Form EIB 92-37 EIB 92-37 Beneficiary Certificate & Agreement

OMB No. 3048-0022
Expires 02/28/2011

EXPORT-IMPORT BANK BENEFICIARY CERTIFICATE
of the UNITED STATES & AGREEMENT (For Use With)

Print Form

Bank Letter of Credit Export Credit Insurance Policy or
Financial Institution Buyer Credit Export Credit Insurance Policy or
Medium Term Export Credit Insurance Policy
1 Polcyholder

2 Beneficiary

Address

Address

City

State

Zip Code

City

State

Country

Country

Policy Number

Beneficiary's Dun & Bradstreet Number

Zip Code

(to be completed by the policyholder, also see No.4.e)

Taxpayer ID Number

Congressional District

Is the majority ownership of your business represented by:

Women or

a minority

Upon representation that the Export-Import Bank of the United States ("Ex-Im Bank") has issued to the policyholder identified above an
export credit insurance policy, and in consideration of either (check one):
a) the payment, acceptance or negotiation of an irrevocable letter of credit in our favor; or,
b) the financing of an export,
We, the Beneficiary, hereby certify to the policyholder and to Ex-Im Bank as follows:
1. The policyholder has either (check one):
a) informed us of an irrevocable letter of credit with Identification No
and we have presented, or shall
present, documents which are in compliance with the terms and conditions of such irrevocable letter of credit; or,
b) to our belief, established an obligation of the foreign buyer named below to make repayment of funds on a specified
term in support of an export, for which we have received payment.
2. The above referenced irrevocable letter of credit or the buyer's obligation to pay the policyholder is in support of an export transaction
described as follows:
Buyer's Address

a) Name of Buyer

City

New

Used

Zip Code

Country

b) Description and quantity of product(s)/service(s)

c) The product(s) are:

State

If used, attach Used Equipment Questionnaire form EBD-M-25.

d) Place of Shipment

e) Date of Shipment

f) Contract Price to Buyer:
(i)

Products/Service

(ii)

Less discounts or similar allowances

iii)

Plus total insurance, freight or other delivery charges included in the transaction
Subtotal:

iv)
EIB92-37
12/2011

Less cash payment
(minimum 15% required for MT)

(v)

Total final net delivered financed portion

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OMB No. 3048-0022
Expires 02/28/2011

3. To the best of our knowledge and belief, the products described above were shipped from the United States, in accordance with
paragraph 2 above.
4. With respect to products
a) which could be used for military purposes,
b) which could be components of a product or equipment which could be used for military purposes,
c) which could be used to manufacture products or equipment which could be used for military purposes,
d) listed on the United States Munitions List (part 121 of Title 22 of the Code of Federal Regulations), or
e) purchased by or for use by security, military or defense organizations,

we

Initial

have or

the policyholder

Initial

has received the written approval of the Ex-Im Bank for such sale prior to shipment of the products and attached it to this certificate.
Submit a Defense Product Questionnaire EIB92-61 in order to obtain such approval.
5. The products do not consist of technology, fuel, equipment, materials or goods and services to be used in the construction, alteration,
operation or maintenance of nuclear power, enrichment, reprocessing, research or heavy water production facilities.
6. To the best of our knowledge and belief the products are for use only in countries in accordance with Ex-Im Bank's Country Limitation
Schedule in effect on the date of shipment. See Ex-Im Bank's Internet Website www.exim.gov Country and Fee Information.

EIB92-37
12/2011

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CERTIFICATIONS AND NOTICES

OMB No. 3048-0022
Expires 02/28/2011

The Applicant (hereafter “Applicant” or “it”) CERTIFIES, ACKNOWLEDGES and COVENANTS to the Export-Import Bank of the United
States (hereafter “Ex-Im Bank”) that to the best of Applicant's knowledge and belief, after due diligence, the statements set forth below are true
and correct. Any reference below to “this transaction” shall refer to either the individual transaction or the Ex-Im Bank program or Insurance
Policy that is the subject of the application, as appropriate.

A.

B.

C.

D.

