Form DOT 2301-1 (Rev.1) DOT 2301-1 (Rev.1) Short Term Lending Program (STLP) Application for Loan G

	U.S. Department of Transportation Short Term Lending Program (STLP) Application for Loan Guarantee							OMB Approval Number: 2105-0555 Expiration Date: MM/DD/YYYY Form DOT 2301-1
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. Public burden reporting for this collection of information is estimated to be 120 minutes per response including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information 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, 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.
PART A - APPLICANT BUSINESS AND CONTACT INFORMATION
Full Legal Name of Business:			TIN (Federal Tax ID No):				a. Dun & Bradstreet (DUNS) #: b. NAICS Code(s):
Full Street Address, City, State, and Zip Code of Primary Business Location:				County:					Fax Number:
Primary Business Contact Name:		Primary Contact Telephone:				Primary Contact Email Address:
Legal Structure of Business: a. Sole Proprietorship b. LLC c. LLP d. General Partnership e. Corporation f. S. Corporation g. Other					Date Business Established:
					Business Website:

Doing Business As (DBA) Name(s):

Number of Employees At Time of Application:

I f Application is Approved: a . Number of Employees Retained b . Number of Employees Created c. Total Employees

Rev. 5/12 OPI:  Office of Small Disadvantage Business Utilization

Brief Description of Goods and/or Services Provided by the Business:				Is the Business Bonded? Yes No
Business’s Bank or Lender:	Lender Contact Person:		Lender Officer’s Phone Number:
PART B - ELIGIBLE SMALL BUSINESS CERTIFICATION(S)
Disadvantaged Business Enterprise (DBE) Certification: The definition of a DBE, which includes woman-owned businesses and minority-owned businesses, is set forth in Title 49 Code of Federal Regulations, Parts 23 and 26. Name of Transportation Agency which Certified your Business as a DBE: _________________________________________ b. State: _____ c. Original Certification Date:_______________ d. Current Renewal or Annual Affidavit Date: _____________
Other Eligible Federal Government Certification:
a. Section 8(a)		YES			NO
b. Small Disadvantaged Business (SDB)		YES			NO
c. Historically Underutilized Business Zone (HUBZone)		YES			NO
d. Service-Disabled Veteran-Owned Small Business (SDVOSB)		YES			NO

		U.S. Department of Transportation Short Term Lending Program (STLP) Application for Loan Guarantee			OMB Approval Number: 2105-0555 Expiration Date: MM/DD/YYYY Form DOT 2301-1
PART C - TRANSPORTATION-RELATED CONTRACTS TO BE FINANCED WITH STLP LINE OF CREDIT
Transportation-Related Contracts to be Financed with the STLP Line of Credit: The Transportation-Related Contract(s), Subcontract(s), Service Agreement(s), Work Order(s) and/or Task Order(s) supporting the STLP line of credit application will be the first source of loan repayment, the primary loan collateral, and must be assigned to the lender, along with the receivables and other monies due under the contracts. "Transportation-Related" means that the Scope of Work pertains to a transportation project for the maintenance, rehabilitation, restructuring, improvement, or revitalization of any of the nation's modes of transportation; and that the transportation project is funded in whole, or in part, with funds from the U.S. Department of Transportation. If additional space is needed, please attach a separate page with this information to the application package.
a. Project Name			b. Contract Number			c. Contract Amount
1						$
2						$
3						$
4						$
5						$
6						$
7						$
d. Total amount of transportation contracts:						$
PART D - BUSINESS DEBT SCHEDULE
Outstanding Business Debt: List All Current Outstanding Business Debt Below.

	a. Name of Creditor	b. Original Loan Date (MM/DD/YYYY)	c. Original Loan Amount or Line Limit	d. Current Balance	e. Maturity Date (MM/DD/YYYY)	f. Security or Collateral Pledged
1			$	$
2			$	$
3			$	$
4			$	$
5			$	$
6			$	$
7			$	$

U.S. Department of Transportation Short Term Lending Program (STLP) Application for Loan Guarantee

OMB Approval Number: 2105-0555 Expiration Date: MM/DD/YYYY Form DOT 2301-1

PART E – CURRENT AND PREVIOUS FEDERAL DEBT AND ASSISTANCE

24. Current and Previous Federal Government Debt (Leave Blank if Not Applicable): Complete the section below if; 1) the business or any of its principal owners has ever received any financial assistance from the Federal Government; or 2) the business or any of its principal owners currently owes any Federal taxes for prior years. Debts owed to the Federal Government by either the business or its principal owners must be current and in good standing to be eligible for an STLP loan guarantee. If the business or any of its principal owners currently owe any delinquent Federal taxes, there must be an approved federal tax installment repayment plan in place and repayment must be in good standing. If additional space is needed, please attach a separate page with this information to the application package.

