RD 5001-03 Application for Loan Guarantee

Form RD 5001-3
(00-00)

FORM APPROVED
OMB NO. 0000-0000

Position 3
UNITED STATES DEPARTMENT OF AGRICULTURE
RURAL DEVELOPMENT

APPLICATION FOR LOAN GUARANTEE
AGENCY PROGRAM TYPE:
Community Facilities
(Subpart B 7 CFR 5001.101)

Water and Waste
(Subpart B 7 CFR 5001.102)

Business and Industry
(Subpart B 7 CFR 5001.103)

Rural Energy for America
(Subpart B - 7 CFR 5001.104)

Each program type has a separate Subpart B of this form that must be completed as well. Based on the program type, please select the appropriate Subpart B
of this form.
LENDER INFORMATION
1. NAME OF LENDER:

2. TAX ID NUMBER:

3. LENDER’S URL:

4. CONTACT PERSON:

5. CONTACT’S TELEPHONE NUMBER:
(
)

6. CONTACT’S E-MAIL ADDRESS:

7. AMOUNT OF LOAN:
$

8. PERCENT GUARANTEE REQUESTED:

9. LENDER’S LOAN NUMBER:

10. LENDER STATUS:
(check one)

APPROVED LENDER

11. INTEREST RATE INFORMATION:

VARIABLE:

PREFERRED LENDER

Variable

Fixed

Both

FIXED:

Guaranteed Rate ___________
Unguaranteed Rate_________

Name of Published Index: ___________________________________________________________________
Guaranteed Portion:
Interest Rate _________
Rate Cap ______ Rate Index _________ Payment Cap _________
Rate Change Period ___________
Rate Incremental Difference +/- _______
Unguaranteed Portion:

Interest Rate _________
Rate Cap ______
Rate Change Period ___________

Rate Index _________ Payment Cap _________
Rate Incremental Difference +/- _______

12.LIST ANY LENDER OFFICER, DIRECTOR, STOCKHOLDER, EMPLOYEE OR OTHER OWNERS (AS SPECIFIED IN 7 CFR 5001.33(a)(13)) WHO
HAS A : (a) SUBSTANTIAL FINANCIAL INTEREST IN THE BORROWER OR VICE VERSA, AND DESCRIBE THE RELATIONSHIP AND INTEREST:
(b) CONFLICT OF INTEREST OR POTENTIAL CONFLICT OF INTEREST, AND DESCRIBE THE INTEREST:

13.LIST ALL FEES LENDER WILL CHARGE FOR THE LOAN, INCLUDING THE AGENCY GUARANTEE FEE:

BORROWER INFORMATION
14.NAME OF BORROWER:

15.TAX ID NUMBER:

17.ADDRESS (Include Zip Code):

18.TYPE OF BORROWER:
Proprietorship
Cooperative
Partnership
Corporation

Indian Tribe
Political Subdivision

16.BORROWER’S URL:

19.DUNS NUMBER:
Non-profit
Individual
20. CONGRESSIONAL DISTRICT:

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 valid OMB
control number. The valid OMB control number for this information collection is 0000-0000. The time required to complete this information collection is estimated to average 10 - 20 hours per response.
including the time for reviewing instructions, searching exsisting data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Form RD 5001-3 Page 1 of 13

21. IF BORROWER IS AN INDIVIDUAL:
A. Is he or she an eligible citizen or a legally admitted permanent resident pursuant to 7 CFR 5001.8(a)(1)?
B. Is he or she a Veteran?

YES
NO

YES

NO

22.LIST ANY PERSON OWNING 20% OR GREATER INTEREST IN BORROWER: (Will also require the completion of Form RD 5001-14)
NAME AND POSITION

RACE *

SEX *

U.S. CITIZEN
YES OR NO

ANNUAL
COMPENSATION

% OF
OWNERSHIP

OUTSIDE
NET WORTH

PERSONAL/PARTNERSHIP
CORPORATE
GUARANTEE: YES OR NO

CO-BORROWER INFORMATION: For each co-borrower, provide the information specified in items 14 through 22 as an attachment to this form.
Provide a separate attachment for each co-borrower.
PROJECT INFORMATION
23.PURPOSE OF PROJECT:

