Treasury Loan Application Form for Businesses Critical t

DELIBERATIVE PRE-DECISIONAL SENSITIVE WORKING DRAFT

OMB Approved No. 1505-0263

Expiration Date: 09/30/2020

TREASURY LOAN APPLICATION FORM

for Businesses Critical to Maintaining National Security

April [23], 2020

This application form is for informational purposes only, to enable potential applicants to begin preparing the required information. Treasury is not accepting applications at this time. In the coming days, Treasury will provide a web-based form for application submissions.

This application is for loans from the U.S. Department of the Treasury to eligible businesses that are critical to maintaining national security (“Borrowers”).

Borrowers are encouraged to submit their completed application materials by 3:00 p.m. EDT on May 1, 2020, for expedited review. Applications received after 3:00 p.m. on May 1, 2020, may not be considered, but the Treasury Department may, in its discretion and subject to the availability of funds, consider such applications for approval.

The definitions of the terms contained in this application appear in Division A, Title IV, Subtitle A of the Coronavirus Aid, Relief and Economic Security Act, Pub. L. 116-136 (Mar. 27, 2020) (the “Act”), and in the Procedures and Minimum Requirements for Loans to Air Carriers and Eligible Businesses and National Security Businesses under Division A, Title IV, Subtitle A of the Act, as updated (the “Procedures”).

BORROWER INFORMATION

• Borrower’s Name [Alphanumeric Field]

• Borrower’s Taxpayer ID Number [Alphanumeric Field]

• Borrower’s DUNS Number [Alphanumeric Field]

• Borrower’s Address [Alphanumeric Field]

• Contact Person’s Name [Alphanumeric Field]

• Contact Person’s Title [Alphanumeric Field]

• Contact Person’s Phone [Alphanumeric Field]

• Contact Person’s E-mail [Alphanumeric Field]

Provide a general description of the Borrower’s corporate structure, including type of business entity (LLC, corporation, sole proprietorship, etc.) and tax classification (C Corporation, S Corporation, partnership, etc.) and whether the Borrower is publicly or privately owned.

• Corporate Structure [Alphanumeric Field]

• Ownership Structure (choose one)

• Public [Selection Box]

• Private [Selection Box]

• Borrower’s Jurisdiction of Organization or Formation [Alphanumeric Field]

• Names and Jurisdiction of Organization or Formation of Parent Companies and Material Affiliates (including companies that control, are controlled by, or are under common control with the Borrower) (if applicable) [Alphanumeric Field for One or More Names of Companies]

• Top-Level Parent’s Jurisdiction of Organization or Formation (if applicable) [Alphanumeric Field]

Identify the primary and secondary North American Industry Classification System (NAICS) codes for the Borrower. [Alphanumeric Field]

Did the Borrower apply for or receive loans provided or guaranteed under the Act?

• Y/N [Selection Boxes]

BORROWER PROFILE

Does the Borrower perform under a DX priority rated contract or order under the Defense Priorities and Allocations System regulations (15 CFR part 700)?

• Y/N [Selection Boxes]

• If yes, please describe these contracts/orders. [Alphanumeric Field]

Does the Borrower currently operate under a valid Top Secret facility security clearance pursuant to the National Industrial Security Program regulations (32 CFR Part 2004)?

• Y/N [Selection Boxes]

• If yes, please describe this Top Secret facility security clearance, provide the relevant CAGE code(s), and attach the relevant form DD-254, Contract Security Classification Specification.

[Alphanumeric Field]

[File Selection and Upload Function]

If the response to either of these criteria above is classified, please contact the Treasury Department at [email protected].

Applicants that do not satisfy either of these two criteria may be considered if, based on a recommendation and certification by the Secretary of Defense or the Director of National Intelligence that the applicant business is critical to maintaining national security, the Secretary of the Treasury determines that the applicant business is critical to maintaining national security. The Treasury Department will process such applications upon receipt of such certification.

DEBT, ASSETS, AND EQUITY

Debt. Provide a description of the Borrower’s outstanding secured and unsecured debt, including debt securities, notes, loans, and bank lines of credit.

