Office of Small and Disadvantaged Business Utilization

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                        Office of Small and Disadvantaged Business Utilization
                             SHORT TERM LENDING PROGRAM
                           BANK VERIFICATION
                         LOAN ACTIVATION FORM









Participating Lender

Borrower’s Name

City     ___________________________
State  _________________

Loan Amount  $ __________________

DOT Guarantee Amount  $ _______________

Loan has been activated this date

Bank Representative (print)   


Signature



Do Not Write Below - For Internal Use Only
Date Received  __________________
Administrative Fee $_______________
Notes: 
OSDBU Director  ____________________ 

 Date  ___________________



PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
A Federal agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. The OMB Control No. for this information collection is 2105-0555. The information requested on this form is being collected and disseminated by the U.S. Department of Transportation, Office of the Secretary as a courtesy to the public. Public reporting for this collection of information is estimated to be 30 minutes per response, including time for reviewing instructions, and completing and reviewing the collection of information. All responses to this collection are mandatory. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to: Information Collection Clearance Officer, U. S. Department of Transportation , Office of the Secretary, Office of Small and Disadvantaged Business Utilization Financial Assistance Division, 1200 New Jersey Ave., S.E., 5th Floor, W56-448, Washington, DC 20590.

PRIVACY ACT STATEMENT
The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this form is solicited under the authority of Title 49 U.S.C. 332(b)(3)(4)(5) which authorizes DOT OSDBU to assist Disadvantage Business Enterprises and Small and Disadvantaged Businesses in acquiring access to working capital and to debt financing, in order to obtain transportation related contracts funded by DOT. STLP loans are provided through lenders that serve as STLP Participating Lenders (PL).  The PLs enter into a Cooperative Agreement with DOT’s OSDBU. The STLP is subject to budgeting and accounting requirements of the Federal Credit Reform Act of 1990 (FCRA).  The PL must carry out processes to activate, monitor, service and close out STLP loans. To fulfill the requirements of FCRA, the PL submits reports and the forms to OSDBU.  Provisions of the requested information are voluntary; however it is a requirement of the Cooperative Agreement.