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displays a valid OMB control number. The valid OMB control number for this information collection is 0572-0023. The time required to complete this information collection is
estimated to average 2 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.
USDA-RUS
FORM APPROVED OMB NO. 0572-0023
FINANCIAL REQUIREMENT STATEMENT
(RUS; RTB; FFB)
INST. - Submit an original & 2 copies to RUS. See Bull. 327-1
RUS USE ONLY
DATE RECEIVED
RUS NUMBER
BORR. DESIG.
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
,
APPROVED PURPOSES
(Use Supplemental Sheets
as necessary)
1.
a.
b.
c.
d.
e.
f.
g.
2.
b.
3.
b.
4.
b.
c.
5.
6.
7.
b.
8a.
8b.
9
10.
11.
b.
c.
12.
TOTAL
ADVANCES
TO DATE
(3)
ADVANCES
NOW
REQUESTED
(4)
RUS USE ONLY
ADVANCES
CURRENTLY
APPROVED
(5)
TOTAL
DISBURSEMENTS
& CREDITS AS
OF JAN-00
(6)
Construction
Engineering-a.
Operating Equip.
General-a.
RTB Stock
Operating Funds
Debt Retirement
Acquisitions-a.
Land and Buildings
Closed Budget-Unaudited
Closed Budget-Audited
Subtotals-All Funds
Sale of Property
Other-a.Req'd Non-Loan
Interest Income
Net Totals - Loan Funds
TOTAL LOAN
13.
14.
15.
16.
AMOUNT ENCUMBERED
RUS USE ONLY
TOTAL
WITHHELD ON
APPROVED
CONTRACT
FOR ADVANCE
(1)
(2)
RUS LOAN
RTB LOAN
FFB LOAN
TOTAL
Central Office Equipment
Outside Plant and Station Equipment
Land and Buildings
Engineering-a.
UNDER NOTE
PREVIOUSLY
ADVANCED
ADVANCED
THIS FRS
17. Cash Bal. Per Gen. Ledger
18. Adv. Not Deposited FRS -1
19. Other Adjustments (Specify)
20. Total Item 12,Col 6+17,18&19
21. Funds Not Released
UNENCUMBERED RESERVES (This Space For RUS Use Only)
General and Contingency
Special Projects
Funds Not Deposited (CR)
Total Unencumbered Reserves
CERTIFICATION
On behalf of the designated borrower, I request that the amount set forth as "Advances Now Requested" (Item 12, Col. 4 above) be advanced under the loan
contract. "Loan contract" includes in addition to the RUS and RTB loan contracts, the Federal Financing Bank - RUS Loan Commitment Agreement, and
the related Commitment Notice and correspondence concerning loan terms and conditions, I certify that the amount so requested is for a purpose or purposes
for which funds have either been approved for advance or for which approval is requested herewith; that the amount advanced will be deposited in the Trustee,
RUS Construction Fund account of the corporation in the
bank, which is a member of the FDIC; that the loan and other funds required to be
deposited in such bank account will be disbursed only for the purposes and not to exceed the amounts approved for each purpose in Column (2) "Total
Approved for Advance" of the Financial Requirement Statements; that the cash balance shown hereon is the balance of the Construction Fund-Trustee
account of the general ledger as of
; and that the disbursements reported in Column (6) were made in the
amounts stated for each purpose; all in accordance with the provisions of the loan contract.
SIGNATURE (ORIGINAL MUST APPEAR ON EACH PAGE)
TITLE (Authorized Corporate Officer or Manager)
RUS FORM 481 (Rev. 5-03)
PAGE _1_ OF _1_ PAGES
COPY 1 - SEND TO RUS
USDA-RUS
FORM APPROVED OMB NO. 0572-0023
FINANCIAL REQUIREMENT STATEMENT
(RUS; RTB; FFB)
INST. - Submit an original & 2 copies to RUS. See Bull. 327-1
RUS USE ONLY
DATE RECEIVED
RUS NUMBER
BORR. DESIG.
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
,
APPROVED PURPOSES
(Use Supplemental Sheets
as necessary)
1.
a.
b.
c.
d.
e.
f.
g.