24 a. USE OF FUNDS (check all that apply):
Purchase Land
Furnishings
Debt Restructuring
Professional Fees
Working Capital
Other
Real Estate Improvements
Equipment
Initial O&M
New Business
Lender & Guarantee Fees
Line of Credit (for B&I program only):
Amount ($):
Leasehold interest or improvement

c. Does project have an energy efficiency or renewable energy component?
YES
NO
If YES, please indicate which technology type is applicable (check all that apply):
Biomass :
Anaerobic Digester
Biodiesel
Ethanol
Solid Fuel
Thermal Conversion
Landfill Gas
Solar:
Electric
Thermal
Wind:
Large
Small
Hydropower:
Large
Small
Micro
Other (describe):

b. JOBS: Created _________ Saved ___________

Geothermal:
Direct Use
Electric Generation
Hydrogen:
Biomass
Wind
Solar
Geothermal
Natural Gas
Energy Efficiency:
Buildings
Industrial
Ocean:
Tidal
Wave
Current
Thermal
Feedstock (describe):

Projected quantity of energy produced, saved or replaced, as applicable:
________
________
Quantity
Units
25. Is the business a startup business (as defined in 7 CFR 5001.2)?
YES

NO

If NO, enter date business was established: ___________________
26. FACILITY INFORMATION:
Name:
______________________________________
Address: ______________________________________
______________________________________
______________________________________
Contact Person:
E-mail Address

NAICS Code:
County:
Congressional District:
On EPA Violations List?

______________________________________
______________________________________

____________________
____________________
____________________
YES
NO

Contact’s Phone Number:
Fax:

____________________
____________________

Form RD 5001-3 Page 2 of 13

27.LOAN SECURITY/COLLATERAL:
Presently Owned or
to be Acquired

Value

Valuation
Method

Lender’s Discount
Factor

Current Liens*

Net Collateral
Value

Accounts Receivable
Inventory
Office Furniture and Equipment
Automotive Equipment
Machinery and Equipment
(if a fixture)
Building
Land
Other:
TOTALS
* Indicate by asterisk liens to be paid off with Agency guaranteed loan funds.

ATTACH THE FOLLOWING DOCUMENTS PURSUANT TO 7 CFR 5001.12:
PREFERRED LENDER OR SIMPLIFIED APPLICATIONS:
28. Information sufficient for the Agency to confirm project and borrower eligibility.
29. A copy of lender’s loan evaluation and anlysis.
30. An internal loan approval document showing approval by in-house appropriate office/committee.
31. Environmental information required by the Agency to conduct its environmental reviews as specified in 7 CFR 5001.16(h).
APPROVED LENDER APPLICATIONS:
32. Lender’s credit evaluation as required in 7 CFR 5001.12(a)(2).
33. Environmental information required by the Agency to conduct it environmental reviews as specified in 7 CFR 5001.16(h).
34. Technical reports, energy audits, and energy assessments as required in 7 CFR 5001.12(a)(4).
35. Appraisal reports in accordance with 7 CFR 5001.12(a)(5).
36. Business Plan as required in 7 CFR 5001.12(a)(6).
37. Feasibility Study as required in 7 CFR 5001.12(a)(7).
38. Credit reports, including credit scores that meet the provisions of 7 CFR 5001.12(a)(9), for each individual signing the Promissory
Note or guaranteeing repayment of loan.
39. Financial Statements as required by 7 CFR 5001.12(a)(10).
40. Where applicable, two copies of the preliminary engineering report.
41. Where applicable, a copy of the preliminary architectural report.
42. Where applicable, a copy of the complete organizational documents of the borrower, a complete list of governing board members
of the borrower, a copy of the management agreement and other legal documents between the borrower and the proposed
management company.
Form RD 5001-3 Page 3 of 13

LENDER CERTIFICATIONSAND DETERMINATIONS
Ineligible entities
Lender has obtained certifications from the Borrower that the Borrower and any owner with more than 20 percent ownership interest in
the borrower does not have any outstanding judgments obtained by the U.S. in a Federal Court (other than U.S. Tax Court), is not
delinquent on the payment of Federal income taxes, is not delinquent on Federal debt, or is not debarred or suspended from receiving
Federal assistance.
Legal authority and responsibility.
Lender has determined that the Borrower has the legal authority necessary to construct, operate, and maintain the proposed facility and
services and to obtain, give security for, and repay the proposed loan.
Citizenship.
Lender has obtained a Borrower certification that entities owning an interest in the Borrower are at least 51 percent owned by persons
who are eligible citizens or are legally admitted permanent residents residing in the U.S. pursuant to 7 CFR 5001.8(a)(1).
Loan schedule and term
Lender certifies that the loan term will be based on the use of proceeds, the useful economic life of the assets being financed, and the
Borrower’s repayment ability; and in no event will the term exceed 40 years.
Lender certifies that the principal balance of a guaranteed loan is properly amortized within the prescribed loan maturity and that the
periodic payment will retire the debt over the term of the loan without a balloon payment.
Other Lender Certifications
Lender certifies that it possesses and has reviewed all relevant documentation related to this loan guarantee request in accordance with
7 CFR part 5001.
Lender certifies that it has identified and reported to the Agency any significant risks that would jeopardize the repayment of the loan.
Lender is unaware of any certifications or representations made by the Borrower that are materially false. Lender is further unaware of
any adverse change in the borrower’s financial condition. Adverse changes include, but are not limited to, judgment liens, tax liens,
mechanics’ liens, bankruptcy, financial reverses, litigation, change in the form of organization, etc.