	a. Name of Government Agency	b. Purpose of Loan	c. Date of Loan (MM/DD/YYYY)	d. Original Loan Amount	e. Current Balance	f. Past Due Amount	g. Settlement / Workout Plan – Date Approved (MM/DD/YYYY)
1				$	$	$
2				$	$	$
3				$	$	$
4				$	$	$
5				$	$	$
6				$	$	$

25. Previous Declined Applications for Assistance (Leave Blank if Not Applicable): Complete the section below if the business or any of its principal owners has ever applied for, but did not receive, any direct or guaranteed financial assistance from a lender.

	a. Name of Loan Program	b. Type of Assistance	c. Date of Application (MM/DD/YYYY)	d. Amount Applied for	e. Reason for Decline
1				$
2				$
3				$
4				$

	U.S. Department of Transportation Short Term Lending Program (STLP) Application for Loan Guarantee	OMB Approval Number: 2105-0555 Expiration Date: MM/DD/YYYY Form DOT 2301-1
PART F – MANAGEMENT INFORMATION AND OWNERSHIP INTEREST
Management Information/Ownership Interest: Part F must be completed by all individuals or business entities that own at least 20% or more of ownership in the business. If more than one person or business has an ownership interest, copy this page, Part F and complete it for each owner. Attach each of the additional Part F responses to the application package.

a. Name:

b. Position or Title:

c. Complete Address:

d. % Owned:

e. Annual Compensation Amount:

6. List the percentage of ownership to total 100% below.

	(1) Name	(2) Email address	(3) Ownership %
1
2
3

Have you or any of your other businesses ever defaulted on any direct or guaranteed financial assistance from the Federal Government, including student loans or disaster loans, or Federal Taxes? If yes, please explain on a separate sheet of paper and attach any supporting documentation to the application:
Yes No
Are you past due on any federal, state, or local taxes? If yes, please explain on a separate sheet of paper and attach any supporting documentation from the taxing agency to the application:
Yes No
Are you past due on any liabilities, other than federal, state, or local taxes? If yes, please explain on a separate sheet of paper and attach any supporting documentation to the application:
Yes No
Are there currently, or has there ever been, any bankruptcy proceedings, insolvency proceedings, lawsuits, or judgments against you? If yes, please explain on a separate sheet of paper and attach any supporting documentation to the application:
Yes No
Are you delinquent on any obligation to pay child support arising by an administrative order; a court order; a repayment agreement; or a repayment agreement from a State agency with child support enforcement services?
Yes No If “Yes”, how many months delinquent: _______________

	U.S. Department of Transportation Short Term Lending Program (STLP) Application for Loan Guarantee	OMB Approval Number: 2105-0555 Expiration Date: MM/DD/YYYY Form DOT 2301-1
PART G – AGREEMENTS AND CERTIFICATIONS
Certifications and Signature READ THE FOLLOWING STATEMENT CAREFULLY. If the Applicant knowingly makes a false statement on this form or on any of the application attachments and materials, this act is a violation of Federal Law and punishable under Title 18 USC §1001. A false statement may be subject to imprisonment of not more than 5 years and may be fined under this Title. If this application is submitted to a federally insured institution, under Title 18 USC §1014 imprisonment of not more than 30 years and/or a fine of not more than $1,000,000 may be imposed. In submitting the foregoing application, the undersigned certifies that the facts stated and the certifications and representations made in this application are true, to the best of the applicant’s knowledge and belief after due inquiry, with the intent that this information may be relied upon by a STLP Participating Lender and by the U.S. Department of Transportation in extending credit to undersigned; and it warrants that the undersigned has not, knowingly, withheld any information that may affect its credit evaluation; and the undersigned expressly agrees to immediately notify said lender and the U.S. Department of Transportation, in writing, of any material change in its program eligibility and/or financial condition. I/we authorize the U.S. DOT to have its agent, the Participating Lender, to conduct such credit and personal history report and information checks about me/us as may be needed in order for the lender to carry out its fiduciary responsibilities and such other due diligence as may be necessary for the purpose of determining my/our eligibility for the programs authorized by the U.S. DOT and its Office of Small and Disadvantaged Business Utilization under 49 U.S.C. 332. I waive all claims against the DOT and its consultants for any management and technical assistance that may be provide In consideration for assistance from the DOT, I hereby agree that I will comply with all Federal laws and regulations to the extent that they are applicable to such assistance, including conditions set forth in this application. I certify that: No one connected with the Federal Government has been paid for help in getting this loan. I/we also agree to report to the U.S. DOT Office of the Inspector General, Washington, DC 20590, any Federal Government employee who offers, in return for any type of compensation, help in getting this loan approved. No overlapping relationship exists between the business, including its principals, and the Participating Lender that could create the appearance of a conflict of interest as defined in 13 CFR 120.140 or violate 13 CFR 120.851. No such relationship existed within six months of this application or will be permitted to exist while assistance is outstanding. No principal(s) in the business, their spouses, or any other member of their household(s), or anyone who owns, manages, or directs the business, their spouses, or other members of their household do not work for the DOT or the Participating Lender. The business, or any of its principals, are not currently, nor have been in the preceding three years: 1) debarred, suspended, or declared ineligible from participating in any Federal program; 2) formally proposed for debarment, with a final determination still pending; 3) voluntarily excluded from participation in a Federal transaction; or 4) indicted, convicted, or had a civil judgment rendered against it for any of the offenses listed in the Regulations Governing Debarment and Suspension (Government-wide Non-procurement Debarment and Suspension Regulations: 49 C.F.R. Part 29).

