RD 4279-1A Application for Loan Guarantee (Business and Industry Sh

Form RD 4279-1A
(Rev. 11-06)

Position 3

FORM APPROVED
OMB No. 0570-0017
OMB No. 0570-0050

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

APPLICATION FOR LOAN GUARANTEE
(Business and Industry Short Form– One-Doc and Rural Energy for America Program)
This form may be used for loan applications in accordance with 7 CFR 4279-B, § 4279.161(c) and with 7 CFR 4280-B, § 4280.128(c).

Section 1001 of Title 18, United States Code provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United
States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact or makes any false, fictitious or
fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or
fraudulent statement or entry shall be fined under this title or imprisoned for not more than five years or both.”
CERTIFICATION: Information contained below and in attached exhibits is true and complete to my best knowledge. Misrepresentation of material
facts may be the basis for denial of credit by the United States Department of Agriculture (USDA).

PART I: Completed by Applicant
Shaded area for USDA use only.

A. Applicant Business Information
1. Tax ID#/Social Security # 2. Applicant Name

3. Loan Amount Requested

4. Contact Person

5. Mailing Address

6. Project Street Address

7. Contact phone number

8. City

9. County

10. E-mail address (optional)

11. State

12. Zip Code

13. Borrower Type (e.g., corp, )

14. Nature of Business

15. NAICS Code

16. If Individual, Veteran?
Y/N
19. # Full-Time-Equivalent
Jobs to be Retained

17. Loan Purpose(s)

18. Business in operation since:

20. # Full-Time-Equivalent Jobs
to be Created

21. Average wage rate of
employees after loan
$
per hour
22. If purpose of loan is a transfer of ownership or debt refinance, explain how this will save or create jobs.

B. Ownership Information
23. List all owners in order of ownership interest:
Owner Name
Race
Eth*
nicity
*

Eligible amount?

OK

Population?
Rural?

OK

Targeted area?
Congress District?
Eligible Purpose?

OK

Jobs benefit?

OK

Justified.

OK

USDA use

Sex
*

% owned

US Citizen
Position in
Personal
Outside
or Perm.
Company
Guaranty? Net Worth
Resident
M/F
%
Y/N
Y/N
$
OK
M/F
%
Y/N
Y/N
$
OK
M/F
%
Y/N
Y/N
$
OK
M/F
%
Y/N
Y/N
$
OK
M/F
%
Y/N
Y/N
$
OK
M/F
%
Y/N
Y/N
$
OK
*This information is requested in order to monitor the Lender’s compliance with the Equal Credit Opportunity Act.
Shaded area for USDA use only.
You are not required to furnish this information but are encouraged to do so. However, if you choose not to
furnish it, the Lender is required to note race and sex on the basis of visual observation or surname under
CAIVRS check?
OK
Federal regulations.
23. Schedule of Financial Activities. (Reference number 21 in the application)
The Rural Development Socio-Economic Benefits Assessment System (SEBAS) assess the effectiveness of Rural Development loan and grant
programs, which include reporting contributions to gross domestic product (GDP). The following SEBAS schedule identifies information related to
the Rural Development guaranteed loan and grant. The schedule will be completed in accordance with RD Instruction 4270-A,
§4279.161(b)(11)(xiv). Applicant/borrower prepares using the financial statements based on Generally Accepted Accounting Principles (GAAP).
Expenses are stated on a cash basis.
1. Number of employees: _______
Full Time _________
Part Time __________
Seasonal __________
Jobs related to guaranteed loan/grant:
Created ___________
Saved ____________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0570-0017 and 0570-0050. The time required to complete this information collection is estimated to
average 4.5 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.

2. Selected Operating Data:
Average hours per/week worked
Average weeks worked per year
Average weekly wages and salaries
Average weekly benefits
3. Selected Revenue Data – all sources
Total Revenue
4. Selected Expense Data:
Total Wages and Salaries
Total Employee Benefits
Cost of Goods Sold
Services
Purchase of manufactured inputs
Agricultural commodities
Forestry and logging
Mined ores and other raw resources
Transportation
Insurance
Utilities
Real estate rent/leasing
Financing, interest
Equipment and software purchases
Construction – Building, Land, Other
Business and local taxes
Total Selected Expenses
6. Selected Other Data
Dividends/Cash Distributions
Retained Earnings/Patronage
(allocated/unallocated)
7. Difference between Revenue and
Expenses/Other Items

