740g Application for Headquarters Facility

U.S. DEPARTMENT OF AGRICULTURE
RURAL UTILITIES SERVICE

Form Approved
OMB No. 0572-0032
BORROWER DESIGNATION

APPLICATION FOR HEADQUARTERS FACILITIES
INSTRUCTIONS - Submit to RUS an original and two (2) copies and
applicable supporting data. See attached for detailed instructions.

NAME OF BORROWER

1. PURPOSE OF PROJECT (Purchase, remodel or construct, main or branch facilities)

BORROWER'S
ESTIMATED COST

2.

RUS USE ONLY

ESTIMATED COST OF PROJECT:
a.

PURCHASE PRICE OF PROPERTY (exclude value of land and show in Items p)

b.

OFFICE PORTION (Construction

c.

OFFICE PORTION (Remodeling)

d.

SERVICE PORTION (Construction

e.

SERVICE PORTION (Remodeling)

f.

HVAC

g.

SITE DEVELOPMENT (Grading, roads, drainage structures, etc)

h.

FENCE

i.

WATER SUPPLY (Well, well house, pump, long connection to main, water treatment, etc.)

j.

SEWAGE DISPOSAL (Disposal System, long connection to main, etc.)

Sq. Ft. Ca

Per Sq. Ft.)

Sq. Ft Ca

Per Sq. Ft.)

LINEAR FT. @

$

$

$

$

$

$

Ft.)

PER FT. (Height

k.
l.
m.

CONTINGENCIES
SUBTOTAL

n.
o.

ARCHITECTURAL SERVICES

p.

LAND

q.

LEGAL EXPENSES
TOTAL

r.

Energy Efficiency

Show all cost, in the space to the right, that are associated with additional
energy efficiency measures beyond the required Federal, state or local building
codes and standards. This cost may or may not be part of the overall building
construction cost shown above. Please identify, in the Remarks section, the
measure taken, the estimated savings to be realized in addition to the cost.

Cost Estimate
3a. NO. OF EMPLOYEES REQUIRING
DESK SPACE

3b. NO. OF VEHICLES
TO BE GARAGED

5. METHOD OF FINANCING
740c CODE
a. RUS FINANCING

4a. DID ARCHITECT ASSIST IN PREP. OF COST ESTIMATE?
YES

$

b. GENERAL FUNDS

NO

c. OTHER (Specify)

4b. NAME OF ARCHITECT

d. TOTAL

$

REMARKS

Headquarters Certification: In compliance with 7 CFR 1724.51 (e), the undersigned certify that the design and construction of the headquarters facility shall comply with all applicable Federal, State,
and local laws and regulations, including, but not limited to: (1) Section 504 of the Rehabilitation Act of 1973, (29 U.S.C. 794), which states that no qualified individual with a handicap shall, solely by
reason of their handicap, be excluded from participation in, be denied the benefits of, or be subject to discrimination under a program or activity receiving Federal financial assistance. The Uniform
Federal Accessibility Standards (41 CFR part 101-19.6, appendix A) are the applicable standards for all new or altered borrower buildings, regardless of the source of financing. (2) The Architectural
Barriers Act of 1968 (42 U.S.C. 4151), which requires that buildings financed with Federal funds are designed and constructed to be accessible to the physically handicapped. (3) The Earthquake
Hazards Reduction Act of 1977 (42 U.S.C. 7701 et seq.), and executive Order 12699, Seismic Safety of Federal and Federally Assisted or Regulated New Building Construction (3 CFR 1990 Comp.,
p 2 69). Appropriate seismic provisions are required for new buildings for which RUS provides financial assistance. (See part 1792, subpart C.)

SIGNATURE OF MANAGER

DATE

SIGNATURE OF PRESIDENT

DATE

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to, a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0572-0032. The time required to complete this information is estimated to average 3 hours per response including the time for reviewing,
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

RUS Form 740g Rev. 5, 2/25/2010