2.
b.
3.
b.
4.
b.
c.
5.
6.
7.
b.
8a.
8b.
9
10.
11.
b.
c.
12.
TOTAL
ADVANCES
TO DATE
(3)
ADVANCES
NOW
REQUESTED
(4)
RUS USE ONLY
TOTAL
ADVANCES
DISBURSEMENTS
CURRENTLY
& CREDITS AS
APPROVED
OF JAN-00
(5)
(6)
Construction
Engineering-a.
Operating Equip.
General-a.
RTB Stock
Operating Funds
Debt Retirement
Acquisitions-a.
Land and Buildings
Closed Budget-Unaudited
Closed Budget-Audited
Subtotals-All Funds
Sale of Property
Other-a.Req'd Non-Loan
Interest Income
Net Totals - Loan Funds
TOTAL LOAN
13.
14.
15.
16.
AMOUNT ENCUMBERED
RUS USE ONLY
TOTAL
WITHHELD ON
APPROVED
CONTRACT
FOR ADVANCE
(1)
(2)
RUS LOAN
RTB LOAN
FFB LOAN
TOTAL
Central Office Equipment
Outside Plant and Station Equipment
Land and Buildings
Engineering-a.
UNDER NOTE
PREVIOUSLY
ADVANCED
ADVANCED
THIS FRS
17. Cash Bal. Per Gen. Ledger
18. Adv. Not Deposited FRS -1
19. Other Adjustments (Specify)
20. Total Item 12,Col 6+17,18&19
21. Funds Not Released
UNENCUMBERED RESERVES (This Space For RUS Use Only)
General and Contingency
Special Projects
Funds Not Deposited (CR)
Total Unencumbered Reserves
CERTIFICATION
On behalf of the designated borrower, I request that the amount set forth as "Advances Now Requested" (Item 12, Col. 4 above) be advanced under the loan
contract. "Loan contract" includes in addition to the RUS and RTB loan contracts, the Federal Financing Bank - RUS Loan Commitment Agreement, and
the related Commitment Notice and correspondence concerning loan terms and conditions, I certify that the amount so requested is for a purpose or purposes
for which funds have either been approved for advance or for which approval is requested herewith; that the amount advanced will be deposited in the Trustee,
RUS Construction Fund account of the corporation in the
bank, which is a member of the FDIC; that the loan and other funds required to be
deposited in such bank account will be disbursed only for the purposes and not to exceed the amounts approved for each purpose in Column (2) "Total
Approved for Advance" of the Financial Requirement Statements; that the cash balance shown hereon is the balance of the Construction Fund-Trustee
account of the general ledger as of
; and that the disbursements reported in Column (6) were made in the amounts
stated for each purpose; all in accordance with the provisions of the loan contract.
SIGNATURE (ORIGINAL MUST APPEAR ON EACH PAGE)
TITLE (Authorized Corporate Officer or Manager)
PAGE _1_ OF _1_ PAGES
RUS FORM 481 (Rev. 5-03)
COPY 2 - SEND TO RUS
USDA-RUS
FORM APPROVED OMB NO. 0572-0023
FINANCIAL REQUIREMENT STATEMENT
(RUS; RTB; FFB)
INST. - Submit an original & 2 copies to RUS. See Bull. 327-1
RUS USE ONLY
DATE RECEIVED
RUS NUMBER
BORR. DESIG.
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
,
APPROVED PURPOSES
(Use Supplemental Sheets
as necessary)
1.
a.
b.
c.
d.
e.
f.
g.
2.
b.
3.
b.
4.
b.
c.
5.
6.
7.
b.
8a.
8b.
9
10.
11.
b.
c.
12.
TOTAL
ADVANCES
TO DATE
(3)
ADVANCES
NOW
REQUESTED
(4)
RUS USE ONLY
TOTAL
ADVANCES
DISBURSEMENTS
CURRENTLY
& CREDITS AS
APPROVED
OF JAN-00
(5)
(6)
Construction
Engineering-a.
Operating Equip.
General-a.
RTB Stock
Operating Funds
Debt Retirement
Acquisitions-a.