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

8. This information is based on audited: (check one)

unaudited: ________________

financial statement ____________

By my signature, I certify that I have read the General Borrower Certifications and completed the Schedule of Financial Activities contained in this
application. My signature represents my agreement to comply with the limitations outlined in the General Borrower Certifications.
CORPORATE SEAL
ATTEST
TITLE

APPLICANT SIGNATURE
BY
TITLE
DATE

Form RD 4279-1A
(Rev. 11-06)
Page 2 of 10

GENERAL BORROWER CERTIFICATIONS
(1) ENVIRONMENTAL CERTIFICATION
The applicant business certifies that it is in compliance with all local, state, and federal environmental laws and regulations and will continue to
comply with these laws and regulations. In addition, the applicant business certifies it has no knowledge of any environmental contamination of any
real or personal property to be pledged as collateral for the loan which violates any such laws and regulations (other than as disclosed on Form RD
1940-20, “Request for Environmental Information,” submitted in connection with this application).
(2) ASSURANCE AGREEMENT (TITLE VI, CIVIL RIGHTS ACT OF 1964)
“Recipient” herein hereby assures the U.S. Department of Agriculture (USDA) that Recipient is in compliance with and will continue to comply with
Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), 7 CFR part 15, and USDA regulations promulgated hereunder, including 7 CFR
§ 1901.202. In accordance with that Act and the regulations referred to above, Recipient agrees that in connection with any program or activity for
which Recipient receives Federal financial assistance (as such term is defined in 7 CFR 15.2) no person in the United States shall, on the grounds of
race, color, national origin, or sexual orientation be excluded from participation in, be denied the benefits of, or be otherwise subjected to
discrimination.
A.

Recipient agrees that any transfer of any aided facility, other than personal property, by sale, lease, or other conveyance of contract, shall
be, and shall be made expressly, subject to the obligations of this agreement and transferee’s assumption thereof.

B.

The Recipient shall:
(1) Keep such records and submit to the Government such timely, complete, and accurate information as the Government may determine
to be necessary to ascertain compliance with this agreement and the regulations.
(2) Permit access by authorized employees of the USDA during normal business hours to such books, records, accounts and other sources
of information and its facilities as may be pertinent to ascertaining such compliance.
(3) Make available to users, participants, beneficiaries and other interested persons such information regarding the provisions of this
agreement and the regulations, and in such manner as the USDA finds necessary to inform such persons of the protection assured them
against discrimination.

C.

The obligations of this agreement shall continue:
(1) As to any real property, including any structure, acquired or improved with the aid of the Federal financial assistance, so long as such
real property is used for the purpose for which the Federal financial assistance is made or for another purpose which affords similar
services or benefits, or for as long as the Recipient retains ownership or possession of the property, whichever is longer.
(2) As to any personal property acquired or improved with the aid of the Federal financial assistance, so long as Recipient retains
ownership or possession of the property.
(3) As to any other aided facility or activity, until the last advance of funds under the loan or grant has been made.

D.

Upon any breach or violation of this agreement the Government may, at its option:
(1) Terminate or refuse to render or continue financial assistance for the aid of the property, facility, project, service or activity.
(2) Enforce this agreement by suit for specific performance or by any other available remedy under the laws of the United States or the
State in which the breach or violation occurs.

Rights and remedies provided for under this agreement shall be cumulative.
(3) EQUAL OPPORTUNITY AGREEMENT (EXECUTIVE ORDER 11246, AS AMENDED)
“Recipient” (whether one or more) and USDA, pursuant to the rules and regulations of the Secretary of Labor (“Secretary”) issued under the
authority of Executive Order 11246, as amended, agree:
In consideration of financial assistance (whether by a loan, grant, loan guaranty, or other form of financial assistance) made or to be made by USDA
to Recipient, Recipient hereby agrees, if the cash cost of construction work performed by Recipient or a construction contract financed with such
financial assistance exceeds $10,000 – unless exempted by rules, regulations or orders of the Secretary issued pursuant to section 204 of Executive
Order 11246 of September 4, 1965:

Form RD 4279-1A
(Rev. 11-06)
Page 3 of 10

GENERAL BORROWER CERTIFICATIONS (continued)
A.

