3575-1 Application for Loan and Guarantee

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

Form RD 3575-1
(6-00)

Form Approved
OMB No. 0575-0137

APPLICATION FOR LOAN AND GUARANTEE
Community Facilities Program

Water and Waste Disposal Programs

PART A - Guarantee Request:
Loan Amount $

Percent of Guarantee Requested

Proposed Interest Rate

%

%

Repayment Term

Yrs.

If Rate is Variable, Provide Index and

Variable or Fixed?

Frequency of Adjustments

PART B - Lender Information:
Tax ID Number:

Name:

Date organized:

Address:
Zip
Contact Person:

Phone:
Fax:
Contact's Extension:

PART C - Organization Information:
Tax ID Number:
Name:

Date organized:

Address:

Phone:
Zip

Contact Person:

Fax:
Contact's Extension:

Part D - Facility Information:
NAICS CODE (RHS only):
Name:

County:

Address:

Date Established:
Zip

Contact Person:
Population of
city, town, etc.
PART E - Project Purpose & Funding
Purchase Land
Real Estate Improvements
Furnishings
Equipment
Debt Restructuring
Initial O&M
Professional Fees
Lender & Guarantee Fees
Working Capital
Other
TOTAL PROJECT

Phone:
Fax:
Contact's Extension:
Population Served:

Project
Budget

Guaranteed
Loan

$0

Other
Funding

Owner
Funds

$0

$0

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 0575-0137. The time required to complete this information collection
is estimated to average 10 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.

PART F - Attachments

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The Lender must attach the following supporting documentation:
1. Current and previous year's financial and income statement.
2. Operating budget for current operating cycle.
3. Narrative statement describing organization's services, scope of operation, and geographical area served, including any proposed
management agreements or leases.
4. Financial feasibility analysis and projected budgets.
5. Preliminary construction plans and cost estimates (including contingency fund).
6. Intergovernmental review and State clearinghouse comments or recommendations (when available).
7. For Community Programs loans - Form RD 1940-20, "Request for Environmental Information," with attachments. When
applicable, FEMA Form 81-93, ''Standard Flood Hazard Determination.''
8. For Water and Waste Disposal Programs - Submit an environmental report consistent with 7 CFR part 1794 and RUS Bulletin
1794A-602. If applicable, attach FEMA Form 81-93.
9. Record of any pending litigation or regulatory action.
10. Provide a ''Certificate of Need'' for facilities when required by State law.
11. Lender's credit evaluation.
12. Proposed loan agreement.
13. Security available for loan.
14. Copies of organizational documents (nonprofit organizations).
15. Evidence of community support.
16. Other documents used by lender that are material to making a credit decision.
PART G - Signatures

LENDER'S CERTIFICATION AND AGREEMENT
Lender hereby certifies that it has reviewed the Lender Agreement and Certification contained in this application. Lender further certifies
that it has completed a comprehensive analysis of the proposal and has determined its loan applicant is eligible, the loan is for authorized
purposes, and there is reasonable assurance of repayment based on its loan applicant's history, projections, and community support for
the facility. Lender also certifies that it has no undisclosed conflicts of interest.
The signature of lender's representative is the lending institution's agreement to comply with the terms, agreements, and limitations
outlined in the Lender Agreement and Certification and the applicable regulations.

Name:
(Date)

By:
Title:

ORGANIZATION'S CERTIFICATION AND AGREEMENT
The organization certifies that its representative has read the Organization Agreement contained in this application. The organization, by
its representative's signature, agrees to comply with conditions and requirements outlined in the Organization Agreement and applicable
regulations.
I certify as the organization's representative, that the organization applying for this loan and its members, or those controlling or controlled by the organization applying for the loan, do not have any judgments against them by the United States and are not presently
delinquent on any non-tax Federal debt. I further certify that information entered or attached to this application is correct or is a true
copy of original documents contained in the organization records.

Name:
(Date)

By:
Title:

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LENDER AGREEMENT AND CERTIFICATION
The lender representative's signature on this application shall satisfy regulatory requirements for completion
of Form AD-1047 and compliance with 18 U.S.C .§ 1913,31 U.S.C .§ 1352, and 42 U.S.C .§ 3601 et seg.
(I) RESTRICTIONS AND DISCLOSURE OF LOBBYING ACTIVITIES - AGREEMENT APPLICABLE TO
LOAN EXCEEDING $150,000
The lender agrees to complete and submit Form SF LLL, ''Disclosure of Lobbying Activities," in accordance
with the form's instructions 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 this loan.
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 Form SF LLL is subject to a civil penalty of not less than
$10,000 and not more than $100,000 for each such failure.
(II) COMPLIANCE WITH FAIR HOUSING ACT
If this loan finances a housing-related facility such as a nursing home, group home, or assisted living
facility, the lender agrees to monitor its borrower for compliance with Fair Housing Act requirements
including approving and having a Form HUD 935.2, "Affirmative Fair Housing Marketing Plan," in effect
at all times.
(III) CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS
The following certification is required by 7 C.F.R. § 3017.510, copies of which may be obtained from
USDA.
(A) The prospective lender certifies 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 3-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for (i) commission of a fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract
under a public transaction; (ii) violation of Federal or State antitrust statutes; or
(iii) commission of embezzlement, theft, forgery, bribery, falsification or destruction of records,
making a false statement, 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 3-year period preceding this application or proposal had one or more public
transactions (Federal, State, or local) terminated for cause.
(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 application.