Land and Buildings
Closed Budget-Unaudited
Closed Budget-Audited
Subtotals-All Funds
Sale of Property
Other-a.Req'd Non-Loan
Interest Income
Net Totals - Loan Funds
TOTAL LOAN
13.
14.
15.
16.
AMOUNT ENCUMBERED
RUS USE ONLY
TOTAL
WITHHELD ON
APPROVED
CONTRACT
FOR ADVANCE
(1)
(2)
RUS LOAN
RTB LOAN
FFB LOAN
TOTAL
Central Office Equipment
Outside Plant and Station Equipment
Land and Buildings
Engineering-a.
UNDER NOTE
PREVIOUSLY
ADVANCED
ADVANCED
THIS FRS
17. Cash Bal. Per Gen. Ledger
18. Adv. Not Deposited FRS -1
19. Other Adjustments (Specify)
20. Total Item 12,Col 6+17,18&19
21. Funds Not Released
UNENCUMBERED RESERVES (This Space For RUS Use Only)
General and Contingency
Special Projects
Funds Not Deposited (CR)
Total Unencumbered Reserves
CERTIFICATION
On behalf of the designated borrower, I request that the amount set forth as "Advances Now Requested" (Item 12, Col. 4 above) be advanced under the loan
contract. "Loan contract" includes in addition to the RUS and RTB loan contracts, the Federal Financing Bank - RUS Loan Commitment Agreement, and
the related Commitment Notice and correspondence concerning loan terms and conditions, I certify that the amount so requested is for a purpose or purposes
for which funds have either been approved for advance or for which approval is requested herewith; that the amount advanced will be deposited in the Trustee,
RUS Construction Fund account of the corporation in the
bank, which is a member of the FDIC; that the loan and other funds required to be
deposited in such bank account will be disbursed only for the purposes and not to exceed the amounts approved for each purpose in Column (2) "Total
Approved for Advance" of the Financial Requirement Statements; that the cash balance shown hereon is the balance of the Construction Fund-Trustee
account of the general ledger as of
; and that the disbursements reported in Column (6) were made in the amounts
stated for each purpose; all in accordance with the provisions of the loan contract.
SIGNATURE (ORIGINAL MUST APPEAR ON EACH PAGE)
TITLE (Authorized Corporate Officer or Manager)
PAGE _1_ OF _1_ PAGES
RUS FORM 481 (Rev. 5-03)
COPY 3 - RETAIN THIS COPY IN YOUR FILES
FORM APPROVED OMB NO. 0572-0023
USDA-RUS
FINANCIAL REQUIREMENT STATEMENT
(RUS; RTB; FFB)
BORR. DESIG
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
INST. - Submit an original & 2 copies to RUS. See Bull. 327-1
RUS USE ONLY
DATE RECEIVED
RUS NUMBER
,
FFB LOAN MATURITY - In accordance with instructions on front of worksheet, show requested maturity of this FFB Loan Advance:
Long Term
Short Term
(_________________, 20 ___)
APPROVAL OF PAYMENT UNDER LOAN CONTRACT (RUS USE ONLY)
COMPLIANCE
GEN. FUNDS
SIGNATURE
ADDRESS
ITEMS VERIFIED
RUS FORM 266
RUS FORM 268
(Initials of Checker)
INSURANCE
BANK
ACCOUNT SYMBOL
I CERTIFY that the borrower has complied with all the provisions of its loan contract therein required to be performed
in order to obtain the payment approved under this request, that all certificates, statements, and documents, and the
obligations required from the borrower in connection herewith by the provisions of said loan contract have been
received, examined and found to be satisfactory, and payment is approved in amounts as follows:
RUS LOAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________
RTB LOAN:
CASH ADVANCE . . . . . . . . . . . . . . . . . $______________
RTB STOCK PURCHASE. . . . . . . . . . . $______________
$_______________________
FFB LOAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________
OTHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________
TOTAL . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $_______________________
AUTHORIZED SIGNATURE
Item
State
Borr.
TITLE
Account No.
DATE
NOTES
Class B Stock
Amount (Dollars)
Stock Reg. No.
