RD 4280-1 Survey of Recipients of Rural Development Loan and Grant

Form RD 4280-1
(06-07)

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

FORM APPROVED
OMB NO.0570-0035

SURVEY OF RECIPIENTS OF RURAL DEVELOPMENT
LOAN AND GRANT PROGRAM
1. Name of RUS Utility and Intermediary ID Number

6. Name of Loan Recipient:

2. Address

7. Address

3. City / State / ZIP:

8. City / State / ZIP:

4. Contact Person & Title

9. Contact Person & Title

5. Telephone Number:

10. Telephone Number:

11. Loan Amount:

12. Date of Loan Agreement

13. Repayment Terms (Monthly payment, maturity date, and for revolving loan funds, the interest rate):

0%
14. Briefly describe the funded project (including its location):

15. Which of the following best describes the project:
a. Business expansion
b. Business startup
c. Business incubator
d. Community development

e.
f.
g.
h.

Infrastructure (Water, waste water disposal, etc.)
Speculative building/land available for new business
Medical Care
Education/Training
YES

16. Was the project completed or implemented as proposed in the application?
If answer is YES, insert the start and completion dates below:
Project start date (Month/Year):
Project completion date (Month/Year):

NO

If project was not completed, please explain the reason:
Is the project still in operation?

YES

17. Actual number of new jobs created:

NO If answer is NO, please explain:
18. Number of jobs retained/saved as a result of project:

19. Briefly describe any secondary positive or negative impacts of the project on the community. Consider economic, social,
and/or environmental impacts:

20. Grant recipients only-If the loan was made from a revolving loan fund, the total dollar amount that has been loaned, including this
and 2.) the Intermediary's contribution
loan, from 1.) initial grant funds
Mark one - this loan was made from:
the initial grant & RUS borrower's contribution, or
repayments from initial loans.

Signature of Authorized Official of Intermediary

Date
Form RD 4280-1

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 0575-0035. The time required to complete this information
collection is estimated to average 1 hour 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.