E.
F.

Neither Applicant, nor any of its Principals (as defined in the Debarment Regulations identified below), has, within the past 3 years, been:
1) debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a Covered Transaction (as defined in the ExIm Bank and Government-wide debarment regulations, found at 2 CFR Part 3513 and 2 CFR Part 180, respectively) (collectively the “Debarment
Regulations”);
2) formally proposed for debarment from participating in a Covered Transaction, with a final determination still pending;
3) indicted, convicted or had a civil judgment rendered against it for any conduct or offenses described at 2 CFR § 180.800 in the Debarment Regulations;
4) delinquent on any amounts due and owing to the U.S. Government or its agencies or instrumentalities as of the date of execution of this certification; or
5) listed on any of the publically available debarment lists of the following international financial institutions: the World Bank Group; the African
Development Bank; the Asian Development Bank; the European Bank for Reconstruction and Development, and the Inter-American Development Bank;
or
the Applicant has received a written statement of exception from Ex-Im Bank attached to this certification, permitting acceptance of this application
notwithstanding an inability to make all of the certifications in clauses1) through 5) of this section A.
Applicant has conducted and will conduct reasonable due diligence in connection with this transaction, including checking the Excluded Parties List
System (http://www.epls.gov/epls/search.do) (“EPLS”) and the Specially Designated Nationals (“SDN”) List of the Department of the Treasury,
Office of Foreign Assets Control (“OFAC”) (http://www.ustreas.gov/offices/enforcement/ofac/sdn/). Applicant will not knowingly enter into any sales,
leasing or financing agreements in connection with this transaction with any individual or entity that is listed on the EPLS or the SDN List (or is otherwise
prohibited from conducting business with U.S. public and private entities pursuant to OFAC Regulations).
Either: (1)To the best of Applicant's knowledge and belief, no funds have been paid or will be paid to any person in connection with this application for
influencing or attempting to influence:
(a) an officer or employee of any U.S. Government agency, or
(b) a Member of Congress or a Member's employee, or
(c) an officer or employee of Congress;
(This does not apply to commissions paid by the Bank to insurance brokers.)
or (2) Applicant will complete and submit Form-LLL (the Anti-Lobbying Declaration/Disclosure forms available at http://www.exim.gov/tools/appsforms/
documents/eib95-10all.pdf)
Neither Applicant nor any agent or representative acting on Applicant's behalf, has or will engage in any activity in connection with this transaction that is a
violation of: 1) the Foreign Corrupt Practices Act of 1977, 15 U.S.C. § 78dd-1, et seq.; 2) the Arms Export Control Act, 22 U.S.C.§ 2751 et seq., 3) the
International Emergency Economic Powers Act, 50 U.S.C. § 1701 et seq., 4) the Export Administration Act of 1979,50 U.S.C. § 2401 et seq., and,
5) the regulations issued by the OFAC. Applicant also certifies that neither Applicant nor any agent or representative acting on Applicant's behalf, has
been found by a court of the United States to be in violation of any of the foregoing statutes or regulations within the preceding 12 months, and to the best
of its knowledge, the performance by the parties to this transaction of their respective obligations does not violate any of the foregoing or any other
applicable law.
Neither the Applicant nor any agent or representative acting on Applicant's behalf in connection with this transaction is currently under charge or has
been, within the past 5 years, convicted in any court of any country, or subject to national administrative measures of any country, for bribery of public
officials.
The representations made and the facts stated in this application and its attachments are true and Applicant has not misrepresented or omitted any
material facts. Applicant further covenants that if any statement(s) set forth in this application becomes untrue, or is discovered to have been untrue when
made, Applicant will promptly inform Ex-Im Bank of such change. Applicant further understands that in accepting or approving this application, Ex-Im Bank
is relying upon Applicant's statements set forth in the application and on the foregoing certifications, and all statements and certifications to Ex-Im Bank are
subject to the penalties for false or misleading statements to the U.S. Government (18 USC § 1001, et. seq.).

NOTICES
The applicant is hereby notified that information requested by this application is done so under authority of the Export-Import Bank Act of 1945, as amended (12
USC 635 et. seq.); provision of this information is mandatory and failure to provide the requested information may result in Ex-Im Bank being unable to determine
eligibility for support. If any of the information provided in this application changes in any material way or if any of the certifications made herein become untrue,
the applicant must promptly inform Ex-Im Bank of such changes. The information provided will be reviewed to determine the participants' ability to perform and
pay under the transaction referenced in this application. Ex-Im Bank may not require the information and applicants are not required to provide information
requested in this application unless a currently valid OMB control number is displayed on this form (see upper right of each page). Ex-Im Bank reserves the right
to decline to process or to discontinue processing of an application.

Paperwork Reduction Act Statement: Reporting for this collection of information is estimated to average 1/4 hour per response, including reviewing
instructions, searching data sources, gathering information, completing, and reviewing the application. Send comments regarding the burden estimate, including
suggestions for reducing it, to Office of Management and Budget, Paperwork Reduction Project OMB# 3048-0022, Washington, D.C. 20503.

EIB92-37
12/2011

(Signature)

(Print Name and Title)

(Date)
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