Certification of Non-Relocation and Market Capacity Report

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Position 3

Form 4279-2
(Rev. 4-97)

FORM APPROVED
OMB NO. 0570-0017

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL BUSINESS-COOPERATIVE SERVICE (RBS)

CERTIFICATION OF NON-RELOCATION
AND
MARKET AND CAPACITY INFORMATION REPORT
(To be completed by applicant)
This form is to be executed by applicants for financial assistance for loan guarantees or grants under provisions of the Consolidated Farm and Rural
Development Act.
1. Name of Applicant:
1a. Employer ID No.
2.

Name of Benefited Business or Industry:

2a. Employer ID No.
2b. Labor File No.

3.

Location of Proposed Project:

4.

5.

This Project is:
A new business venture
A new branch or facility
An expansion of an existing facility
Affiliate or Subsidiary of

6.

Amount of Loan or Grant:

7.

Purpose of Loan or Grant - (Specify)

8.

a.

Refinance of Existing Loan
A Transfer of Ownership
Other (Explain)

Information about your products or services: (NOTE: Describe each principal product or service to be furnished through this project. Do
not list products or services already being offered unless this project also offers them and they are essentially an expansion of past
activities. Enter in Column 6 the same information as provided in Column 4 except it should relate to employment at full capacity. Be
specific. For example, ''MANUFACTURE FURNITURE-OFFICE-WOOD DESKS''.

Principal
Product

Products or Services
and S.I.C. Number

Col. (1)

(2)

Projected Annual Sales and Average Employment to
be Generated by each product:
Latest Annual Total
At Full Capacity
Sales
Employment
Sales
Employment
(3)

(4)

(5)

(6)

Product #1
S Value
In Units
Product #2
S Value
In Units
Product #3
S Value
In Units
Product #4
S Value
In Units
According to the Paperwork Reduction Act of 1995, no persons are 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. The time required to complete this information is estimated to average 2 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.

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b.

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Principal Occupations:

Occupational Job Title
Col. (1)

9.

a.

(2)

(3)

(4)

(5)

INFORMATION ABOUT YOUR MARKET List below, for each principal product or service, the states in which you expect to make the
greatest part of your sales. You need list only those states in which you expect to sell at least 5 percent of your volume. If your sales are
nationwide, enter the word ''NATIONAL'' in the right hand column. If more than 5 percent of your total projected sales are to be in any
standard metropolitan statistical area (for example, Chicago and its nearby suburbs), enter the name of the area. If possible, give the
approximate percentage of your total sales which you expect to make in the states and metropolitan areas listed. (See sample entry in the table
below.)

Principal Product
or Service
(Sample entry)
Product ''X''

10.

Average Employment and Wage Rates
Current Period
When Fully
Operational
Average
Average
Employment
Wage Rate
Employment
Wage Rate

States and Standard Metropolitan Statistical Areas in Which Sales Are Projected
Chicago (8%)
Kentucky (15%)

Indiana (12%)
Iowa (20%)

Wisconsin (20%)
Nebraska (10%)

INFORMATION ABOUT YOUR COMPETITORS Please list the principal competitors offering the same or similar service or manufacturing
a similar or identical product, regardless of where they are located, but only those who are selling in the market area you have indicated in
section 9 above, where you intend to sell. Also indicate the location of your competitor's plants from which he is most likely to be serving your
market area. If your market is national, omit a listing of competitors shipping points.
NOTE: In terms of the following listing, a competitor should be considered an enterprise offering essentially similar services or products.
Thus, a summer resort providing golf, swimming and tennis is not competitive with a winter resort offering only skiing and skating. By the
same token, gypsum board or particle board are not considered competitive with plywood, nor wood furniture with metal furniture. Names of
Competitors
Location of plants serving market (Include street,
city, state and zip code).
1.
2.
3.
4.

b.

5.
To the best of your knowledge, has any competitor recently ceased operations or withdrawn from your market area? Give name and state
reason, if known.

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C.

Are you aware of any potential new entries or planned expansions which will be competitive in your market area? If known, describe by name
and location.

11.

Applicant must check one of a, b, or c below: (NOTE: ''Related Company'' as used in this form means any affiliate, subsidiary, or other
business entity under direct, indirect or common control with applicant.)
a. New Business Venture. This project is a new business venture unrelated to existing business facilities, and that the applicant is not a
company related to an existing business facility. (NOTE: If applicant or a related company has ceased or substantially reduced operations
during the 24 months preceding the date of this request, the information required by Section 12 below must be attached.)
b.

Expansion of Applicant's Only Business Facility. This project is an expansion of an existing business facility located at:

Which carries on the following operations-

c.

12.

Applicant or Related Company with Business Facility at Another Location. Applicant has attached
pages
containing the information required by section 12 of this form concerning business operations conducted by the Applicant or by a
related company at other locations than the location of the proposed project. Applicant has included business operations which have
ceased or have been substantially reduced during the 24 months preceding the date of this request if such operations were conducted
by Applicant or a related company.
It is not the intention of the Applicant or any related company to relocate any present operation as a result of the proposed Project-,
that to the extent said Project is undertaken to assist in the expansion of the operations of Applicant through the establishment of a
new branch, affiliate or subsidiary of Applicant, such expansion will not result in an increase of unemployment in the area of original
location or in any area where Applicant or any related company now conducts related business operations, that any such expansion is
not being undertaken with the intention of closing down or curtailing any existing operations of Applicant or of any related company,
and that such Project is not being undertaken with the intention of performing as contractor or subcontractor work heretofore
performed by Applicant or a related company, the transfer of which work would result in the transfer of employment opportunities
from one location to another and an increase in unemployment at the previous location of such work.
I agree further that if within one year of the commencement of operations of the Project for which the United States Department of
Agriculture (USDA) has made a grant, loan, or guarantee, there should occur a significant and related decline in employment in a
present location or locations conducted by Applicant or a related company, the lender, pursuant to instructions from USDA, shall
liquidate the loan or accelerate the repayment of any financial assistance guaranteed, insured, or provided by USDA. I understand
that there shall arise a rebuttable presumption that a decline in employment in a present location or locations is significant and related
to USDA assistance to the Project, if the reduction in average employment in present facilities and location is equal to (a) 50% for all
locations or (b) 25% for one location, of the level of employment in this USDA assisted Project. These understandings and
agreements are applicable to all transferees and successors in interest.

The information required by this section must be supplied if Applicant or a related company now conducts business operations at a location
other than the location of the proposed Project, or if Applicant or a related company has ceased or substantially reduced operations within the
24 months preceding the date of this application. A separate sheet of paper should be used for each location. Give the following information:
(1) Name of company, (2) Full address of site on which business operations are or were conducted, (3) Relationship of Applicant to business
entity conducting operation, (4) Brief description of articles produced or services provided at location, (5) Underline production articles or
services provided which are similar to articles to be produced or services to be provided by the proposed Project, (6) Average number of
persons employed at the location, (7) Average number of persons employed in production of articles or services similar to those provided by
the proposed Project, (8) If applicable, date on which operations ceased, or were substantially reduced, and (9) If applicable, the size of the
reduction.

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13.

Please give below name, address, telephone number and title of person to be contacted if any questions arise concerning this form.

14.

CERTIFICATION: I, hereby certify that the information reported on this form, and any attachments to this form, are to the best of my belief
and knowledge, truly representative of the facts and reflect the future intentions of the Applicant as of this date:

(Date)

(Signature of authorized official)

(Title)

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