28. Certifications and Signature (Continued) I certify that: This business complies with, and/or will comply with, all provisions of Title VI of the Civil Rights Act of 1964 (42U.S.C 2000d et seq.) To the best of his or her knowledge and belief, that: No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any Federal contract grant, loan, or cooperative agreement. If any funds other than Federal appropriated funds have been paid 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 Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form - LLL, "Disclosure of Lobbying Activities" in accordance with its instructions. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 21, U.S. Code. Any Person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. The undersigned is an authorized representative of the applicant. BY: Signature ___________________________________ Title: ___________________________ Date: ____________________ Print Name: _________________________________
PART H – GUARANTOR(S)
	Guarantor(s) Each individual Business Owner, whether a proprietor, member, partner, corporate officer, or other owner, that has a 20% or more interest in the Applicant Business must personally guarantee this loan. By signing below, the following individual(s) agree to this requirement. Signature ___________________________________ Date: ____________________ Print Name: _________________________________ Signature ___________________________________ Date: ____________________ Print Name: _________________________________ Signature ___________________________________ Date: ____________________ Print Name: _________________________________ Signature ___________________________________ Date: ____________________ Print Name: _________________________________

General Instructions

Purpose of Form

Use Form 2301-1 Application for Loan Guarantee, OMB Control Number 2105-0555, to apply for a U.S. Department of Transportation (DOT) loan guarantee under its Short Term Lending Program (STLP) from one of DOT’s STLP Participating Lenders. The STLP is a short term (usually one year) revolving line of credit made to eligible businesses.

Who is Eligible for the Guarantee?

To be eligible, the business must:

• Be a for-profit entity;

• Be certified as a Disadvantaged Business Enterprise (DBE) by authorized state or local transportation agency

OR

Be certified by the SBA as a Section 8(a) or Historically Underutilized Business Zone (HUBZone) firm; or as a Small Disadvantaged Business (SDB) or Service-Disabled Veteran-Owned Small Business (SDVOSB);

• Have proven track record in its industry (start ups are not eligible for the STLP);

• Be current on all Federal, state, and local tax liabilities; or have an approved repayment plan in place, and demonstrate compliance with the plan;

• Demonstrate an eligible use for the desired credit.

How do I Obtain More Information?

You can contact the U.S. Department of Transportation, Office of the Secretary, Office of Small and Disadvantaged Business Utilization for further information.

Voice. 1-800-532-1169 or 202-366-1930. A long-distance charge to callers located outside of the local calling area will apply when calling the 202-366-1930 number.

Or you may obtain direct assistance, please contact the Small Business Transportation Resource Center (SBTRC) that serves your state. A complete list of SBTRCs, the states that each center serves, and the local contact information is found at http://www.osdbu.dot.gov/regional/index.cfm.

Internet Guidance. Further information on the STLP is located at http://www.osdbu.dot.gov/financial/stlp.cfm.

How to Apply

You must apply directly with one of the STLP Participating Lenders, which are listed on the internet website. However, we strongly urge you to contact the SBTRC that serves your state prior to submission of your request to request assistance with the application package and supporting documentation.

