HRSA Loan Guarantee Program Application

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HRSA LOAN GUARANTEE PROGRAM APPLICATION
Please send a complete application and all requested attachments to [email protected]. Contact the HRSA Loan Guarantee Program with questions on how to complete this application. 
	
Part A. Borrower Information 
Legal Name 

D/B/A

H80 Grant Number 

Street Address

State & ZIP Code 


Tax ID

Contact Person 
Name   

Title

Telephone

E-mail

Part B. Lender Information 
Lender Name 

Street Address

State & Zip Code 


Tax ID 

Contact Person 
Name

Title 

Telephone

Email

Part C. Loan Information 
Loan Amount

Loan Term (Years)

Interest-only Period 
(Months, if applicable)

Amortization Period (Years)

Proposed Interest Rate

Fixed (Y/N):
Variable (Y/N):
If Variable, cite index & adjustment frequency

Collateral



Part D. Project Information 
    1. Project Type (check all that apply):  






    2. Facility Address: _______________________________________________________________
(Street)				(City, State)		(Zip Code)
    3. Site in Scope? (Y/N):  	
    4. Site Control (select one):   Owned/To Be Purchased/Leased    

Part E. Project Funding Sources & Uses 

1. USES. Check all that apply and provide total amount.
      Use 

Amount ($)
Comments (if any)

Land/Building Acquisition




Hard Construction Costs




Construction Contingency




Environmental Remediation




Furnishings, Fixtures & Equipment




Soft Costs (Professional & Other Fees)




Soft Costs Contingency




Lender's Fees & Expense




Other (Specify)




Other (Specify)



Total Project Budget 




2. SOURCES. Indicate amount from each source in‐hand or committed, and if the funds are restricted to a specific use. 

Amount ($)

Source
In-Hand ($)

Committed ($)
Use Restrictions (if any)
Guaranteed Loan




Borrower’s Funds 




Other-Specify:             




Other-Specify:             




Other-Specify:             




Total 





Public Burden Statement: 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  06/30/2029. 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.