Loan Guarantee Progress Report

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     OMB No: 0915-0285  Expiration Date: XX/XX/XXXX
DEPARTMENT OF HEALTH AND HUMAN SERVICES
HRSA Resources and Services Administration
Loan Guarantee Progress Report
Date Report for Quarter Ending
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Borrower Information 
Health Center Name 
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H80 Number
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Health Center Project Site Address
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Contact Name
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Phone
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Email
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Lender Information
Lender Name
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Lender Address
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Contact Name
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Phone
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Email
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Loan Information 
                                                                                     Loan #1
Loan #2 (if applicable)
Loan Date Issued
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Maturity Date
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Initial Loan Amount
$Click or tap here to enter text.[Enter amount]
$Click or tap here to enter text.[Enter amount]
Current Loan Balance
$Click or tap here to enter text.[Enter amount]
$Click or tap here to enter text.[Enter amount]
Current Interest Rate (if Variable Rate) 



Project Information 
Total Billable Visits at Project Site
Actual Visits for Current Quarter
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Budgeted Visits for Current Quarter
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Health Center Fiscal Year Start Date
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Health Center Fiscal Year End Date
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Loan Status – During Quarterly Reporting Timeframe (unless noted)
Questions
Yes / No
Details / Explanation
Has the Borrower made all required loan payments since loan inception?
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If No, provide details.Click or tap here to enter text.
Did the Borrower make all payments on time during this quarter? 
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If No, provide details on missed or late payments.Click or tap here to enter text.
Was the Borrower in compliance with all financial covenants outlined in the loan documents during this quarter?
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If no, please explain: which covenant(s) was violated; the calculation of the covenant; and what action was taken or will be taken by the Lender.Click or tap here to enter text.
Was the Borrower in compliance with all other terms and conditions outlined in the Loan Agreement, including but not limited to insurance and reporting requirements during this quarter? 
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If no, please explain: which requirement(s) is out of compliance; and what action was taken or will be taken by the Lender.Click or tap here to enter text.
During this quarter, did the Lender approve any amendments, modifications to or waivers of, the provisions of the loan documents? 

Reminder: Material Amendments require prior approval by the HRSA Loan Guarantee Program. Non-material amendments, modifications and waivers must be provided by Lender to HRSA LGP staff and the Lender Coordinator within 20 days of execution.
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If Yes, describe the amendment, modification, or waiver and provide the execution date. Click or tap here to enter text.

Attachments 
Required
                                                                                     Included Yes / No
Borrower’s most recent internal financial statements including balance sheet, revenue and expense reports with budget comparison
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If Applicable
Most recent audited financial statements. Due no later than 150 days after health center’s fiscal year end. 
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Revised payment schedule, if revised during the current quarter.
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Revised amortization schedule, if revised during the current quarter.
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Financial covenant violation calculation and related Lender actions, if not previously provided to HRSA LGP staff and the Lender Coordinator. 
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Non-financial covenants and terms violations and related Lender actions, if not previously provided to HRSA LGP staff and the Lender Coordinator.  

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Certification and Signatures
By signing below, the Borrower and Lender certify that the information provided in this quarterly report is complete and accurate. The Borrower and Lender have no knowledge of the occurrence of any Event of Default under the Loan Agreement that was not previously reported or remedied, or of any event that, with notice or lapse of time, would constitute an Event of Default and that required supporting documentation is attached, as applicable.
Borrower
Name and Title
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Signature
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Date
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Lender
Name and Title
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Signature
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Date
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Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. 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 OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.