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The inability of a lender to provide this certification will not necessarily result in denial of participation in
this covered transaction. The prospective lender shall submit an explanation of why it cannot provide this
certification. The certification or explanation will be considered in connection with the agency's determination whether to enter into this transaction. However, failure of the prospective lender to furnish either a
certification or an explanation will disqualify such lender from participation in this transaction.
The certification in this clause is a material representation of fact upon which reliance was placed when
the 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 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 contained in 7 C.F.R. part 3017.
The prospective lender 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 agency entering into this transaction.
The prospective lender further agrees by signing this form that it will include the clause titled "Certification
Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion - Lower Tier Transactions,"
provided by the USDA, without modification, in all lower tier covered transactions.
A participant in a covered transaction may rely upon a certification of a prospective participant in a lower
tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the
covered transaction, unless the participant 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 debarment 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. If a participant in a covered transaction knowingly enters into a lower tier
covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from
participation in this transaction, in addition to other remedies available to the Federal Government, the
agency may terminate this transaction for cause.

ORGANIZATION AGREEMENT

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The organization representative's signature on this application shall satisfy regulatory requirements for
signatures on Form RD 400-1, Form RD 400-4, and Form RD 410-9 and compliance with 18 U.S.C. § 1913
and 31 U.S.C. § 1352.
(I) COMPLIANCE WITH FAIR HOUSING ACT
If this loan finances a housing-related facility such as a nursing home, group home, or assisted living
facility, the organization agrees to comply with Fair Housing Act requirements and have an approved Form
HUD 935.2, "Affirmative Fair Housing Marketing Plan" in effect at all times.
(II) ASSURANCE AGREEMENT (TITLE VI, CIVIL RIGHTS ACT OF 1964)
The organization assures the U. S. Department of Agriculture (USDA) that it 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 seg.), 7 C.F.R. part
15, and 7 C.F.R. § 1901.202. In accordance with that Act and the regulations referred to above, the
organiza- tion agrees that in connection with any program or activity for which the organization receives
Federal financial assistance (as such term is defined in 7 C.F.R. § 15.2) no person in the United States
shall, on the basis of race, color, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination.
(A) The organization agrees that any transfer of any aided facility, other than personal property, by sale,
lease, or other conveyance, shall be, and shall be made expressly, subject to the obligations of
this agreement and transferee's assumption thereof.
(B) The organization 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 USDA employees or their representatives 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 information
regarding the provisions of this agreement and related regulations in such manner as USDA finds
necessary to inform such persons of their rights.
(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 organization 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 organization 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.

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(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.
(III) EQUAL OPPORTUNITY AGREEMENT (EXECUTIVE ORDER 11246)
Unless the Secretary of Labor (Secretary) issues an exemption by rule, regulation, or order pursuant to
section 204 of Executive Order 11246, the organization (whether one or more) and USDA, agree that when
construction costs exceed $10,000, the organization will:
(A) 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'':
Equal Opportunity Clause
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, 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, 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, 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
under this agreement, 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 with all rules, regulations, and relevant orders of the Secretary of Labor.
(5) The contractor will furnish all information and reports required by Executive Order 11246, rules,
regulations, and orders, and will permit access to the contractor's books, records, and accounts by
USDA, Office of Civil Rights, and the Secretary, or their representatives for purposes of investigation to ascertain compliance with such rules, regulations, and orders.

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(6) In the event of the contractor's noncompliance with the Equal Opportunity 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 this Equal Opportunity 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 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.
However, 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) Except for public bodies and federally recognized Indian tribes, be bound by the provisions of the
Equal Opportunity Clause with respect to its own employment when it participates in federally assisted
construction work.
(C) Notify all prospective contractors to file the required "Compliance Statement," Form RD 400-6, with
their bids.
(D) Impose bid conditions for all nonexempt Federal and federally assisted construction contracts that
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) Assist and cooperate with USDA and the Secretary in obtaining the compliance of contractors and
subcontractors with the provisions of the Equal Opportunity Clause and the rules, regulations, and
orders. The organization will furnish USDA and the Secretary information as they may require for
supervision of compliance. Such information may include Form AD 560, ''Certification of Nonsegregated Facilities,'' and Form CC-257, "Monthly Employment Utilization Report."
(F) Refrain from entering into any contract, or contract modification, subject to Executive Order 11246
with a contractor debarred from, or who has not demonstrated eligibility for, Government contracts
and federally assisted construction contracts pursuant to the Executive Order. The organization will
carry out such sanctions and penalties for violation of the Equal Opportunity Clause as may be
imposed upon contractors and subcontractors by USDA or the Secretary pursuant to part II, subpart
D, of the Executive Order.
(G) Be subject to USDA refusing to extend additional assistance to the organization under the program or
taking any other appropriate legal action, including referring the case to the Department of Justice, if
the organization fails to comply with this agreement.

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(IV) FEDERAL EQUAL CREDIT OPPORTUNITY ACT NOTICE
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants
on the basis of race, color, religion, national origin, sex, marital status, or age (provided the applicant has
the capacity to enter into a binding contract); because all or part of the applicant's income derives from any
public assistance program, or because the applicant has in good faith exercised any right under the
Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning
USDA is the Federal Trade Commission, Washington, D.C. 20580. If a person believes he or she was
denied assistance in violation of this law, they should contact the Federal Trade Commission, Washington,
D.C. 20580.

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
provision of the Freedom of Information Act (5 U.S.C. 522).
Much information not clearly marked "Confidential" may routinely be released if requested. 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 likely 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.