LGC10 Loan Guarantee Certificate

IA Form LGC10
Revised X 202X

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

Department of the Interior
Loan Guarantee Certificate
No. _____________________
Date:_______________, 20___

Lender:
Address:

__________________________________
__________________________________
__________________________________
__________________________________

Borrower:
Address:

__________________________________
__________________________________
__________________________________
__________________________________

Loan Guarantee Percentage:_______%
Original Loan Principal Amount: $__________________________

(Exclusive of amounts potentially added pursuant to 25 CFR §§ 103.8, 103.34, or 103.36.)

Lender’s Internal Loan Number: ___________________________
Interest Subsidy, if any:
Approved
Not Approved

The Department of the Interior guarantees payment to the Lender of the listed percentage of any loss of principal, accrued
interest, and authorized charges the Lender sustains on the identified loan. This guarantee is subject to the provisions of the
Loan Guarantee, Insurance and Interest Subsidy Program, 25 U.S.C. §§ 1481 et seq., 1511 et seq., and 25 CFR Part 103, the
Conditions of Approval attached to this Loan Guarantee Certificate as “Exhibit A,” and any subsequent modifications to the
loan or to this guarantee authorized and approved by the Department. To constitute evidence of the Department’s guarantee,
this Loan Guarantee Certificate must have specific Conditions of Approval attached.
The Lender may sell the loan and this Loan Guarantee Certificate in accordance with the requirements of 25 CFR Part 103.

United States Department of the Interior

By:
Title:

_______________________________
_______________________________

Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to
establish the respective rights and responsibilities of the respondent and the Federal government. 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. 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.