Form 490 Application for Telecommunications Loan & Loan Guarantee

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 0572-0079. The time required to complete this information collection is estimated to average 30 minutes 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.

Form Approved
0572-0079
Expires 9/30/16

U.S. Department of Agriculture
Rural Utilities Service

APPLICATION FOR TELECOMMUNICATIONS
LOAN OR LOAN GUARANTEE
INSTRUCTIONS - Prepare two copies of this form. For further information, see 7 CFR 1735 and 7 CFR 1737.
1. NAME AND ADDRESS OF BORROWER (Street, City, State, Zip Code)

2. TYPE OF ORGANIZATION (Check one)

3. INDICATE THE LOAN MATURITY BEING REQUESTED (Check one)
a.
b.

a.

COMMERCIAL CORPORATION

b.

COOPERATIVE OR MUTUAL

C.

PUBLIC BODY

4. AMOUNT OF LOAN APPLIED FOR:

YEARS (Maximum of 35),
COMPOSITE ECONOMIC LIFE OF FACILITIES FINANCED PLUS 3 YEARS.

5. NUMBER OF EXCHANGES:

6. NUMBER OF SUBSCRIBERS:

a. IN EXISTING SYSTEM

a. IN EXISTING SYSTEM

b. TO BE FINANCED BY THIS LOAN

b. TO BE ADDED DURING FORECAST PERIOD ...

7. PURPOSE OF LOAN (Explain the purposes for which loan funds are intended and state the amount required for each purpose.)

FEDERAL DEBT DELINQUENCY CERTIFICATION
YES (If Yes, provide explanatory information below.)
8. IS THE BORROWER DELINQUENT ON ANY FEDERAL DEBT? (Check one)
NO
NOTE: Examples of debts include, but are not limited to, delinquent taxes, guaranteed or direct government loans (more than 31 days past due), and other administrative
debts.

APPLICANT CERTIFICATION
FEDERAL COLLECTION POLICIES FOR COMMERCIAL DEBT

The Federal Government is authorized by law to take any or all of the following actions in the event that a borrower's loan payments become delinquent
or the borrower defaults on its loan: (1) Report the borrower's delinquent account to a credit bureau; (2) Assess additional interest and penalty charges for
the period of time that payment is not made; (3) Assess charges to cover additional administrative costs incurred by the Government to service the
borrower's account; (4) Offset amounts owed to the borrower under other Federal programs; (5) Refer the borrower's debt to the Internal Revenue Service
for offset against any amount owed to the borrower as an income tax refund; (6) Refer the borrower's account to a private collection agency to collect the
amount due; and (7) Refer the borrower's account to the Department of Justice for litigation in the courts.
All of these actions can and will be used to recover any debts owed when it is determined to be in the interest of the Government to do so.

CERTIFICATION

I have read and understand the actions the Federal Government can take in the event that I fail to meet my scheduled payments in
accordance with the terms and conditions of my agreements and certify that the information contained herein is accurate and complete
to the best of my knowledge and belief.
SIGNATURE OF AUTHORIZED OFFICIAL

RUS Form 490 (Rev. 09-2003)

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