Lender’s Name

Date

By:
Officer Signature

Officer Title

Form RD 5001-3 Page 4 of 13

Certifications Made by Borrower
Borrower(s) certify that they have read the General Borrower Certifications contained in this application and agree to comply with the
limitations outlined in the General Borrower Certifications. Borrower(s) further certify that information contained in this application and
below and in attached exhibits is true and complete to the best of our knowledge.

Borrower’s Name

Date

Borrower’s Name

Date

By:
Officer Title

Officer Signature

TO BE COMPLETED BY THE AGENCY
40.ELIGIBLE RURAL AREA:
YES

NO

41. IS THIS PROJECT IN A FLOOD HAZARD AREA:
YES

NO

BE ADVISED
All information supplied to USDA by you or your agents in connection with your loan application may be released to interested third parties, including
competitors, without your knowledge or consent under the provision of the Freedom of Information Act (5 U.S.C. 522).
Much of the information not clearly marked “Confidential” may routinely be released if a request is received for same. Further, if we receive a request for
information marked “Confidential,” the Federal Government will release the information unless you can demonstrate to our satisfaction that release of the
information would be likely to produce substantial competitive harm to your business or would constitute a clearly unwarranted invasion of personal
privacy. Also, forms, consultant reports, etc., cannot be considered confidential in their entirety if confidential material contained therein can reasonably be
segregated from other information.
Information submitted may be made available to the public during the time it is held in Government files regardless of the action taken by USDA on your
application.
FEDERAL EQUAL CREDIT OPPORTUNITY ACT STATEMENT
Federal law does not allow discrimination of any kind. You cannot be denied a loan because of your race, color, religion, national
origin, sex, marital status, handicap, or age (if you can legally sign a contract). You cannot be denied a loan because all or part of your
income is from a public assistance program. If you believe that you have been discriminated against for any of these reasons, you can
write the Secretary of Agriculture, Washington, D.C. 20250. You cannot be denied a loan because you exercised your rights under
the Consumer Credit Protection Act. You must have exercised these rights in good faith. The Federal Agency responsible for
seeing this law is obeyed is the Federal Trade Commission, Washington, D.C. 20580.

Section 1001 of Title 18, United States Code provides: “Whoever, in any matter within the jurisdiction of any department or agency of the
United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact or makes any false,
ficitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false,
ficitious or fraudulent statement or entry shall be fined under this title or imprisoned not more that five years or both.”

Form RD 5001-3 Page 5 of 13

GENERALBORROWER CERTIFICATIONS
(1) ASSURANCE AGREEMENT
All borrowers or recipients shall adhere to the requirements and provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation
Act of 1973, Equal Credit Opportunity Act of 1974, Age Discrimintation in Employment Act of 1975, Title XI of the Education Amendments of 1972,
Title VIII Fair Housing Amendments Act of 1988, Executive Order 11246 (Construction Contracts), and Executive Order 12898 (Federal Action to
Address Environmental Justice in Minority Population and Low-Income Populations, and Other Equal Opportunity and Nondiscrimination
Requirements).

A.

Recipient agrees that any transfer of any aided facility, other than personal property, by sale, lease or other conveyance of
contract, shall be, and shall be made expressly, subject to the obligations of this agreement and transferee’s assumption thereof.

B.

Recipient shall:
(1) Keep such records and submit to the Government such timely, complete, and accurate information as the Government may
determine to be necessary to ascertain compliance with this agreement and the regulations.
(2) Permit access by authorized employees of the USDA during normal business hours to such books, records, accounts and other
sources of information and its facilities as may be pertinent to ascertaining such compliance.
(3) Make available to users, participants, beneficiaries and other interested persons such information regarding the provisions
of this agreement and the regulations, and in such manner as the USDA finds necessary to inform such persons of the protection
assured them against discrimination.

