5001-11D Guaranteed Loan Report Of Loss - Interest Loss/Recovery/

RD Form 5001-11D
(00-00)

1. STATE - COUNTY - GLS BORROWER ID

FORM APPROVED
OMB NO.0572-0155

GUARANTEED LOAN REPORT OF LOSS
INTEREST LOSS/RECOVERY/OR
VOLUNTARY PAYMENT
2. AGENCY
LOAN NO.

3. LOAN TYPE

Community Programs ____
Water and Waste Disposal ____
Business and Industry ____
Rural Energy for America Program ____

4. BORROWER NAME

5. LENDER TAX ID NO.

6. AGENCY’S LENDER
BRANCH NO.

7. LENDER ROUTING NUMBER

8. LENDER ACCOUNT NUMBER

9. ACCOUNT TYPE
___Savings ___Checking

GUARANTEED LOAN ITEMS:

$ DOLLARS

10. DATE OF SETTLEMENT
Mo
Da
Yr.

LOSS GUARANTEED:

$ DOLLARS
(Percent)

12. PERCENT OF LOSS GUARANTEED
13. AMOUNT TO BE PAID
(Item 11 X item 12)

11. ACCRUED INTEREST OWED

14. Product of (Prin. Advanced on Loan +
Item 11) X Item 12
15. MAXIMUM LOSS ALLOWED
(Lesser of Items 13 or 14)

$__________
$_________
$___________

ADJUSTMENTS TO PROTECTIVE ADVANCES &
INTEREST:
16. PERCENT OF GUARANTEED PORTION
HELD BY LENDER

(Percent)

17. LOSS ON GUARANTEED PORTION
HELD BY LENDER (Item 15 X Item 16)
18. UNPAID ANNUAL/LATE FEES
19. AMOUNT DUE LENDER
(Item 17 minus 18)

AMOUNT DUE LENDER OR USDA: (If Applicable)
20. PAID ANNUAL/LATE FEES
21 BALANCE DUE LENDER (Item 19 + Item 20)

22. AMOUNT DUE USDA BY LENDER

$______________
$_____________
$______________

23. NAME OF LENDER
24. LENDER SIGNATURE
25. LENDER REP. TITLE

26. DATE
27. NAME OF USDA REPRESENTATIVE
28. USDA SIGNATURE
29. USDA REPRESENTATIVE TITLE
30. DATE
FINANCE OFFICE ONLY
31. CHECK ISSUE CODE

1 = SYSTEM GENERATED
2 = MANUAL CHECK
3 = NO CHECK ISSUED
4 = REFUND
5 = EFT

32. PAYMENT DATE
Mo
Da
Yr.

33. DATE OF DEPOSIT
Mo

Da

Yr.

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