• Debt [Alphanumeric Fields for One or More Types of Debt]

  • Type

  • Current Amount Outstanding

  • Maximum Commitments Available

  • Seniority [Secured/Senior Unsecured/Subordinated]

  • Lien Ranking

  • Maturity Date(s)

• Lines of Credit [Numeric Fields for One or More Bank Lines]

• Current Amount Outstanding

• Maximum Commitments Available

• Maturity Date(s)

• Other Material Indebtedness [Alphanumeric Fields for One or More Types of Other Debt]

• Description

• Current Amount Outstanding

• Maximum Commitments Available

• Maturity Date(s)

• Total Debt Currently Outstanding [Numeric Field that Sums All Debts]

• Total Debt Commitments Currently Available [Numeric Field that Sums All Amounts Available]

Intercompany Debt and Guarantees. Provide a description of the existing intercompany debt and guarantee arrangements of the Borrower and any of its subsidiaries, with current amounts outstanding.

• Intercompany Debt and Guarantees [Alphanumeric Field]

Restrictions on Indebtedness. Provide a description of any restrictions on the Borrower or any of its subsidiaries incurring additional indebtedness.

• Restrictions on Indebtedness [Alphanumeric Field]

Restrictions on Collateral. Provide a description of any restrictions on the Borrower or any of its subsidiaries granting additional security interests in collateral.

• Restrictions on Collateral [Alphanumeric Field]

• Does the Borrower have a judgment lien against the Borrower’s property for a debt owed to the United States? [Yes/No]

Debt Service. Provide, for the Borrower and its subsidiaries on a consolidated basis, the amounts of principal and interest currently scheduled to be paid on outstanding debt for the next 3 years.

• 2020 [Numeric Field]

• 2021 [Numeric Field]

• 2022 [Numeric Field]

Assets. Provide the total assets in the Borrower’s 2019 financial statements.

• Total Assets [Numeric Field]

Available Security. Provide a brief description of the type and general value of all assets, property, and revenue streams of the Borrower and its affiliates available to be pledged to secure the loan to the Borrower.

[Alphanumeric Fields for One or More Types of Security]

• Type of Asset, Property, Revenue Streams

• General Value

• Available Payment Seniority / Lien Rank

• If Applicable, Debt Instruments Secured By Asset

Available Guarantees. Provide a list of the parent companies, subsidiaries, and affiliates of the Borrower that will provide guarantees and indicate whether such persons have other material debt.

Equity. List each class of outstanding equity interests in the Borrower.

• Common Stock [Number of Shares]

• Preferred Stock [Name/Number of Shares]

Ratings. Provide the Borrower’s issuer credit rating and issue level ratings for any senior unsecured debt as of December 31, 2019, from any Nationally Recognized Statistical Ratings Organizations (NRSROs).

• Issuer Credit Ratings [Alphanumeric Fields for Multiple Ratings]

• Issue Ratings for Senior Unsecured Debt [Alphanumeric Fields for Multiple Issues and Ratings]

FINANCIAL INSTITUTION INFORMATION

(For electronic payment. The account listed below should be the same account used by the Borrower to make tax payments to the IRS.)

Routing Transit Number
Borrower’s Account Number	Checking or savings (circle one)
Financial Institution Name
Financial Institution Address
Financial Institution Telephone Number
Primary contact at financial institution for payment process validation (name, title, email, and phone number)

UNITED STATES OPERATIONS

Describe the operations of the Borrower in the United States.

• [alphanumeric field]

List the number of employees of the Borrower based in the United States (including territories or possessions) on March 24, 2020. For purposes of these calculations, include full-time, part-time, temporary, and leased employees, but do not include independent contractors or corporate officers.

• U.S. employees [Numeric Field]

List the number of employees of the Borrower on March 24, 2020.

• Worldwide employees [Numeric Field]

Describe any changes to the Borrower’s U.S. employment levels between March 24, 2020 and the date of this application.

• Planned Employment Changes [Alphanumeric Field]

Describe any changes that are planned in the Borrower’s U.S. employment levels between the date of this application and December 31, 2020.

• Planned Employment Changes [Alphanumeric Field]

COVERED LOSSES

List the Borrower’s revenue and expenses in 2019 and in the first quarter of 2020.

• 2019 Revenue [Numeric Field]

• 2019 Expenses [Numeric Field]

• Q1 2020 Revenue [Numeric Field]

• Q1 2020 Expenses [Numeric Field]

List each category of revenue loss or new unbudgeted expense that the Borrower has incurred or expects to incur directly or indirectly as a result of the coronavirus through March 30, 2021, and the actual or expected revenue loss or new expense for each category. Categories of revenue losses or new unbudgeted expenses may include, for example, reduced demand, unavailability of credit, and new medical expenses.

