Claim Control No.:

( * An asterisk denotes that the field is a required entry)
Certifier is the Guaranteed Lender? Yes ____ No ______
*

Name of Authorized Certifier
Lender
Street Address
City
State
Zip Code
Phone Number

*
*
*
*
*
*

Fax Number
E-mail Address
Submit Claim

Paperwork Reduction Act Statement: We estimate that it will take you about 1 and 1/2 hours per response, that includes the time it will
take to read the instructions, gather the necessary facts and fill out the form. However, you are not required to provide information
requested unless a valid OMB control number is displayed on the form. If you have comments or suggestions regarding the above estimate
or ways to simplify this form, forward correspondence to Ex-Im Bank and the Office of Management and Budget, Paperwork Reduction
Project, OMB # 3048-XXXX, Washington, DC 20503.

EIB 10-05
Revised 11/10