Form EIB 10-04 EIB 10-04 Notice of Claim & Proof of Loss, Working Capital Guarant

OMB No. 3048-0035
PENDING OCTOBER 2020

NOTICE OF CLAIM AND PROOF OF LOSS
WORKING CAPITAL GUARANTEE
SECTION A. Name and Address (Please provide full names and addresses. For additional
parties, add a separate page.)
GUARANTEED LENDER MAKING DEMAND FOR PAYMENT
EXIM Transaction No.
Master Guarantee Agreement (MGA) No.
Name
Address
City
State/Province
Postal Code
Country
Contact Name
Email
Phone Number

Current Holder of Original Promissory Note
BORROWER
Name
Address
City
State/Province
Postal Code
Country
Contact Name
Email
Phone Number
GUARANTOR
Name
Address
City
State/Province
Postal Code
Country
Contact Name
Email
Phone Number
EIB 10-04 (9/20)

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OMB No. 3048-0035
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SECTION B. General Information
EXIM LOAN FACILITY
Reason for claim filing

Was this guarantee approved under Lender's delegated
authority?
Is this a transaction-specific loan?
Is there a Forbearance Agreement?
Type of loan facility

Is this loan under a fast track lender program?
Is this a supply chain loan?
Is this a loan under city/state program?
Is this loan under a trade association partnership
program?

Effective date of the Facility
Last date Facility was renewed
Facility extension(s) granted
(please list all extensions)
Maximum amount of Facility approved
Final Disbursement Date approved
Advance rate of collateral

Yes No
Yes No
Date: MM/DD/YYYY
Yes No
revolving loan facility
transaction-specific loan facility
transaction-specific revolving facility
Yes No
Yes No
Yes No
Yes No

MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY

$
MM/DD/YYYY

___% inventory
___% receivables
Other _________________________________________

What are the products provided by the Borrower?

Date of last disbursement
Principal balance of the EXIM loan disbursements
Claim filing extension granted by EXIM?
Indirect export(s) included?
Date of default
Status of Borrower’s operation
Demand Letter to Borrower
Demand Letter to Guarantor(s)

MM/DD/YYYY

$
Yes No
Yes No

Date(s):

MM/DD/YYYY

MM/DD/YYYY
MM/DD/YYYY

DOMESTIC LINES AND COLLATERALIZATION
Is there a domestic loan?
Outstanding amount of the domestic line
Is the domestic line current?

EIB 10-04 (9/20)

Yes No
$
Yes No

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OMB No. 3048-0035
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Domestic line collateralized?
Is there cross-collateralization?
Other loan facilities extended to the Borrower
(list the Facilities and amount extended)
Collateral of the domestic line and other credit facilities
extended

Yes No
Yes No

LOAN INSURANCE
Is there a related insurance policy from EXIM?
EXIM Policy number(s)
Is there a related insurance policy from another
insurer?
If 'Yes', give policy number(s), name and address of the
insurer(s) etc.

SECTION C

Yes No
Yes No

BUSINESS STRUCTURE INFORMATION

NAICS Code
Business structure of the Borrower

Borrower’s type of business

EIB 10-04 (9/20)

Proprietorship
Corporation
Partnership
Limited Partnership
Government Non-Sovereign
Government Sovereign
Wholesale
Manufacturing
Retail
Processing
Contractor
Service
Government
Other

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OMB No. 3048-0035
PENDING OCTOBER 2020

SECTION D - DOCUMENTATION as per MGA Article 5.01
Were Disbursements made after receipt of a Borrowing
Base Certificate and its supporting documentation as
per MGA Article 4.06?

Yes

Were Disbursements made prior to the Final
Disbursement Date?

Yes

No
Add Comments:
No
Add Comments:

Was the Borrower current under the Working Capital
loan facility at time of disbursement(s)?

Yes
No
Add Comments:

Were all disbursements under the Working Capital loan
facility less than or equal to the borrowing base (net of
reserves for letters of credit, or allowed over advances,
unless as otherwise allowed in the MGA)?
Were Disbursements made in agreement with the
conditions and prohibitions stated in the Loan
Authorization Agreement, the Borrower Agreement,
and the Master Guarantee Agreement?
Are the items financed those identified in the Loan
Authorization Agreement?

Yes
No
Add Comments:
Yes
No
Add Comments:
Yes
No
Add Comments:

Is the transaction in compliance with all special
conditions?

Yes
No
Add Comments:

Is the transaction in compliance with requirements of
the Country Limitation Schedule in force at time of
approval?

Yes
No
Add Comments:

Is the Loan Authorization Agreement or Notice (Annex
A) signed by an authorized officer of Lender or affiliate
and EXIM?

Yes

Is the Borrower Agreement signed by all relevant
parties?

Yes

No
Add Comments:
No
Add Comments:

To the best of the Borrower's knowledge, all terms and
conditions of the Borrower Agreement have been met.

Yes
No
Add Comments:

Are the loan documents free of any binding alternative
dispute resolution provisions?

Yes
No
Add Comments:

Has the Borrower provided all financial statements to
the Lender as required under the Borrower Agreement
and the special conditions of the Loan Authorization, if
applicable?
EIB 10-04 (9/20)

Yes
No
Add Comments:

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OMB No. 3048-0035
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Are all loan documents governed by the laws of states,
territories and commonwealths within the U.S.?

