Form NIL10 Notice of Insured Loan

IA Form NIL10 OMB Control No. 1076-0020

Revised March 2010 Expires: _________

Notice of Insured Loan

(Using this form is optional, but it complies with 25 CFR § 103.18(b).

Lender:_______________________________________

Address:______________________________________

______________________________________

______________________________________

______________________________________

Borrower:_____________________________________

Address:______________________________________

______________________________________

______________________________________

______________________________________

The Lender hereby notifies the United States Department of the Interior (“Department”) that the Lender has extended a loan to the Borrower pursuant to Department Loan Insurance Agreement number ______________ (the “Agreement”), 25 U.S.C. §§ 1481 et seq., and 25 CFR Part 103, the Indian Loan Guarantee, Insurance and Interest Subsidy Program (the “Program”). The Lender intends for the Department to insure the loan in accordance with the Agreement and the Program, and provides the following information to comply with Agreement and Program requirements:

Original loan principal amount: $____________________________

(Exclusive of amounts potentially added pursuant to 25 CFR §§ 103.8, 103.34, or 103.36.)

Lender’s internal loan number: _____________________________

Interest rate:  Fixed at _____%

 Variable at _____% over the prime rate announced by ________________________

________________________________________________________ from time to time.

Loan term (the period over which the loan is to be repaid): _________________________________

Payment schedule (specify number of payments, due dates, maturity, and any special terms such as

periods of interest only payment or periodic pay down requirements for a revolving

loan): __________________________________________________________________

__________________________________________________________________________

Date on which the loan closed: ___________________, 20___

If the loan was not fully funded on the date it closed, please explain here: _________________________

_________________________________________________________________________

The Borrower is a(n):

 individual Indian

 partnership under _________________ law

 limited partnership under _________________ law

 corporation under _________________ law

 limited liability company under _________________ law

 Indian tribe

 Indian tribal enterprise (name tribe and reference organizational resolutions or other

source of authority for enterprise) ___________________________________________

________________________________________________________________________

 other (specify kind of organizational structure and source of legal authority) ______

________________________________________________________________________

Premium due (1% of original loan principal amount): $__________________

Is the Department’s loan insurance premium payment enclosed?

 Yes

 No (please explain): ____________________________________________________

Lender:______________________________

ABA No.: _______________

By:__________________________________

Its:__________________________________

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to notify the Federal government of a contingent liability. . 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 ½ hour 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.

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