C.

The obligations of this agreement shall continue:
(1) As to any real property, including any structure, acquired or improved with the aid of the Federal financial assistance, so
long as such real property is used for the purpose for which the Federal financial assistance is made or for another purpose
which affords similar services or benefits, or for as long as the recipient retains ownership or possession of the property,
whichever is longer.
(2) As to any personal property acquired or improved with the aid of the Federal financial assistance, so long as Recipient
retains ownership or possession of the property.
(3) As to any other aided facility or activity, until the last advance of funds under the loan or grant has been made.

D.

Upon any breach or violation of this agreement the Government may, at its option:
(1) Terminate or refuse to render or continue financial assistance for the aid of the property, facility, project, service or activity.
(2) Enforce this agreement by suit for specific performance or by any other available remedy under the laws of the United States
or the State in which the breach or violation occurs.

Rights and remedies provided for under this agreement shall be cumulative.
(2) EQUAL OPPORTUNITY AGREEMENT (EXECUTIVE ORDER 11246, AS AMENDED)
“Recipient” (whether one or more) and the USDA, pursuant to the rules and regulations of the Secretary of Labor (“Secretary”) issued
under the authority of Executive Order 11246, as amended, agree:
In consideration of financial assistance (whether by a loan, grant, loan guaranty, or other form of financial assistance) made or to be
made by the USDA to Recipient, Recipient hereby agrees, if the cash cost of construction work performed by Recipient or a
construction contract financed with such financial assistance exceeds $10,000—unless exempted by rules, regulations or orders of the
Secretary issued pursuant to section 204 of Executive Order 11246 of September 4, 1965.
A.

To incorporate or cause to be incorporated into any contract for construction work, or modification thereof, subject to the
relevant rules, regulations, and orders of the Secretary or of any prior authority that remain in effect, which is paid for in whole
or in part with the aid of such financial assistance, the following “Equal Opportunity Clause”:

Form RD 5001-3 Page 6 of 13

During the performance of this contract, the contractor agrees as follows:
(1) The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex
or national origin. The contractor will take affirmative action to ensure that applicants are employed, and that employees are
treated during employment, without regard to their race, color, religion, sex or national origin. Such action shall include, but
not be limited, to the following; employment, upgrading demotion or transfer; recruitment or recruitment advertising;
layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship.
The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be
provided by the USDA setting forth the provisions of this nondiscrimination clause.
(2) The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that
all qualified applicants will receive consideration for employment without regard to race, color, religion, sex or national
origin.
(3) The contractor will send to each labor union or representative of workers with which he has a collective bargaining
agreementor other contract or understanding, a notice, to be provided by the USDA, advising the said labor union or
workers’ representative of the contractor’s commitments under this agreement as required pursuant to section 202(3)
of Executive Order 11246, and shall post copies of the notice in conspicuous places available to employees and
applicants for employment.
(4) The contractor will comply with all provisions of Executive Order 11246, and of all rules, regulations and relevant orders
of the Secretary of Labor and of any prior authority which remain in effect.
(5) The contractor shall furnish all information and reports required by Executive Order 11246, rules, regulations, and
orders, or pursuant thereto, and will permit access to his books, records, and accounts by the USDA, Office of Civil
Rights, and the Secretary for purposes of investigation to ascertain compliance with such rules, regulations, and orders.
(6) In the event of the contractor’s noncompliance with the Equal Opportunity (Federally Assisted Construction) clause or
with any of the said rules, regulations, or orders, this contract may be cancelled, terminated, or suspended in whole or in part
and the contractor may be declared ineligible for further Government Contracts or Federally Assisted construction
contracts in accordance with procedures authorized in Executive Order No. 11246, and such other sanctions may be
imposed and remedies invoked as provided in Executive Order 11246, or by rule, regulation or order of the Secretary, or as
provided by Law No. _________.
(7) The contractor will include the provisions of this Equal Opportunity (Federally Assisted Construction) clause in every
subcontract or purchase order, unless exempted by the rules, regulations, or orders of the Secretary of Labor issued
pursuant to section 204 of Executive Order 11246, so that such provisions will be binding upon each
such subcontractor or vendor. The contractor will take such action with respect to any subcontract or purchase order
USDA may direct as a means of enforcing such provisions, including sanctions for non compliance: Provided, however,
that in the event the contractor becomes involved in or is threatened with litigation with a subcontractor or vendor as a
result such direction by the USDA, the contractor may request the United States to enter into such litigation to protect the
interest of the United States.
B.

