Form 34 HRSA Loan Guarantee Program Application

The Health Center Program Application Forms

HRSA Loan Guarantee Program Application

HRSA Loan Guarantee Program Application

OMB: 0915-0285

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OMB No.: 0915-0285. Expiration Date: XX/XX/20XX



HRSA LOAN GUARANTEE PROGRAM APPLICATION

Please send a complete application and all requested attachments to [email protected]. Contact the HRSA Loan Guarantee Program with questions on how to complete this application.

Part A. Borrower Information

Legal Name


D/B/A


H80 Grant Number


Street Address


State & ZIP Code



Tax ID


Contact Person

Name


Title


Telephone


E-mail


Part B. Lender Information

Lender Name


Street Address


State & Zip Code



Tax ID


Contact Person

Name


Title


Telephone


Email


Part C. Loan Information

Loan Amount


Loan Term (Years)


Interest-only Period

(Months, if applicable)


Amortization Period (Years)


Proposed Interest Rate


Fixed (Y/N):

Variable (Y/N):

If Variable, cite index & adjustment frequency


Collateral




Part D. Project Information

  1. Project Type (check all that apply):


New Construction


Alteration/Renovation


Land Acquisition


Facility Acquisition







  1. Facility Address: _______________________________________________________________

(Street) (City, State) (Zip Code)

  1. Site in Scope? (Y/N):

  2. Site Control (select one): Owned/To Be Purchased/Leased


Part E. Project Funding Sources & Uses


1. USES. Check all that apply and provide total amount.

Use


Amount ($)

Comments (if any)


Land/Building Acquisition





Hard Construction Costs





Construction Contingency





Environmental Remediation





Furnishings, Fixtures & Equipment





Soft Costs (Professional & Other Fees)





Soft Costs Contingency





Lender's Fees & Expense





Other (Specify)





Other (Specify)




Total Project Budget






2. SOURCES. Indicate amount from each source in‐hand or committed, and if the funds are restricted to a specific use. 


Amount ($)


Source

In-Hand ($)


Committed ($)

Use Restrictions (if any)

Guaranteed Loan





Borrower’s Funds





Other-Specify:





Other-Specify:





Other-Specify:





Total






Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleHealth Center Loan Guarantee Program Application
SubjectHealth Center Loan Guarantee Program Application
AuthorHRSA
File Modified0000-00-00
File Created2021-01-14

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