12. Net Totals - Loan Funds
CERTIFICATION
On behalf of the designated borrower, I request that the amount set forth as "Advances Now Requested" (Item 12, Col. 4 above) be advanced under the loan
contract. "Loan contract" includes in addition to the RUS and RTB loan contracts, the Federal Financing Bank - RUS Loan Commitment Agreement, and
the related Commitment Notice and correspondence concerning loan terms and conditions, I certify that the amount so requested is for a purpose or purposes
for which funds have either been approved for advance or for which approval is requested herewith; that the amount advanced will be deposited in the Trustee
RUS Construction Fund account of the corporation in the
bank, which is a member of the FDIC; that the loan and other funds required to be
deposited in such bank account will be disbursed only for the purposes and not to exceed the amounts approved for each purpose in Column (2) "Total
Approved for Advance" of the Financial Requirement Statements; that the cash balance shown hereon is the balance of the Construction Fund-Trustee
account of the general ledger as of
; and that the disbursements reported in Column (6) were made in the amounts
stated for each purpose; all in accordance with the provisions of the loan contract.
SIGNATURE (ORIGINAL MUST APPEAR ON EACH PAGE)
TITLE (Authorized Corporate Officer or Manager)
RUS FORM 481 (Rev. 5-03)
PAGE _1_ OF _1_ PAGES
COPY 4 - SEND THIS COPY TO RUS
USDA-RUS
FORM APPROVED OMB NO. 0572-0023
FINANCIAL REQUIREMENT STATEMENT
(RUS; RTB; FFB)
INST. - Submit an original & 2 copies to RUS. See Bull. 327-1
RUS USE ONLY
DATE RECEIVED
RUS NUMBER
BORR. DESIG.
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
,
APPROVED PURPOSES
(Use Supplemental Sheets
as necessary)
1.
a.
b.
c.
d.
e.
f.
g.
2.
b.
3.
b.
4.
b.
c.
5.
6.
7.
b.
8a.
8b.
9
10.
11.
b.
c.
12.
TOTAL
ADVANCES
TO DATE
(3)
ADVANCES
NOW
REQUESTED
(4)
TOTAL
RUS USE ONLY
DISBURSEMENTS
ADVANCES
& CREDITS AS
CURRENTLY
OF JAN-00
APPROVED
(6)
(5)
Construction
Engineering-a.
Operating Equip.
General-a.
RTB Stock
Operating Funds
Debt Retirement
Acquisitions-a.
Land and Buildings
Closed Budget-Unaudited
Closed Budget-Audited
Subtotals-All Funds
Sale of Property
Other-a.Req'd Non-Loan
Interest Income
Net Totals - Loan Funds
TOTAL LOAN
13.
14.
15.
16.
AMOUNT ENCUMBERED
RUS USE ONLY
TOTAL
WITHHELD ON
APPROVED
CONTRACT
FOR ADVANCE
(1)
(2)
RUS LOAN
RTB LOAN
FFB LOAN
TOTAL
Central Office Equipment
Outside Plant and Station Equipment
Land and Buildings
Engineering-a.
UNDER NOTE
PREVIOUSLY
ADVANCED
ADVANCED
THIS FRS
17. Cash Bal. Per Gen. Ledger
18. Adv. Not Deposited FRS -1
19. Other Adjustments (Specify)
20. Total Item 12,Col 6+17,18&19
21. Funds Not Released
UNENCUMBERED RESERVES (This Space For RUS Use Only)
General and Contingency
Special Projects
Funds Not Deposited (CR)
Total Unencumbered Reserves
CERTIFICATION
On behalf of the designated borrower, I request that the amount set forth as "Advances Now Requested" (Item 12, Col. 4 above) be advanced under the loan
contract. "Loan contract" includes in addition to the RUS and RTB loan contracts, the Federal Financing Bank - RUS Loan Commitment Agreement, and
the related Commitment Notice and correspondence concerning loan terms and conditions, I certify that the amount so requested is for a purpose or purposes
for which funds have either been approved for advance or for which approval is requested herewith; that the amount advanced will be deposited in the Trustee,
RUS Construction Fund account of the corporation in the
bank, which is a member of the FDIC; that the loan and other funds required to be
deposited in such bank account will be disbursed only for the purposes and not to exceed the amounts approved for each purpose in Column (2) "Total
Approved for Advance" of the Financial Requirement Statements; that the cash balance shown hereon is the balance of the Construction Fund-Trustee
account of the general ledger as of
; and that the disbursements reported in Column (6) were made in the amounts
stated for each purpose; all in accordance with the provisions of the loan contract.
