RD 1940-Q, Exhibit Statement for Loan Guarantees

RD Instruction 1940-Q
Exhibit A-2

STATEMENT FOR LOAN GUARANTEES
The undersigned states, to the best of his or her knowledge and belief,
that:
If any funds have been or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this commitment providing for the United States to
guarantee a loan, the undersigned shall complete and submit Standard Form LLL, "Disclosure of Lobbying Activities," in accordance with its instructions.
Submission of this statement is a prerequisite for making or entering into
this transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required statement shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each such failure.

______________________________________
(name)

_________________________________
(organization)

______________________________________
(title)

_________________________________
(date)

oOo

(08-21-91)

PN 171