To incorporate or cause to be incorporated into any contract for construction work, or modification thereof, subject to the relevant rules,
regulations, and orders of the Secretary or of any prior authority that remain in effect, which is paid for in whole or in part with the aid of
such financial assistance, the following “Equal Opportunity clause” is required:
“During the performance of this contract, the contractor agrees as follows:
(1) The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual
orientation or national origin. The contractor will take affirmative action to ensure that applicants are employed, and that employees
are treated during employment, without regard to their race, color, religion, sex, sexual orientation or national origin. Such action
shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment
advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship.
The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by
USDA setting forth the provisions of this nondiscrimination clause.
(2) The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified
applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation or national origin.
(3) The contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other
contract or understanding, a notice, to be provided by USDA, advising the said labor union or workers’ representative of the
contractor’s commitments required by this Equal Opportunity clause pursuant to section 202(3) of Executive Order 11246, and shall
post copies of the notice in conspicuous places available to employees and applicants for employment.
(4) The contractor will comply with all provisions of Executive Order 11246, and of all rules, regulations and relevant orders of the
Secretary of Labor and of any prior authority which remain in effect.
(5) The contractor will furnish all information and reports required by Executive Order 11246, rules, regulations, and orders, or pursuant
thereto, and will permit access to the contractor’s books, records, and accounts by USDA, Office of Civil Rights, and the Secretary for
purposes of investigation to ascertain compliance with such rules, regulations, and orders.
(6) In the event of the contractor’s noncompliance with the Equal Opportunity (Federally Assisted Construction) clause or with any of the
said rules, regulations, or orders, this contract may be cancelled, terminated, or suspended in whole or in part and the contractor may
be declared ineligible for further Government contracts or Federally assisted construction contracts in accordance with procedures
authorized in Executive Order 11246, and such other sanctions may be imposed and remedies invoked as provided in Executive Order
11246, or by rule, regulation or order of the Secretary, or as provided by law.
(7) The contractor will include the provisions of this Equal Opportunity (Federally Assisted Construction) clause in every subcontract or
purchase order, unless exempted by the rules, regulations, or orders of the Secretary issued pursuant to section 204 of Executive Order
11246, so that such provisions will be binding upon each such subcontractor or vendor. The contractor will take such action with
respect to any subcontract or purchase order USDA may direct as a means of enforcing such provisions, including sanctions for
noncompliance: Provided, however, that in the event the contractor becomes involved in or is threatened with litigation with a
subcontractor or vendor as a result of such direction by USDA, the contractor may request the United States to enter into such
litigation to protect the interest of the United States.“

B.

To be bound by the provisions of the Equal Opportunity clause in construction work performed by Recipient and paid for in whole or in
part with the aid of such financial assistance.

C.

To notify all prospective contractors to file the required Form RD 400-6, “Compliance Statement,” with their bids.

D.

Form AD-425, “Contractor’s Affirmative Action Plan for Equal Employment Opportunity,” will accompany the notice of award of the
contract. Bid conditions for all nonexempt Federal and Federally assisted construction contracts require inclusion of the appropriate
“Hometown” or “Imposed” plan affirmative action and equal employment opportunity requirements. All bidders must comply with the bid
conditions contained in the invitation to be considered responsible bidders and hence eligible for the award.

E.

To assist and cooperate actively with USDA and the Secretary in obtaining the compliance of contractors and subcontractors with the
provisions of the Equal Opportunity clause and the said rules, regulations, and orders, to obtain and furnish to USDA and the Secretary,
Form AD-560, “Certification of Nonsegregated Facilities,” to submit the Monthly Employment Utilization Report, Form CC-257, as
required and such other information as may be required for the supervision of such compliance, and to otherwise assist USDA in the
discharge of its primary responsibilities for securing compliance.

Form RD 4279-1A
(Rev. 11-06)
Page 4 of 10

GENERAL BORROWER CERTIFICATIONS (continued)
F.

To refrain from entering into any contract, or extension or other modification of a contract, subject to such Executive Order with a
contractor debarred from Government contracts or Federally assisted construction contracts pursuant to part 11, subpart D, of such
Executive Order or to prior authority; and to carry out such sanctions and penalties for violation of the provisions of the Equal Opportunity
clause as may be imposed upon contractors and subcontractors by USDA or the Secretary pursuant to such subpart D.

G.

That if Recipient fails or refuses to comply with these undertakings, USDA may take any or all of the following actions: (a) cancel,
terminate, or suspend said financial assistance in whole or in part; (b) refrain from extending any further assistance under the program
involved until satisfactory assurance of future compliance has been received from Recipient; and (c) refer the case to the USDA Office of
Civil Rights Enforcement and Adjudications Program Complaint and Adjudication Division, U.S. Department of Agriculture, for
appropriate action.