Yes
No
Add Comments:

SECTION D - DOCUMENTATION as per MGA Article 5.01. - All documents must be submitted
with the claim filing.
Promissory Note
Evidence of Payment of the Facility Fee
Executed copy of Loan Authorization Notice or Loan
Authorization Agreement (Annex A of the MGA)
Lenders Loan Agreement with the Borrower
Executed copy of Borrower Agreement
Executed copy of the Loan Agreement
Executed copy of Fast Track Lender Agreement, if
applicable
Delegated Authority Letter Agreement
Security Agreement
Subordination Agreement, if required
Copies of all filed UCC financing statements
Evidence of a lien search of UCC records which
indicates a perfected security interest
Copies of all field examination reports of inspection of
the collateral
Copies of financial statements
Copies of Borrowing Base Certificate(s) for the sixmonth period preceding the date of the Payment
Default (MGA Article 5.01(b)(vii))
Supporting Accounts Receivable Aging Reports and
sample copies of Invoices or export orders (MGA Article
5.01(b)(vii))
Copies of export orders or summaries of export order
and inventory schedules if applicable (MGA Article
5.01(b)(viii))
Copies of records of final foreign purchase if indirect
exports is included in Loan Facility (MGA Article
5.01(b)(x))
Copies of the lender's records regarding disbursements
and application of payments to the loan (loan
transaction history)
Assignment of EXIM or other insurance policy (If
insurance is used)
Material records regarding satisfaction of the Special
Conditions
Demand Letter to Borrower
Demand Letter to Guarantor(s)
EIB 10-04 (9/20)

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Copy of Bankruptcy notice or court order in the event
demand is prohibited under the bankruptcy law
Copies of communication to and from EXIM regarding
Events of Default
Copies of correspondence to and from EXIM
concerning waivers, modifications or extensions
granted
Other Eligible Costs documentation, if applicable
Other

 Attached
 Attached
 Attached

 Attached
 Attached

SECTION E – CLAIM PAYMENT CALCULATION
NOTE
Note amount
Note date
Frequency of interest payment

MM/DD/YYYY

Method of interest calculation
Note repayment terms
Type of interest
Interest rate basis
Guaranteed interest rate
(list all interest rates and time period they apply to)

Fixed
Prime

Principal outstanding
Interest paid to
Last interest payment date

$
Daily
Monthly  Quarterly
Other________________________________________________
360/360 360/365  365/365
Floating
 LIBOR

$
MM/DD/YYYY
MM/DD/YYYY

OTHER ELIGIBLE COSTS CLAIMED
Enforcement Costs Claimed
Collateral Protection Costs Claimed

$
$

CALCULATION OF ESTIMATED LOSS
Principal Outstanding
(+) Interest
(+) Prorated Enforcement Costs
(+) Prorated Collateral Protection
Total of Estimated Loss

EIB 10-04 (9/20)

$
$
$
$
$

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OMB No. 3048-0035
PENDING OCTOBER 2020

SECTION F - WIRE INSTRUCTIONS and TAX ID
Routing Bank Name
Recipient Bank Name
ABA #
Account Name
Account No.
Tax ID No.
Attention
Reference, if any

Additional Comments:

SECTION G – CERTIFICATIONS and SIGNATURE
The Lender certifies that:
1) it has complied with the terms of Section 4.06(c) of the Master Guarantee Agreement – Working Capital
Guarantee Program regarding prohibited Credit Accommodations;
2) the expiration date of any security filings (domestic and foreign) are scheduled to expire within 12 months
following the claim date; and
3) it has obtained the Economic Impact Certification from each Borrower as per the terms of Section 4.09 of
the Master Guarantee Agreement – Working Capital Guarantee Program.
Please refer to the Certifications for the Notice of Claim and Proof of Loss – Working Capital (Section G) posted on
EXIM’s website as document EIB-20-01. THE CERTIFICATIONS FOR NOTICE OF CLAIM AND PROOF OF LOSS –
WORKING CAPITAL (SECTION G) ARE INCORPORATED INTO THIS NOTICE OF CLAIM AS IF FULLY SET FORTH
HEREIN. When signing this Notice of Claim and Proof of Loss in the space provided below, the undersigned
authorized signatory signing for the Lender certifies and represents that he or she is fully authorized to sign on the
Lender’s behalf, and that HE OR SHE HAS READ the Certifications for Notice of Claim and Proof of Loss – Working
Capital (Section G) referenced above AND IS CERTIFYING, as appropriate to all of the certifications set forth in that
document.
Lender
Street Address
City
State/Province
Postal Code
Email
Phone Number
Name of Authorized Certifier
EIB 10-04 (9/20)

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Signature of Authorized Certifier

Public Burden Statement
We estimate it will take you about 1 hour per response, that includes the time it will take to read the instructions, gather
the necessary facts and fill out the form. However, you are not required to provide information requested unless a valid
OMB control number is displayed on the form. If you have comments or suggestions regarding the above estimate or
ways to simplify this form, forward correspondence to EXIM Bank and the Office of Management and Budget,
Paperwork Reduction Project, OMB# 3048-0035, Washington, D.C. 20503.

EIB 10-04 (9/20)

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