Form RGI10 Request to the Department of the Interior for Loan Guara

IA Form RGI10
Revised X 202X

OMB Control No. 1076-0020
Expires: X/XX/202X

Request to the Department of the Interior
for Loan Guarantee, Loan Insurance, and/or Interest Subsidy
Lender:
Address:
ABA No.

___________________________
___________________________
___________________________
___________________________

Telephone:
___________________________
Cell Phone:
___________________________
Email Address:

Request is for:
Loan Insurance
(See 25 CFR § 103.13))
Loan Guarantee
Interest Subsidy

Pursuant to the Loan Guarantee, Insurance and Interest Subsidy Program, 25 U.S.C. §§ 1481 et seq., 1511 et
seq., and 25 CFR Part 103 (the “Program”), the Lender requests the United States Department of the Interior
(“Department”) to guarantee, insure, and/or provide interest subsidy for the following loan:
Borrower:
Address:

___________________________
___________________________
___________________________
___________________________

Telephone:
___________________________
Cell Phone:
___________________________
Email Address:
EIN/TIN:
___________________________
Loan Purpose:
________________________________________
________________________________________
________________________________________
________________________________________

Original Amount of Loan:
$______________________________
Proposed Interest Rate:
_______________________________
Payment Schedule and Maturity:
________________________________

Proposed percentage to be
guaranteed or insured:
_______%

Does the Lender have a Loan Guarantee Agreement or Loan Insurance Agreement in effect, under which
to consider this request?
Yes. Loan Guarantee Agreement dated:_________________, 20____.
Loan Insurance Agreement number __________________, dated ___________________, 20___.
No. The Lender will have to enter into an appropriate agreement with the Department before the
Department will consider this request.
Please complete the application as indicated
in 25 CFR Part 103. Upon completion, please
submit it to a Department official responsible
for the Borrower’s business location. If
requesting interest subsidy, please provide
a specific analysis of the factors set forth in
25 CFR § 103.20.

Lender:_________________________
By:_____________________________
Its:_____________________________
Date of Request:___________, 20____

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to provide basic

IA Form RGI10
Revised X 202X

OMB Control No. 1076-0020
Expires: X/XX/202X

information concerning the applicant’s eligibility for and intended use of Federal program benefits. The information is provided
by respondents to obtain or retain a benefit. In compliance with the Paperwork Reduction Act of 1995, as amended, the
collection has been reviewed by the Office of Management and Budget and assigned a number and an expiration date. The
number and expiration date are at the top right corner of the form. An agency may not sponsor or conduct, and a person is
not required to respond to, a request for information collection unless it displays a currently valid OMB Control Number. The
public reporting burden is estimated to average 2 hours per respondent . This includes the time needed to understand the

requirements, gather the information, complete the form, and submit it to the Department. Comments regarding the burden or
other aspects of the form may be directed to the Indian Affairs Information Collection Clearance Officer, Office of Regulatory
Affairs – Indian Affairs, 1001 Indian School Road NW, Suite 229, Albuquerque, New Mexico 87104.
Privacy Act Statement (5 U.S.C. 552(a)): The authority for collecting this information is 25 U.S.C. 1511. The information will

be used to administer the Loan Guarantee, Insurance and Interest Subsidy Program, 25 U.S.C. 1481 et seq. Disclosures of
this information may be made to track and record payments and unpaid balances and provide information on payments
made for paying interest subsidy, credits obtained, service loans made, and premiums paid by Lenders, and for the
other routine uses described by system of record notice, BIA-13, Loan Management and Accounting System.