(4) FEDERAL COLLECTION POLICIES FOR CONSUMER OR COMMERCIAL DEBTS
A. The recipient (borrower) certifies, acknowledges and agrees that any loss claim(s) paid by the Government to the Lender on account of any
guarantee made pursuant to this application will be a Federal debt owed to the Government by the recipient. In such a case, the Government
may use all legal collection remedies, including those under the Debt Collection Improvement Act. The Government’s right to collect this
Federal debt will not be affected by any release provided to the recipient by the Lender. Lender agrees that any collection by the Government
of this Federal debt will not be shared with the Lender.
B. The Federal Government is authorized by law to take any and all actions listed below in the event your loan payments become delinquent or
you default on your loan:


Report your name and account information to a credit reporting agency.



Assess interest and penalty charges for the period of time that payment is not made.



Assess charges to cover additional administrative costs incurred by the Government to service your account.



Offset amounts to be paid to you under other Federal programs.



Refer your account to a private collection agency to collect the amount due.



Foreclosure on any security you have given for the loan.



Pursue legal action to collect through the courts.



Report any written off debt to the Internal Revenue Service as taxable income.



If you are a current or retired Federal employee, take action to offset your salary or civil service retirement benefits.



Debar or suspend you from doing business with the Federal Government either as a participant or principal throughout the Executive
Branch of the Federal Government for a period of debarment or suspension.

(5) STATEMENT REQUIRED BY THE PRIVACY ACT
USDA is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et seq.) or other Acts administered by USDA to solicit the
information requested on USDA application forms.
Disclosure of information requested is voluntary. However, failure to disclose certain items of information requested, including your Social Security
Number or Federal Identification Number, will result in the rejection of your application.
The principal purposes for collecting the requested information are to determine eligibility for USDA credit or other financial assistance, for the
servicing of your loan, and for statistical analysis. Information provided may be used outside of USDA for the following:


To provide the basis for borrower success stories in USDA news releases.



Referral to the appropriate law enforcement agency as required by 40 FR 38924 (1975).



Referral to employees, businesses, landlords, creditors, or others to determine repayment ability and eligibility for USDA programs.



Referral to a contractor providing services to USDA in connection with your loan.



Referral to a credit reporting agency.
Form RD 4279-1A
(Rev. 11-06)
Page 5 of 10



Referral to a person or organization when USDA decides such referral is appropriate to assist in the collection or servicing of the loans.



Referral to the Treasury Department pursuant to the Debt Collection Improvement Act.



Referral to a Federal Records Center for storage.

Every effort will be made to protect the privacy of applicants and borrowers.

GENERAL BORROWER CERTIFICATIONS (continued)
WARNING
All information supplied to USDA by you or your agents in connection with your loan application may be released to interested third parties,
including competitors, without your knowledge or consent under the provisions of the Freedom of Information Act (5 U.S.C. 522).
Much information not clearly marked “Confidential” may routinely be released if a request is received for same. Further, if we receive a request for
information marked “Confidential,” the Federal Government will release the information unless you can demonstrate to our satisfaction that release
of the information would be likely to produce substantial competitive harm to your business or would constitute a clearly unwarranted invasion of
personal privacy. Also, forms, consultant reports, etc., cannot be considered confidential in their entirety if confidential material contained therein
can reasonably be segregated from other information.
Information submitted may be made available to the public during the time it is held in Government files regardless of the action taken by USDA on
your application.
(6) FEDERAL EQUAL CREDIT OPPORTUNITY ACT STATEMENT
Federal law does not allow discrimination of any kind. You cannot be denied a loan because of your race, color, religion, national origin, sex, marital
status, disability, or age (if you can legally sign a contract). You cannot be denied a loan because all or part of your income is from a public
assistance program. If you believe that you have been discriminated against for any of these reasons, you can write the Secretary of Agriculture,
Washington, D.C. 20250. You cannot be denied a loan because you exercised your rights under the Consumer Credit Protection Act. You must have
exercised these rights in good faith. The Federal Agency responsible for seeing this law is obeyed is the Federal Trade Commission, Washington,
D.C. 20580.
(7) FEDERAL DEBT COLLECTION IMPROVEMENT ACT CERTIFICATION
The loan applicant certifies that the applicant is not delinquent on any Federal debt. The applicant further certifies that no party with a 20 percent or
more ownership interest in the applicant is delinquent on any Federal debt. The loan applicant certifies and acknowledges that any amounts paid by
USDA on account of the liabilities of the guaranteed loan will constitute a Federal debt owed to USDA by the guaranteed loan borrower. In such
case, USDA may use all remedies available to it to collect the debt from the borrower.
(8) AMERICANS WITH DISABILITIES ACT STATEMENT
All areas of public accommodation must be accessible to persons with disabilities in accordance with the Americans with Disabilities Act of 1990.