If you are unable to apply directly with one of the STLP Participating Lenders, you may submit your application package to DOT for its assistance in determining your eligibility and identifying a Participating Lender. Please note that not all geographical areas are currently covered by Participating Lenders; and DOT may not be able to identify one, based upon your business location.

Mail. Mail your signed application and all supporting documentation to the following address:

U.S. Department of Transportation

Office of Small and Disadvantaged Business Utilization

ATT: Manager, Financial Assistance Division

1200 New Jersey Ave., SE, W56-493

Washington, DC 20590

How to Assemble Your Application

Your STLP Application must contain the following documentation in order to be submitted for consideration:

• A completed and signed Form 2301-1 Application for Loan Guarantee. All parts must be completed.

• Additional information in the form of attachments for Parts C, D, E, and F if applicable. Please label each attachment with the corresponding Part letter.

• All of the requested information listed and described in the following STLP Application Instructions and Checklist for Supporting Documents

• Please assemble your STLP Application Package with the forms and checklist items presented in the order listed on the STLP Application Instructions and Checklist for Supporting Documents .

STLP Application Instructions and Checklist for Supporting Documents

1. _____ Completed Short Term Lending Program (STLP) Application for Loan Guarantee (Form 2301-1) must be signed and dated by an authorized representative of the business.

2. _____ Business Formation Documents. Include a copy of the Articles of Incorporation; Partnership Agreement; Articles of Organization; or any other recognized legal document which legally established the business. Note: This is only submitted on the first year application; renewal applicants do not submit unless there is a change in the business formation.

3. _____ Company History and Statement of Expected Benefits. Incude a brief narrative describing the history of the business as well as a statement regarding the expected impact on your business should the STLP loan be approved (can include business capacity statement or business plan). Please be sure to include information regarding the number of employees that the business is expected to retain or newly hire is documented on the application.

4. _____ Bonding Documents (If Applicable). If the business checked “Yes” in Part A, when asked if the business was bonded, provide a copy of the current bonding capacity letter from the agent and/or the specific performance and/or payment bonds directly related to the transportation contracts.

5. _____ Eligible Business Certification. A business must be currently certified as a Disadvantaged Business Enterprise (DBE), Section 8(a), Small Disadvantaged Business (SDB), Historically Underutilized Business Zone (HUBZone), or a Service Disabled Veteran-Owned Small Business (SDVOSB) to be eligible for an STLP Loan Guarantee. Provide the business’ current DBE Certification and/or other eligible SBA Certification. Provide the original certification letter and the most current annual affidavit or letter attesting to continued program eligibility.

6. _____ Transportation-Related Contract(s), Subcontract(s), Service Agreement(s); Work Order(s); and/or Task Order(s). Include a complete and signed copy of the Transportation-Related Contract(s), Subcontract(s), Service Agreement(s), Work Order(s) and/or Task Order(s), collectively referred to as “Contracts”, supporting the STLP line of credit application. These contracts are listed in Part B of the application form, and they will be the primary loan collateral and assigned to the Lender. The STLP loan will fund approved invoices from these contracts. "Transportation-Related" means that the Scope of Work pertains to a transportation project for the maintenance, rehabilitation, restructuring, improvement, or revitalization of any of the nation's modes of transportation; and that the transportation project is funded in whole, or in part, with funds from the U.S. Department of Transportation. You shall provide a copy of every contract listed in Part B of the application.

7. _____ Work in Progress (WIP) Schedule. Provide a current Work in Progress Schedule or Statement to list all jobs that your business currently has under contract. This schedule can also include contracts that may not have been listed in Part B of the application. At a minimum, this schedule should include the following information: Contract owner, project name, contract amount, start date, percentage completed and billed amounts, collected amounts, and estimated completion date.

8. _____ Completed Contracts. Provide a list of all completed contracts during the past 12 month period. At a minimum, list the contract owner, project name, total contract amount, and completion date. These contracts should represent projects that your business has successfully completed.

9. _____ References. Provide at least two (2) Performance Reference Letters relating to your business' performance on existing or prior contracts. (You can include copies of emails and performance reviews.) Include at least one (1) Financial Reference Letter relating to the applicant's handling of trade accounts, credit, or bank loans. It is a good business practice to keep these references current within the past six months of the date of the application submittal.

10. _____ Business Financial Statements. Include a complete copy of Financial Statements for previous three (3) fiscal years. These statements should be compiled by an independent CPA firm and include the accountant’s cover letter, the Balance Sheet, the Profit & Loss or Income Statement, any and all additional CPA statements and schedules, and any and all accompanying CPA notes. Loan Renewals will only require updated information from last application date.

