Form EIB 94-07 EIB 94-07 Exporter's Certificatge for Use with a Short Term Export

EXPORT-IMPORT BANK
of the UNITED STATES

OMB No. 3048-????
Expires 02/12/2012

EXPORTER'S CERTIFICATE
FOR USE WITH A SHORT TERM
EXPORT CREDIT INSURANCE POLICY

Print Form

Policyholders must keep this document and submit it with a Proof of Loss (Claim)
1. Name and Address of Policyholder:

2. Name and Address of Supplier

Name

Name

Address

Address

City

State

City

Zip Code

State

Tax ID #

Policy#:
(to be completed by policyholder, also see B.4.e)

Zip Code

Congressional District:

Supplier's Dun & Bradstreet No.
Indicate (not required) if owned by a woman, or an ethnic minority, describe:

I. To be completed by the policyholder:
The supplier is either the beneficiary of a letter of credit, or the recipient of a funding under a direct buyer credit loan, or the recipient of
the buyer's payment under a reimbursement loan under a Financial Institution Buyer Credit Policy or a Bank Letter of Credit Policy. The
supplier must complete and certify to Sections A and B and sign.
The supplier is not a beneficiary or recipient as described above. The supplier must complete and certify to Section B only and sign.
NOTE: The policyholder must also obtain a Beneficiary Certificate EIB92-37 from the beneficiary.
II. To be completed by the supplier.
Upon representation that the Export-Import Bank of the United States ("Ex-Im Bank") has issued an export credit insurance policy to the
policyholder identified above and, in consideration of the payment, acceptance or negotiation of an irrevocable letter of credit in support of
an export or the financing of an export or the receipt of funding, as a result of an export, either to us or another beneficiary we, the
supplier, hereby certify to Ex-Im Bank and to the policyholder that the policyholder has (check one):
informed us of an irrevocable letter of credit with Identification No.
related to the transaction described in
Section B and we have presented, or shall present, documents which are in compliance with the terms and conditions of such irrevocable
letter of credit; or,
to our belief, established an obligation of the foreign buyer named in Section B to make repayment of funds on a specified term in support
of an export for which we or another beneficiary will receive payment or have received payment on
(date); or,
to our belief, provided a financing facility to the foreign buyer named below in support of the export described in Section B which has been
made on a documentary collection, sight payment basis, the proceeds of which will be paid to us or another beneficiary; or

A

1. To the best of our knowledge and belief, the products were shipped from the U.S.
2. To the best of our knowledge and belief the products are for use in accordance with the terms and conditions of 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.
3. Neither we nor our Principals are currently, nor have been within the preceding three years:
a) debarred, suspended or declared ineligible from participating in any Covered Transaction; or,
b) formally proposed for debarment, with a final determination still pending; or,
c) voluntarily excluded from participation in a Covered Transaction; or,
d) indicted, convicted or had civil judgement rendered against it for any of the offenses listed in the Regulations governing
Debarment and Suspension (Governmentwide Nonprocurement Debarment and Suspension Regulations; Common Rule)
which define Covered Transaction and Principals.

EIB-94-07
Revised 4/12

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EXPORTER'S CERTIFICATE For Use With H A SHORT TERM EXPORT CREDIT INSURANCE POLICY

OMB No. 3048-????
Expires 02/12/2012

In addition, we are not listed on any of the publicly available debarment lists of the following international financial institutions: World Bank
Group, African Development Bank, Asian Development Bank, European Bank for Reconstruction and Development and the Inter-American
Development Bank.
4. Neither we nor our principals are 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.
5. We have not engaged, and will not engage, in any activity in connection with this transaction that is a violation of the Arms Export
Control Act, 22 U.S.C. 2751 et seq., the International Emergency Economic Powers Act, 50 U.S.C. 1701 et seq., or the Export
Administration Act of 1979, 50 U.S.C. 2401 et seq. We have not been found by a court of the United States to be in violation of
any of these statutes within the preceding 12 months, and to the best of our knowledge, the performance by the parties to this
transactio n of their respective obligations does not violate any other applicable law.
6. Neither we nor anyone acting on our behalf, such as agents, have engaged, or will engage, in any activity in
connection with this transaction that is a violation of the Foreign Corrupt Practices Act of 1977, 15 U.S.C. 78dd-1, et seq. (which
provides for civil and criminal penalties against companies and individuals who directly or indirectly make a facilitate corrupt
payments to foreign officials to obtain or keep business).
Further, neither we nor anyone acting on our behalf in connection with this transaction are currently under charge or have been,
within the past 5 years, convicted in any court or been subject to national administrative measures or any country for bribery of
foreign public officials.
To the best of our knowledge, the performance by the parties of their respective obligations covered or to be under this
transaction does not and will not violate any applicable law.