Revenue Losses

• Category Description [Alphanumeric Fields for Multiple Categories]

• Amount [Numeric Fields for Multiple Categories]

New, Unbudgeted Expenses

• Category Description [Alphanumeric Field for Multiple Categories]

• Amount [Numeric Field for Multiple Categories]

FINANCIAL PLAN

Provide a separate document containing a financial plan that includes each of the following components.

(1) Use of Proceeds – an itemized description of the purposes for which the Borrower will use the loan proceeds.

(2) Financial Needs – quantitative information on the Borrower’s total financial needs for the remainder of 2020, including expected revenues, expenses, and types and amounts of expected borrowing, and how the loan fits within those needs.

(3) Operating Plan – a discussion of the Borrower’s (and any subsidiary’s) operating plan for the remainder of 2020, if the loan is approved. Include a description of any changes to management, employment, as well as any strategic focuses or significant ventures or transactions.

(4) Cost Restructuring – a description of any plans the Borrower (and any subsidiary) has to restructure its obligations or contracts with creditors, vendors, or employees to improve the Borrower’s financial condition in 2020.

(5) Prudent Borrowing – a justification based on the Borrower’s financial needs and operating plan demonstrating that the loan is prudently incurred.

(6) Stock Buybacks – a description of any contractual commitment in effect as of March 27, 2020, obligating the Borrower or any affiliate thereof to purchase, before January 1, 2026, an equity security that is listed on a national securities exchange of the Borrower or any parent company of the Borrower.

(7) Lack of Credit Elsewhere – evidence based on market conditions, the Borrower’s circumstances, or relationships with existing or potential creditors that credit is not reasonably available to the Borrower elsewhere.

[File Selection and Upload Function]

ADDITIONAL INFORMATION TO UPLOAD

Borrowers must upload copies of the following information.

The Borrower’s most recently completed IRS Form 941 “Employers Quarterly Federal Tax Return.”

[File Selection and Upload Function]

The consolidated financial statements of the Borrower for the previous three years that (if available) have been audited by an independent certified public accountant, including any associated notes and auditor’s report.

The consolidated financial statements of the Borrower’s corporate parents, if any, for the previous three years that (if available) have been audited by an independent certified public accountant, including any associated notes and auditor’s report.

[File Selection and Upload Function]

Any interim financial statements of the Borrower for the current fiscal year, including any associated notes.

[File Selection and Upload Function]

Please list any outstanding liens with the Federal Government.

[Alphanumeric Field]

TAXPAYER PROTECTION

To receive a loan, each Borrower must provide the Treasury Department with appropriate financial instruments that, in the sole determination of the Secretary, provide for a reasonable participation in equity appreciation or a reasonable interest rate premium appropriate for the benefit of taxpayers.

If the Borrower has issued securities that are traded on a national securities exchange, the Borrower must provide a warrant or equity interest in the Borrower unless the Secretary determines in his discretion that the Borrower cannot feasibly issue warrants or other equity interests. For other Borrowers, the Secretary may, in his discretion, accept senior debt instruments or warrants or other equity interests.

Each Borrower must provide information in the following table that describes in sufficient detail its proposed financial instruments under this requirement. Each Borrower will be notified whether the proposed financial instruments are acceptable prior to application approval.

Borrower Name:

Type of Financial Instrument:

Amount, Value, or Price of the Financial Instrument, as Appropriate:

Seniority or Priority of the Financial Instrument Relative to Other Equity and Debt of the Borrower:

Term or Duration of the Financial Instrument, if Applicable:

Other Terms and Conditions that Could Affect the Value of the Financial Instrument:

ADDITIONAL INFORMATION

Supplementary Information. In order to evaluate the Borrower’s application, the Treasury Department may request additional information from the Borrower. Failure to provide any information requested by the Treasury Department may result in a rejection of the Borrower’s application.

CERTIFICATION

I certify under penalty of perjury that the information and certifications provided in the application and its attachments are true and correct. WARNING: Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to 5 years, fines, and civil penalties. (18 U.S.C. §§ 287, 1001; 31 U.S.C. §3729, 3802).

Name of First Certifying Official
Title of First Certifying Official
Signature of First Certifying Official
Phone Number of First Certifying Official
E-mail of First Certifying Official
Name of Second Certifying Official
Title of Second Certifying Official
Phone Number of Second Certifying Official
E-mail of Second Certifying Official
Signature of Second Certifying Official
Borrower Name
Date

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is two hours per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. 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 control number assigned by OMB.

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