To be bound by the provisions of the Equal Opportunity Clause in construction work performed by Recipient and paid for in
whole or in part with the aid of such financial assistance.

C.

To notify all prospective contractors to file the required “Compliance Statement,” Form RD 400-6, with their bids.

D.

Form AD-425, Instructions to Contractors, will accompany the notice of award of the contract. Bid conditions for all nonexempt
Federal and Federally assisted construction contracts require inclusion of the appropriate “Hometown” or “Imposed” plan
affirmative action and equal employment opportunity requirements. All bidders must comply with the bid conditions contained
in the invitation to be considered responsible bidders and hence eligible for the award.

E.

To refrain from entering into any contract, or extension or other modification of a contract, subject to such Executive Order
with a contractor debarred from Government contracts or Federally assisted construction contracts pursuant to part 11,
subpart D, of such Executive Order or to prior authority; and to carry out such sanctions and penalties for violation of the
provisions of the Equal Opportunity Clause as may be imposed upon contractors and subcontractors by the USDA or the
Secretary pursuant to such subpart D.

F.

That if Recipient fails or refuses to comply with these undertakings, the USDA may take any or all of the following actions: (a)
cancel, terminate, or suspend said financial assistance in whole or in part; (b) refrain from extending any further assistance
under the program involved until satisfactory assurance of future compliance has been received from Recipient; and (c) refer
the case to the USDA Office of Civil Rights Enforcement and Adjudications Program Complaint and Adjudication Division,
U.S. Department of Agriculture for appropriate action.
Form RD 5001-3 Page 7 of 13

(3) FEDERAL COLLECTION POLICIES FOR CONSUMER OR COMMERCIAL DEBTS
A.

The Borrower certifies, acknowledges, and agrees that any loss claim(s) paid by the Agency to the Lender on
account of any guarantee made pursuant to this application will be a Federal debt owed to the Agency by the Borrower.
In such a case, the Agency may use all legal collection remedies, including those under the Debt Collection Improvement
Act. The Agency’s right to collect this Federal debt will not be affected by any release provided to the Borrower by the
Lender. Lender agrees that any collection by the Agency of this Federal debt will not be shared with the Lender.

B.

The Agency is authorized by law to take any and all actions in the event your loan payments become delinquent or you
default on your loan:

• Report your name and account information to a credit reporting agency.
• Assess interest and penalty charges for the period of time that payment is not made.
• Assess charges to cover additional administrative costs incurred by the Agency to service your account.
• Offset amounts to be paid to you under other Federal programs.
• Refer your account to a private collection agency to collect the amount due.
• Foreclosure on any security you have given for the loan.
• Pursue legal action to collect through the courts.
• Report any written off debt to the Internal Revenue Service as taxable income.
• If you are a current or retired Federal employee, take action to offset your salary, or civil service retirement benefits.
• Debar or suspend you from doing business with the Federal Government either as a participant or principal throughout
the Executive Branch of the Federal Government for a period of debarment or suspension.
(4) STATEMENT REQUIRED BY THE PRIVACY ACT
The USDA is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et. seq.) or other Acts administered by
USDA to solicit the information requested on USDA application forms.
Disclosure of information requested is voluntary. However, failure to disclose certain items of information requested including your
Social Security Account or Federal Identification Number may result in a delay in the processing of an application or its rejection.
The principal purposes for collecting the requested information are to determine eligibility for USDA credit or other financial
assistance, the need for interest credit or other servicing actions, for the servicing of your loan, and for statistical analysis.
Information provided may be used outside of the Department of Agriculture for the following purposes:

• To provide the basis for borrower success stories in USDA news releases.
• Referral to the appropriate law enforcement agency as required by 40 FR 38924 (1975).
• Referral to employees, business, landlords, creditors or others to determine repayment ability and eligibility for
USDA programs.

• Referral to a contractor providing services to USDA in connection with your loan.
• Referral to a credit reporting agency.
• Referral to a person or organization when USDA decides such referral is appropriate to assist in the collection or servicing of the loans.
• Referral to a Federal Records Center for storage.
Every effort will be made to protect the privacy of applicants and borrowers.

Form RD 5001-3 Page 8 of 13

SUBPART B - 7 CFR 5001.101 - COMMUNITY FACILITIES
1.