Form RD 4279-1A
(Rev. 11-06)
Page 6 of 10

PART II: Completed by Lender
C. Lender Information
1. Lender Tax ID #

Shaded area for USDA use only.

2. Lender Name

3. Contact Loan Officer

Lender type?
(e.g. bank, S&L,
non-traditional, etc.)

4. Contact phone number

5. Contact fax number

6. Contact e-mail address

7. Loan Processing Office
Street Address

8. Mailing Address (if different)

9. Loan Servicing Office
Mailing Address

10. City

11. City

12. City

13. State

14. State

15. State

16. Zip Code

17. Zip Code

18. Zip Code

Date of Lender’s
Agreement

D. Loan Information (include guaranteed and unguaranteed portions, if different)
19. Loan Amount
20. Interest Rate Formula
21. Term
22. % guarantee requested
%
23. Current Int.
24. Fixed
25. If variable,
26. Installment period (e.g.,
27. Ann. debt
Rate based on
or Variable reset period
monthly, semiannual, annual)
service w/o B&I
formula
loan

Shaded area for USDA use only.

28. E. Source & Use of Funds
Purpose
Borrower
Contribution
Business Acquisition
$
Land
$
RE Improvements
$
Contingency
$
M&E
$
Working capital
$
Refinance other debt
$
Refinance lender debt
$
Rolling stock
$
FF&E
$
Coop. stock purchase
$
Origination fee
$
Guarantee fee
$
Other fees & costs
$
Other
$
Total
$
Percent contribution
%

Shaded area for USDA use only.

B&I Loan
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Other Funds (describe)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

%

OK

Reasonable rates
& terms?

OK

Total
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

%

Eligible amount?

<50% of purpose?

OK

%

Form RD 4279-1A
(Rev. 11-06)
Page 7 of 10

29. F. B&I Tangible Balance Sheet Equity

Rural Energy for America Program

The pro forma balance sheet below is an accurate presentation of the post-closing
balance sheet of the business—reflecting only business assets and liabilities, including
all proposed financing connected with this B&I loan and any assets acquired with it.
Equity cannot include appraisal surplus or subordinated debt.

Cash equity injection or fair market value of equity in real property that is
to be pledged as collateral for the loan.

Total Assets
Less Intangible Assets
Tangible Assets
(=Total Assets – Intangible Assets)
Total Liabilities
Tangible Balance Sheet Equity
(=Tangible Assets – Total Liabilities)

Pro Forma Balance Sheet
$
$
$

Cash equity:
$
Equity in real property:
$
TOTAL EQUITY: $

$
$

Total Eligible Project Cost
$
Equity percentage
(=Total Equity/Total Project
Cost)

Tangible B.S. Equity Ratio
(=Tangible Equity/Tangible Assets)

%

%

NA

NA

Shaded area for USDA use only

≥10% for existing business:
≥20% for new business:

15% Equity if loan ≤ $600,000
25% Equity if loan > $600,000

OK
OK

OK
OK

30. G. Collateral and Insurance
Collateral Schedule
Type
Description

Shaded area for USDA use only.

Source of
Value

Documented
Value
*
RE
$
*
RE
$
*
M&E
$
*
M&E
$
*
Inventory
$
*
A/R
$
*
Other
$
*
Other
$
Total
$
*Appraisal /Orderly Liquidation Value (OLV) /Cost

Discount

Prior Liens

%
%
%
%
%
%
%
%

$
$
$
$
$
$
$
$
$

Collateral Value
$
$
$
$
$
$
$
$
$

Adequate?

OK

Shaded area for USDA use only.

Proposed Insurance Coverage – with lender assignment
Type of Insurance
Insurance on:
Hazard
Key person life
Business Interruption (9006 only)

Insurance amount
$
$
$

Adequate?
Adequate?
Adequate?

