5001-12 Certification of Non-Relocation and Market and Capacity

Position 3
Form RD 5001-12

FORM APPROVED
OMB NO. 0572-0155

UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

CERTIFICATION OF NON-RELOCATION
AND
MARKET AND CAPACITY INFORMATION REPORT
(To be completed by borrower)
This form is to be executed by applicants for financial assistance for loan guarantees under provisions of the
Consolidated Farm and Rural Development Act (7 U.S.C 1932)
1.

2. Unique Identifier Number

Name of Applicant:

3. Name of Benefited Business or Industry:

5.

4. Labor File No. (DOL use only)

Location of Proposed Project:

6.

This Project is:
A New Business Venture
A New Branch or Facility
An Expansion of an Existing Facility
7. Affiliate or Subsidiary of:

Refinance of Existing Loan
A Transfer of Ownership
Other (Explain)

8. Amount of Loan: $ ______________________________
9. Purpose of Loan - (Be specific)

10.

a.

Principal
Product
(1)
Product #1

Information about your products or services: (NOTE: Describe each principal product or service to be furnished through this project.
Do not list products or services already being offered unless this project also offers them and they are essentially an expansion of past
activities. Be specific, for example, “MANUFACTURE FURNITURE-OFFICE-WOOD DESKS”.)

Products or Services
and NAICS Code
(2)

Projected Annual Sales and Average Employment to be Generated
by each Product:
Latest Annual Total
At Full Capacity
$ Sales
# Employees
$ Sales
# Employees
(3)
(4)
(5)
(6)

Product #2

Product #3

Product #4

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The
valid OMB control number for this collection is 0572-0155. The time required to complete this information collection is estimated to average 1 hour 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. Responses to this collection of information are mandatory (7 CFR 5001). Send comments on the
agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to
[email protected]. Include the OMB control number in any correspondence. Do not send the completed form to this address.

b.

Principal Occupations:
Average Employment and Wage Rates
When Fully Operational
Average
Average
# Employees
Wage Rate
# Employees
Wage Rate
(2)
(3)
(4)
(5)

Current Period
Occupational Job Title
(1)

11.

INFORMATION ABOUT YOUR MARKET: List below, for each principal product or service, the states in which you expect to make the
greatest part of your sales. You need list only those states in which you expect to sell at least 5 percent of your volume. If your sales are
nationwide, enter the word “NATIONAL” in the right hand column. If more than 5 percent of your total projected sales are to be in any
standard metropolitan statistical area (for example, Chicago and its nearby suburbs), enter the name of the area. If possible, give the
approximate percentage of your total sales that you expect to make in the states and metropolitan areas listed. Enter no more than
one product or NAICS code per row. (See sample entry in the table below.)

Principal Product
or Service
(Sample entry)
Product “X”

Chicago (8%)
Kentucky (15%)

Indiana (12%)
Iowa (20%)

Wisconsin (20%)
Nebraska (10%)

12. INFORMATION ABOUT YOUR COMPETITORS: Please list the principal competitors off ering the same or similar service or
manufacturing a similar or identical product, regardless of where they are located, but only those who are selling in the market area you have
indicated in section 11 above, where you intend to sell. Also indicate the location of your competitor's plants that is most likely to be
serving your market area. If your market is national, omit a listing of competitor’s shipping points.
NOTE: In terms of the following listing, a competitor should be considered an enterprise offering essentially similar services or products.
Thus, a summer resort providing golf, swimming and tennis is not competitive with a winter resort offering only skiing and skating. By the
same token, gypsum board or particle board are not considered competitive with plywood, nor wood furniture with metal furniture.
a.

Names of Competitors

Location of plants serving market (Include street, city,
state and zip code).

1.
2.
3.
4.
5.
b.

To the best of your knowledge, has any competitor recently ceased operations or withdrawn from your market area?
Provide name and state reason, if known.
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c.

Are you aware of any potential new entries or planned expansions that will be competitive in your market area? If known, describe
by name and location.

13. Applicant must check one of a, b, or c below: (NOTE: “Related Company” as used in this form means any affiliate, subsidiary, or other
business entity under direct, indirect or common control with applicant.)
a. New Business Venture. This project is a new business venture unrelated to existing business facilities, and the borrower is not a
company related to an existing business facility. (NOTE: If applicant or a related company has ceased or substantially reduced operations
during the 24 months preceding the date of this request, the information required by Section 14 below must be attached.)
b.

Expansion of Applicant’s Only Business Facility. This project is an expansion of an existing business facility located at: (Street
Address)

Which carries on the following operations:

c.

Applicant or Related Company with Business Facility at Another Location. Applicant has attached __________ pages containing the
information required by section 14 of this form concerning business operations conducted by the Applicant or by a related company
at other locations than the location of the proposed project. Applicant has included business operations that have ceased orhave
been substantially reduced during the 24 months preceding the date of this request if such operations were conducted by Applicantor a
related company.
It is not the intention of the Applicant or any related company to relocate any present operation as a result of the proposed Project, that
to the extent said Project is undertaken to assist in the expansion of the operations of Applicant through the establishment of a new
branch, affiliate or subsidiary of Applicant, such expansion will not result in an increase of unemployment in the area of original
location or in any area where Applicant or any related company now conducts related business operations, that any such expansion is not
being undertaken with the intention of closing down or curtailing any existing operations of Applicant or of any related company, and
that such Project is not being undertaken with the intention of performing as contractor or subcontractor work heretofore performed by
Applicant or a related company, the transfer of which work would result in the transfer of employment opportunities from one location
to another and an increase in unemployment at the previous location of such work.

12. 14. The information required by this section must be supplied if Applicant or a related company now conducts business operations at a
location other than the location of the proposed Project, or if Applicant or a related company has ceased or substantially reduced operations
within the 24 months preceding the date of this application. A separate sheet of paper should be used for each location. Give the
following information: (l) Name of company, (2) Full address of site on which business operations are or were conducted, (3)
Relationship of Applicant to business entity conducting operation, (4) Brief description of articles produced or services provided
at location,
(5) Underline production articles or services provided that are similar to articles to be produced or services to be provided by the proposed
Project, (6) Average number of persons employed at the location, (7) Average number of persons employed in production of articles
or services similar to those provided by the proposed Project, (8) If applicable, date on which operations ceased, or were substantially
reduced, and (9) If applicable, the size of the reduction.

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13. 15. Please provide below name, address, telephone number and title of person to be contacted if any questions arise concerning this
form.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
14. 16. CERTIFICATION: I hereby certify that the information reported on this form, and any attachments to this form, are to the best of
my belief and knowledge truly representative of the facts and refl ect the future intentions of the Applicant as of this date:
__________________________________________
(Date)

________________________________________________
(Signature of authorized official)

________________________________________________
(Title)

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