PROJECT PURPOSE AND FUNDING:

Item

Borrower Contribution Agency Guaranteed Loan

Other Funds

Total

Land and Rights

Development Costs

Equipment
Debt Restructuring
Initial O&M
Architecture, Engineering, and
Planning

Legal Services
Contingencies
Accounting and Financial Services
Lender & Guarantee Fees
Other

TOTAL
2. Is the Lender willing to provide financing for this project at reasonable rates and terms without the reduced risk derived from the
Agency Loan Guarantee? ___ Yes ___ No
3. If the project is associated with health care, have all applicable certificates, requirements, and state regulations, including Certificate
of Need, been met? ___ Yes ___ No
4. Is the application for 5 or more residential units? _____ Yes _____ No
If yes, attach the Affirmative Fair Housing Marketing Plan.
5. Does the Lender certify that the Borrower has obtained a certificate of support signed by an authorized official from each affected
local government within the service area of the facility? ___ Yes ___ No
6. If the borrower is a private not-for-profit, has the Lender provided evidence that the Borrower has significant ties with the local
rural community in accordance with 7 CFR 5001.101(a)(6)? ___ Yes ___ No (If NO, please attach documentation.)

Form RD 5001-3 Page 9 of 13

SUBPART B - 7 CFR 5001.102 - WATER AND WASTE

1.

PROJECT PURPOSE AND FUNDING:

Borrower Contribution Agency Guaranteed Loan

Item

Other Funds

Total

Land and Rights

Development Costs

Equipment
Debt Restructuring
Initial O&M
Architecture, Engineering, and
Planning

Legal Services
Contingencies
Accounting and Financial Services
Lender & Guarantee Fees
Other

TOTAL

2. Is the Lender willing to provide financing for this project at reasonable rates and terms without the reduced risk derived from the
Agency Loan Guarantee? ___ Yes ___ No
3. Does the Lender certify that the Borrower has obtained a certificate of support signed by an authorized official from each affected
local government within the service area of the facility? ___ Yes ___ No
4. If the borrower is a private not-for-profit, has the Lender provided evidence that the Borrower has significant ties with the local rural
community in accordance with 7 CFR 5001.102(a)(3)? ___ Yes ___ No (If NO, please attach documentation.)

Form RD 5001-3 Page 10 of 13

SUBPART B - 7 CFR 5001.103 - BUSINESS AND INDUSTRY PROGRAMS

1.

PROJECT PURPOSE AND FUNDING:

Item

Borrower Contribution

Agency Guaranteed Loan

Other Funds

Total

Purchase Land
Real Estate Improvements
Furnishing
Equipment
Debt Restructuring
Initial O&M
Professional Fees

Working Capital

Lender & Guarantee Fees
Line of Credit
Other

TOTAL
2. If the project is associated with health care, have all applicable certificates, requirements, and state regulations, including Certificate
of Need, been met? ___ Yes ___ No
3. Is the application for 5 or more residential units? _____ Yes _____ No
If yes, attach the Affirmative Fair Housing Marketing Plan.
4. If appropriate, please attach RD Form 5001-49, “Certification of Non-relocation and Market and Capacity Information Report.”

Form RD 5001-3 Page 11 of 13

SUBPART B - 7 CFR 5001.104 - RURAL ENERGY FOR AMERICA

1. TOTAL PROJECT COST:
$

2. REQUESTED FUNDING AMOUNT:
$

4. USES OF FUNDS:

5. SOURCES OF FUNDS:

Renewable Energy
Energy Efficiency

3. TYPE OF BORROWER:
Agriculture Producer
Rural Small Business

Federal incentives/assistance
State incentives/assistance
Local incentives/assistance
Private Sources

6.

PROJECT PURPOSE AND FUNDING:

Item

Borrower Contribution

Agency Guaranteed Loan

Other Funds

Total

Purchase Land
Real Estate Improvements

Furnishing
Equipment
Debt Restructuring
Initial O&M
Professional Fees

Working Capital

Lender & Guarantee Fees

Other

TOTAL
7. Pursuant to 7 CFR 5001.104(d)(3), is an energy assessment or its equilvant (for loans with total eligible project costs of less than
$50,000) or an energy assessment/audit (for loans with total eligible project costs of $50,000 or more) attached?
______ Yes _____ No
8. Pursuant to 7 CFR 5001.104(d)(2), is the Technical Report attached? ___ Yes ___ No
9. Pursuant to 7 CFR 5001.104(d)(1), does the Lender certify that the project demonstrates technical merit and that the borrower is an
agricultural prodcuer or a rural small business?___ Yes ___ No

Form RD 5001-3 Page 12 of 13