OK
OK
OK

Form RD 4279-1A
(Rev. 11-06)
Page 8 of 10

Attachments: *


31. Lender's complete written analysis, including spreadsheets of the balance sheets and income statements for the 3 previous years (for existing
businesses), pro forma balance sheet at startup, and 2 years projected yearend balance sheets and income statements, with appropriate ratios and
comparisons with industrial standards (such as Dun & Bradstreet or Robert Morris Associates). All data must be shown in total dollars and also
in common size form, obtained by expressing all balance sheet items as a percentage of assets and all income and expense items as a percentage
of sales. The lender's credit analysis must address the borrower's management, repayment ability including a cash-flow analysis, history of debt
repayment, necessity of any debt refinancing, and the credit reports of the borrower, its principals, and any parent, affiliate, or subsidiary. The
Rural Energy for America Program requires 3 years of projected financial statements.



32. Lender’s proposed loan agreement. (Please refer to 7 CFR 4279-B, § 4279.161(b)(11), for guidance on minimum required content.) For
the Rural Energy for America Program, see § 4280.128(b)(2)(xii).



33. Applicant’s current (not more than 90 days old) business balance sheet.



34. Form RD 1940-20, "Request for Environmental Information," and attachments, unless the project is categorically excluded under Agency
environmental regulations. (Please contact USDA for assistance in determining what environmental information will be needed.)



35. Intergovernmental consultation comments in accordance with RD Instruction 1940-J and 7 CFR part 3015, subpart V. (Please contact
USDA for assistance in meeting your state requirements.)



36. Technical Report (Rural Energy for America Program only, see § 4280.128(b)(1)(vi) or § 4280.128(c)(1)(ii), as applicable.)

* USDA may request additional information.

Lender certifies that it has reviewed the Lender Certifications contained in this application. Lender’s signature represents the lending institution’s
certification and agreement to these certifications.
Lender certifies that it meets all criteria to be considered an eligible Lender.
Lender certifies that it has completed a comprehensive analysis of the proposal, the proposed borrower is eligible, the loan is for authorized purposes,
and there is reasonable assurance of repayment ability based on the proposed borrower’s history, projections, equity, and the collateral to be obtained.

Lender’s Name

Date

Officer’s Signature

Officer’s Title

Form RD 4279-1A
(Rev. 11-06)
Page 9 of 10

LENDER CERTIFICATIONS
(1) LOAN PROCEEDS TO AN OWNER OR CLOSE RELATIVE OF OWNER
Lender certifies that no loan proceeds will be paid to an owner or close relative of an owner, unless the party being paid is being completely bought
out in connection with the B&I or Rural Energy for America Program loan and will retain no ownership interest.
(2) DEBT REFINANCING OF LOANS OTHER THAN THOSE OWED TO THE LENDER (B&I only)
Lender certifies that the refinancing will result in improved cash flow or job creation or retention at the borrower’s business.
(3) DEBT REFINANCING OF LENDER’S OWN LOANS
Lender certifies that either (a) no loans owed to the lender are being refinanced; or (b) if loans owed to the lender are being refinanced, such loans
have been current for at least the past 12 months not due to debt restructuring, the lender is providing better rates and/or terms, and the refinance is a
secondary part of the loan.
(4) CERTIFICATION OF COMPLETE APPLICATION ON FILE WITH LENDER
Lender certifies that all documentation required by 7 CFR 4279-B, § 4279.161 (for Rural Energy for America Program, § 4280.128), has been
obtained and supports the data presented in this application.
(5) LENDER’S CREDIT ANALYSIS
Lender certifies that, after completing appropriate due diligence, it has analyzed the proposed credit and found it to be sound. A complete copy of the
lender’s credit analysis is being provided to USDA in connection with this application.
(6) BUSINESS REPUTATION & CREDIT HISTORY
Lender certifies that it has obtained a current commercial credit report on the business to be financed and its parent, affiliates, or subsidiaries and
current credit reports on all of the owners with a 20% or greater interest. The credit reports reflect good credit and indicate a history of meeting
obligations as agreed. Any exceptions are in the lender’s credit analysis and sufficiently addressed to eliminate concerns about creditworthiness.
(7) ADEQUACY OF FINANCIAL POSITION
Lender certifies that it has (a) analyzed the applicant’s balance sheets and has determined that the business has adequate solvency necessary to
succeed and to accomplish its proposed business plan; (b) analyzed the liquidity and cash flow projections of the borrower’s proposed operation, and
there is adequate working capital available to meet the needs of the business; and (c) analyzed the applicant’s historical and projected income
statements and determined that the business projections are reasonable and attainable; and (d) determined that the business has the ability to repay the
proposed B&I or Rural Energy for America Program loan.
(8) ADEQUACY OF MANAGEMENT
Lender certifies that it has assessed the qualifications, experience, and background of the applicant’s management team. The management ability is
sufficient to successfully operate the business.
(9) ADEQUACY OF COLLATERAL
Lender certifies that it has obtained appraised values and/or confirmed cost information to document that there is adequate collateral to fully secure
the proposed loan. The collateral schedule in this application is an accurate representation of the proposed collateral for the proposed B&I Rural
Energy for America Program loan.
(10) ADEQUACY OF INSURANCE
Lender certifies that the proposed insurance is adequate in accordance with 7 CFR 4279-B, § 4279.143 and for Rural Energy for America Program, §
4280.150.
(11) NO SIGNIFICANT ENVIRONMENTAL CONCERN
Lender certifies that it has completed environmental due diligence on the security property and the proposed activity to be financed. Based on this
analysis, there are no recognized environmental conditions associated with the security property that are not addressed on Form RD 1940-20,
“Request for Environmental Information.”
(12) CONFLICT OF INTEREST
Lender certifies that no officer, director, stockholder or employee of the lender has a financial interest in the borrower or vice versa.
(13) RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES
If any funds have been or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the
United States to guarantee a loan, the undersigned shall complete and submit SF-LLL, “Disclosure of Lobbying Activities,” in accordance with its
instructions.

