Form RGI10 Request for Loan Guarantee or Insurance

IA Form RGI10 OMB Control No. 1076-0020

Revised March 2010 Expires: ________

Request to the Department of the Interior

for Loan Guarantee, Loan Insurance, and/or Interest Subsidy

Lender: ___________________________ Request is for:

Address: ___________________________

___________________________  Loan Insurance

___________________________ (See 25 CFR § 103.13))

___________________________

 Loan Guarantee

Telephone: ___________________________

Contact: ___________________________  Interest Subsidy

Pursuant to the Loan Guaranty, Loan Insurance and Interest Subsidy Program, 25 U.S.C. §§ 1481 et seq., 1511 et seq., and 25 CFR Part 103 (the “Program”), the Lender requests the United States Department of the Interior (“Department”) to guarantee, insure, and/or provide interest subsidy for the following loan:

Borrower: ___________________________ Original Amount of Loan:

Address: ___________________________ $______________________________

___________________________

___________________________ Proposed Interest Rate:

_______________________________

Telephone: ___________________________

Contact: ___________________________ Payment Schedule and Maturity:

_______________________________

Loan Purpose: _______________________________

________________________________________

________________________________________ Proposed percentage to be

________________________________________ guaranteed or insured:

________________________________________ _______%

Does the Lender have a Loan Guarantee Agreement or Loan Insurance Agreement in effect, under which to consider this request?

 Yes. Loan Guarantee Agreement dated:_________________, 20____.

Loan Insurance Agreement number __________________, dated ___________________, 20___.

 No. The Lender will have to enter into an appropriate agreement with the Department before the Department will consider this request.

Please complete the application as indicated Lender:_________________________

in 25 CFR Part 103. Upon completion, please

submit it to a Department official responsible

for the Borrower’s business location. If By:_____________________________

requesting interest subsidy, please provide Its:_____________________________

a specific analysis of the factors set forth in

25 CFR § 103.20. Date of Request:

________________________, 20____

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to provide basic information concerning the applicant’s eligibility for and intended use of Federal program benefits. The information is provided by respondents to obtain or retain a benefit. In compliance with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and an expiration date. The number and expiration date are at the top right corner of the form. An agency may not sponsor or conduct, and a person is not required to respond to, a request for information collection unless it displays a currently valid OMB Control Number. The public reporting burden is estimated to average 2 hours per respondent. This includes the time needed to understand the requirements, gather the information, complete the form, and submit it to the Department. Comments regarding the burden or other aspects of the form may be directed to the Indian Affairs Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.

Privacy Act Statement (5 U.S.C. 552(a)): The authority for collecting this information is 25 U.S.C. 1511. The information will be used to administer the Loan Guarantee, Insurance and Interest Subsidy Program, 25 U.S.C. 1481 et seq. Disclosures of this information may be made to track and record payments and unpaid balances and provide information on payments made for paying interest subsidy, credits obtained, service loans made, and premiums paid by

Lenders, and for the other routine uses described by system of record notice, BIA-13, Loan Management and Accounting System.