RUS 740g Application for Headquarters Facilities

U.S. DEPARTMENT OF AGRICULTURE
RURAL UTILITIES SERVICE

Form Approved
OMB No. 0572-0032
BORROWER DESIGNATION

APPLICATION FOR HEADQUARTERS FACILITIES
INSTRUCTIONS - Submit to RUS an original and two (2) copies and
applicable supporting data. See attached for detailed instructions.

NAME OF BORROWER

1. PURPOSE OF PROJECT (Purchase, remodel or construct, main or branch facilities)

BORROWER'S
ESTIMATED COST

2.

RUS USE ONLY

ESTIMATED COST OF PROJECT:
a.

PURCHASE PRICE OF PROPERTY (exclude value of land and show in Items p)

b.

OFFICE PORTION (Construction

c.

OFFICE PORTION (Remodeling)

d.

SERVICE PORTION (Construction

e.

SERVICE PORTION (Remodeling)

f.

HVAC

g.

SITE DEVELOPMENT (Grading, roads, drainage structures, etc)

h.

FENCE

i.

WATER SUPPLY (Well, well house, pump, long connection to main, water treatment, etc.)

j.

SEWAGE DISPOSAL (Disposal System, long connection to main, etc.)

Sq. Ft. Ca

Per Sq. Ft.)

Sq. Ft Ca

Per Sq. Ft.)

LINEAR FT. @

PER FT. (Height

$

$

$

$

$

$

Ft.)

k.
l.
m.

CONTINGENCIES
SUBTOTAL

n.
o.

ARCHITECTURAL SERVICES

p.

LAND

q.

LEGAL EXPENSES
TOTAL

r.

Show all cost, in the space to the right, that are associated with additional
energy efficiency measures beyond the required Federal, state or local building
codes and standards. This cost may or may not be part of the overall building
construction cost shown above. Please identify, in the Remarks section, the
measure taken, the estimated savings to be realized in addition to the cost.

3a. NO. OF EMPLOYEES REQUIRING
DESK SPACE

3b. NO. OF VEHICLES
TO BE GARAGED

Energy Efficiency

Cost Estimate

5. METHOD OF FINANCING
740c CODE
a. RUS FINANCING

$

b. GENERAL FUNDS
4a. DID ARCHITECT ASSIST IN PREP. OF COST ESTIMATE?
YES

c. OTHER (Specify)

NO

4b. NAME OF ARCHITECT

d.

$
TOTAL

REMARKS

Headquarters Certification: In compliance with 7 CFR 1724.51 (e), the undersigned certify that the design and construction of the headquarters facility shall comply with
all applicable Federal, State, and local laws and regulations, including, but not limited to: (1) Section 504 of the Rehabilitation Act of 1973, (29 U.S.C. 794), which states
that no qualified individual with a handicap shall, solely by reason of their handicap, be excluded from participation in, be denied the benefits of, or be subject to
discrimination under a program or activity receiving Federal financial assistance. The Uniform Federal Accessibility Standards (41 CFR part 101-19.6, appendix A) are the
applicable standards for all new or altered borrower buildings, regardless of the source of financing. (2) The Architectural Barriers Act of 1968 (42 U.S.C. 4151), which
requires that buildings financed with Federal funds are designed and constructed to be accessible to the physically handicapped. (3) The Earthquake Hazards Reduction
Act of 1977 (42 U.S.C. 7701 et seq.), and executive Order 12699, Seismic Safety of Federal and Federally Assisted or Regulated New Building Construction (3 CFR 1990
Comp., p 2 69). Appropriate seismic provisions are required for new buildings for which RUS provides financial assistance. (See part 1792, subpart C.)
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to, a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0572-0032. The time required to complete this information is estimated to
average 3 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.

RUS Form 740g Rev. 5, 2/25/2010

INSTRUCTIONS

See RUS Regulations 7 CFR 1710, 1724, 1726, 1788, 1792, and 1794 and Bulletin 1724E-400 for RUS policy and procedure for obtaining
headquarters facilities, and the methods of financing.
See RUS Bulletin 86-3 (Electric) for RUS policy and procedure for obtaining headquarters facilities, and the methods of financing.
Submit to RUS an original and two (2) copies of this form and applicable supporting data, as set forth below.
The cost of items 2(b) and (d) is automatically determined when the number of square feet and appropriate cost per square foot are centered in the
appropriate locations. Include the cost of all mechanical work except air conditioning.
The cost of other construction (except fence) is to be estimated on a lump-sum basis.
Describe any exceptions to the compliance with Public Law 90-480 (42 U.S.C. 415I).

SUPPORTING DATA REQUIRED FOR ELECTRIC BORROWERS

A.

If New Construction, furnish:
1.

A justification for the need of the proposed facilities. Include a brief description of all presently used facilities.
Show the approximate number of square feet of space used for office, garage, and warehouse purposes in the
main building and at each branch. State whether they are owned or rented and their present adequacy. Make
known also any plans for future additions, adequacy. Make known also any plans for future additions,
relocations, replacements, disposal r abandonment of any of the facilities.

2.

A description of the site, including:
(a)
(b)
(c)
(d)

B.

A summary statement, indication general location of site and information on its availability, adequacy,
accessibility, desirability, etc.
A plot plan showing size, streets, roads, alleys, existing and proposed structures, distance to nearest
town, and other pertinent information.
A legal description of the property.
Information as to cost of land and evidence of title clearance in accordance with RUS Bulletin 20-8.

3.

A floor plan. Show dimensions and identify the rooms.

4.

A brief outline of the specifications.

5.

An estimate of the annual taxes and insurance costs.

6.

If Energy Efficiency, show all costs, in the space provided, that are associated with additional energy efficiency
measures beyond the required Federal, State, or local building codes and standards. This cost may or may not
be part of the overall building construction cost shown above. Please identify, in the Remarks Section, the
measures taken, the estimated savings to be realized in addition to the cost.

If Purchase, furnish:
Same as 1, 2, and 5 of paragraph A.
A floor plan of the facilities to be purchased; inside and outside photographs; and description of the general condition
and type of construction of walls, floors, roof, ceiling, and plumbing, electric and heating systems.

C.

If Remodeling, furnish:
A description of the proposed alterations. Where extensive remodeling is planned, furnish plans and specifications similar
to 3 and 4, of paragraph A.

RUS Form 740g (Rev. 05-10)