Form RD 4279-1A
(Rev. 11-06)
Page 10 of 10

Submission of this statement is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. 1352. Any person who fails to file
the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Form RD 4279-1A
(Rev. 11-06)
Page 11 of 10

LENDER CERTIFICATIONS (continued)
(14) CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS – PRIMARY COVERED
TRANSACTIONS
This certification is required by the regulations implementing Executive Order 12649, Debarment and Suspension, 7 CFR 3017.510, “Participants’
responsibilities.” Copies of the regulations may be obtained by contacting the Department of Agriculture agency offering the proposed covered
transaction.
The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction.
The prospective participant shall submit an explanation of why it cannot provide the certification set out on this form. The certification or
explanation will be considered in connection with the department or agency’s determination whether to enter into this transaction. However, failure
of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction.
The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter
into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to
other remedies available to the Federal Government, the department, or agency may terminate this transaction for cause.
The terms “covered transaction,” “debarred,” “suspended,” “ineligible,” “lower tier covered transaction,” “participant,” “person,” “primary covered
transaction,” “principal,” and “voluntarily excluded,” as used in this clause, have the meanings set out in Definitions and Coverage sections of rules
implementing Executive Order 12649. You may contact the person to which this proposal is submitted for assistance in obtaining a copy of those
regulations.
The prospective primary participant agrees by submitting this form that, should the proposed covered transaction be entered into, it shall not
knowingly enter into a lower tier covered transaction with a person who is debarred, suspended, ineligible, or voluntarily excluded from participation
in this covered transaction, unless authorized by the department or agency entering into this transaction.
The prospective primary participant further agrees by submitting this form that it will include the clause titled “Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary Exclusion – Lower Tiered Transactions,” provided by the department or agency entering into this covered
transaction, without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
The participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not
debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A
participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may, but is not required to,
check the Non-procurement List.
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification
required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent
person in the ordinary course of business dealings.
Except for transactions authorized under paragraph 5 of this part, if a participant in a covered transaction knowingly enters into a lower tier covered
transaction with a person who is suspended, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies
available to the Federal government, the department, or agency may terminate this transaction for cause or default.
A. The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(1) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions
by any Federal department or agency;
(2) Have not within a three year period preceding this proposal been convicted of or had a civil judgment rendered against them for
commission of a fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public
transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property;
(3) Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, or local) with
commission of any of the offenses enumerated in paragraph (A)(2) of this certification; and
(4) Have not within a three-year period preceding this application or proposal had one or more public transactions (Federal, State, or
local) terminated for cause or default.
B.

Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant
shall attach an explanation to this proposal.
Form RD 4279-1A
(Rev. 11-06)
Page 12 of 10