NOTE: If the STLP Loan Guarantee request is for $250,000 or greater, the statements should be compiled by an independent CPA firm. If the STLP Loan Guarantee request is for $500,000 or greater, the statements should be reviewed by a CPA firm.

STLP Application Instructions and Checklist for Supporting Documents (Continued)

11. _____ Interim Business Financial Statements (If Applicable). Interim Business Financial Statements are required if the business' year-end statements (previous checklist number) are older than 90 days at the time of loan application. Include a current year-to-date Balance Sheet and a current year-to-date Income Statement with a same month-end date, no older than 90 days.Include Interim Business Financial Statements if the period between the application date and the end date of the business’s last fiscal year is longer than 90 days. They should be prepared in Generally Accepted Accounting Principles (GAAP) format.

12. _____ Aging Reports of Both Receivables and Payables. Include Aging Reports of both Receivables and Payables that correspond to the last fiscal year’s Financial Statements submitted in Checklist Number 10 OR if the business must submit Interim Financial Statements, identified in Checklist Number 11, include Aging Reports for both Receivables and Payables as of the date of the Interim Financial Statements.

13. _____ Business Cash Flow Projection. Provide a Business Cash Flow projection covering the term of the requested loan. This report must show, on a monthly basis, total anticipated revenues from both transportation and non-transportation related contracts, as well as any other projected contract revenue; the associated cost of goods and services (direct costs), general and administrative operating costs, net monthly cash flow, and anticipated advances and repayment on the proposed STLP Line of Credit.

14. _____ Business Federal Tax Returns. Include a complete copy of the business Federal Tax Returns for the previous three (3) fiscal years. Loan Renewals will only require updated information from last application date. If an extension has been requested from the IRS for the most recent fiscal year, provide a copy of the extension form.

15. _____ Business Federal Taxes Are Current and in Good Standing. Debts owed to the Federal Government by either the Business or its principal owners must be current and in good standing to be eligible for an STLP loan guarantee. Provide documentation that the business has: 1) paid its Federal Taxes in full; or 2) applied for or received an approved federal tax installment repayment plan. If the business does have an approved federal tax installment repayment plan, attach evidence that the business is current with its payments.

For each Principal Owner of the applicant business (an owner with 20% or more interest in the business), submit the following information:

16. _____ Personal Financial Statements. Include a current Personal Financial Statements (PFS) of the Principal Owner(s), dated within 90 days at the time of application. The Personal Financial Statement shall be dated and signed by the owner(s). The PFS should list all personal assets and liabilities and should include detail schedules. The Small Business Administration (SBA) Form 413 Personal Financial Statement, or an equivalent PFS provided by a lending institution, is acceptable SBA and may be used.

17. _____ Personal Federal Tax Returns. Include a complete copy of personal Federal Tax Returns for the previous three (3) years for each Principal Owner. Loan Renewals will only require updated information from last application date.

18. _____ 20% or More Interest in Other Businesses. For each business listed in “Part F– Any individual or business, include the most recent fiscal year of Financial Statements and/or Federal Tax Returns for that business.

19. _____ Owner(s) Résumé. Provide a current résumés for each Principal Owner of the business.

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 application 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 wholly or partially funded by DOT. The principal purpose for which the information will be used is to evaluate the eligibility of the application for the U.S. DOT STLP. The loan application guarantee request cannot be processed unless the data is complete. Disclosures of name and other personal identifiers are required for a benefit, as DOT requires an individual seeking assistance from DOT to provide sufficient information for the Participating Lender to evaluate the risk of a loan application. In making loan guarantees pursuant to Title 49 U.S.C. 332(b)(3)(4)(5), DOT is required to have reasonable assurance that the loan is of sound value and will be repaid or that is in the best interest of the Government to grant the assistance required. Routine uses of records maintained in the system include: processing of your loan application by authorized Office of Small and Disadvantaged Business Utilization (OSDBU) personnel and recording in the Grant Information System. Contact information will be used to request information omitted in the application package or to request clarification of information submitted to the Participating Lenders to make the loan recommendations. Routine uses of records maintained in the system include the processing, review, and final approval of a loan guarantee by the DOT to a Participating Lender who will directly process, close, service, monitor, and administer the loan. Other possible routine uses of information are published in the Federal Register at 65 F.R. 19476 (April 11, 2000) under “Prefatory Statement of General Routine Uses.” Furnishing the information requested on this form is voluntary, but failure to provide all or part of the information may delay or prevent the processing of your application.

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