B
1. 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:
a) Name and address of buyer
b) Description and quantity of product(s)/service(s)
c) The product(s) are :

New,

Used. If used attache 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) Less cash payment if any (not required) $
(v) Total final net delivered financed portion $
2. Discounts and Allowances. We have not granted or paid, agreed to grant or pay, offered to grant or pay, caused to be granted or
paid, or arranged for, directly or indirectly, any discount, allowance, rebate, commission, fee or other payment, entered into any
barter, buyback, countertrade or offset agreement or other similar agreement in connection with the sale or, or for obtaining the
contract to sell, the products/services described above, except:
a) the discounts and allowances to the buyer, if any, stated above, or,
b) the regular remuneration of our regular full-time directors, officers and employees; or,
c) regular commissions or fees, if any, to our regular sales agent or representative in the country of the buyer,or,
d) other payments, as follows:
Payee or Intended Payee

Address

Amount

(If None, then the word "none" must be inserted in order for this certificate to be considered complete. If any payee is named, a
statement must be attached showing the reason for payment and method of calculation.)

EIB-94-07
Revised 4/12

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EXPORTER'S CERTIFICATE For Use With H A SHORT TERM EXPORT CREDIT INSURANCE POLICY

OMB No. 3048-????
Expires 02/12/2012

3. (a) For SBA defined Small Businesses Only (check appropriate box)
Each of the products itemized in the invoice(s) was manufactured or reconditioned with more than 50% U.S. content (comprised
of all direct and indirect costs including but not limited to, labor, materials, research and administrative costs, but excluding net
profit).
One or more of the products itemized in the invoices(s) was manufactured or reconditioned with 50% or less U.S. content and I
have attached a list with Invoice No., Product Name and the dollar value of the U.S. Content % of each such product.
If a Content Report with respect to each invoice was submitted to the lender at the time of funding you may certify to
one of the following:
The percentage of the aggregate U.S. content (as defined above) of all products on each invoice is more than 50% of the
entire value of the invoice.
The aggregate U.S. content percentage of all products on one or more invoices is, in the aggregate, 50% or less of the entire
value of the invoice. I have attached a list with Invoice No. and dollar value of the aggregate U.S. Content % of each such
invoice.
(b) For Non-SBA Defined Small Businesses: Each of the products itemized in the invoice(s) was manufactured or
reconditioned with more than 50% U.S. content (labor, materials and components, but excluding net profit);
(c) If services were provided, all services were performed exclusively by U.S. personnel (either in the U.S. or on-site);
(d) If commodities were sold, all such commodities were exclusively of U.S. origin; and
In each relevant case above, no value was added to the product by us after export from the U.S.
4. With respect to products/services which, to the best of our knowledge,
a) could be used for military purposes;
b) could be components of a product or equipment which could be used for military purposes;
c) could be used to manufacture products or equipment which could be used for military purposes;
d) are listed on the U.S. Munitions List (part 121 of Title 22 of the Code of Federal Regulations); or,
e) are purchased or are for use by military, defense or security organizations,

we
have or
the policyholder
has received the written approval of Ex-Im Bank for such sale of the
products under the
policy and
Initial
Initial
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.

***********
SIGNATURES
With knowledge that Ex-Im Bank will rely on the certifications and representations made in this certificate, we agree to be liable for all
damages including related costs suffered by Ex-Im Bank's reliance on such certifications and representations. We further understand that
this certification is subject to the penalties for fraud provided in Article 18 U.S.C., Section 1001.
We are certifying to Sections (check appropriate box(es):
A
B
Signature

By
Print Name (Authorized Representative of the Supplier

Title

Date

If the supplier can not make any or all of the required certifications as they are presented here, Ex-Im Bank must be contacted to request
written permission to delete or alter the certification, without which the insurance policy may not be valid.

EIB-94-07
Revised 4/12

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OMB No. 3048-????
Expires 02/12/2012

CERTIFICATIONS AND NOTICES

Paperwork Reduction Act Statement: We estimate that it will take you about 15 minutes to complete this form. This includes the time it
will take to read the instructions, gather the necessary facts and fill out the form. However, you are not required to provide information
requested unless a valid OMB control number is displayed on the form. If you have comments or suggestions regarding the above
estimate or ways to simplify this form, forward correspondence to Ex-Im Bank and the Office of Management and Budget, Paperwork
Reduction Project, Washington, D.C. 20503.

EIB-94-07
Revised 4/12

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