SIGNATURE (ORIGINAL MUST APPEAR ON EACH PAGE)
TITLE (Authorized Corporate Officer or Manager)
Page _1_ of_1_ Pages
RUS FORM 481 (Rev. 5-03)
TEAR OFF THIS WORKSHEET BEFORE PREPARING INFORMATION
USDA-RUS
FORM APPROVED OMB NO. 0572-0023
FINANCIAL REQUIREMENT STATEMENT
SUPPLEMENTAL SHEET
BORR. DESIG.
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
DATE RECEIVED
RUS USE ONLY
RUS NUMBER
,
APPROVED PURPOSES
(Use Supplemental Sheets
as necessary)
AMOUNT ENCUMBERED
RUS USE ONLY
TOTAL
WITHHELD ON
APPROVED
CONTRACT
FOR ADVANCE
(1)
(2)
TOTAL
ADVANCES
TO DATE
(3)
ADVANCES
NOW
REQUESTED
(4)
RUS USE ONLY
TOTAL
ADVANCES
DISBURSEMENTS
CURRENTLY
& CREDITS AS
APPROVED
OF JAN-00
(5)
(6)
1. CONSTRUCTION
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
2. ENGINEERING
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
RUS FORM 481 (Rev. 5-03)
COPY 1 - SEND THIS COPY TO RUS
PAGE 2 OF 2 PAGES
FORM APPROVED OMB NO. 0572-0023
USDA-RUS
FINANCIAL REQUIREMENT STATEMENT
SUPPLEMENTAL SHEET
BORR. DESIG.
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
DATE RECEIVED
RUS USE ONLY
RUS NUMBER
,
APPROVED PURPOSES
(Use Supplemental Sheets
as necessary)
AMOUNT ENCUMBERED
RUS USE ONLY
TOTAL
WITHHELD ON
APPROVED
CONTRACT
FOR ADVANCE
(1)
(2)
TOTAL
ADVANCES
TO DATE
(3)
ADVANCES
NOW
REQUESTED
(4)
TOTAL
RUS USE ONLY
DISBURSEMENTS
ADVANCES
& CREDITS AS
CURRENTLY
OF JAN-00
APPROVED
(6)
(5)
1. CONSTRUCTION
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
2. ENGINEERING
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
RUS FORM 481 (Rev. 5-03)
COPY 2 - SEND THIS COPY TO RUS
PAGE 2 OF 2 PAGES
USDA-RUS
FORM APPROVED OMB NO. 0572-0023
FINANCIAL REQUIREMENT STATEMENT
SUPPLEMENTAL SHEET
BORR. DESIG.
STATEMENT NO.
DATE PREPARED
BORROWER NAME AND ADDRESS
DATE RECEIVED
RUS USE ONLY
RUS NUMBER
,
APPROVED PURPOSES
(Use Supplemental Sheets
as necessary)
AMOUNT ENCUMBERED
RUS USE ONLY
TOTAL
WITHHELD ON
APPROVED
CONTRACT
FOR ADVANCE
(1)
(2)
TOTAL
ADVANCES
TO DATE
(3)
ADVANCES
NOW
REQUESTED
(4)
RUS USE ONLY
TOTAL
ADVANCES
DISBURSEMENTS
CURRENTLY
& CREDITS AS
APPROVED
OF JAN-00
(6)
(5)
1. CONSTRUCTION
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
2. ENGINEERING
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
RUS FORM 481 (Rev. 5-03)
COPY 3 - RETAIN THIS COPY IN YOUR FILES
PAGE 2 OF 2 PAGES
| File Type | application/pdf |
| File Title | form_481-05-03-1b.xls |
| Author | karen.priestly |
| File Modified | 2015-12-30 |
| File Created | 2006-04-26 |