Form EIB 92-41 EIB 92-41 EIB 92-41, Application for Financial Institution Short-T

Print Form

Export-Import Bank of the United States

OMB #3048-0019
10/31/2015

APPLICATION FOR FINANCIAL INSTITUTION
SHORT-TERM, SINGLE-BUYER INSURANCE
This application is to b e completed by a financial institution (or a broker acting on its behalf) in order to obtain a short-te rm
insurance policy covering transactions to a single foreign buyer. Repayment terms can be up to 360 days.
An online version of this application is available on Ex-Im Bank’s web site. Ex-Im Bank encourages customers to apply on
line, as it will facilitate our review and allow custom ers a faster response time. Additional information on how to apply for ExIm Bank insurance can be found at Ex-Im’s web site http://www.exim.gov.
Send this completed application to Ex-Im Bank, 811 Vermont Ave NW, Washington, D.C. 20571. Ex-Im Bank will also accept
e-mailed pdf and faxed applications. Ex-Im Bank will not require the orig inals of these app lications to be m ailed. The
application must be PDF s cans of ori ginal applications and all re quired attachments. (Fax number 202.565.3380, e-mail
exim.applications@exim.gov)
____________________________________________________________________________________________________

Applicant/Lender

APPLICATION FORM

The applicant is the financial institution that extends the Ex-Im Bank insured loan to the buyer.
Applicant legal name:

State:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

Broker (if applicable):
Name of Broker:
Ex-Im Bank Broker #:
Contact Person:
Phone number:
Fax:
E-mail:
1. GENERAL QUESTIONS
A. Coverage Types Requested
Risk coverage
Comprehensive Risk
Political Risk

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APPLICATION FOR FINANCIAL INSTITUTION, SHORT-TERM SINGLE-BUYER INSURANCE
Type of credit
Buyer credit (based on applicant’s relationship with the buyer or guarantor)
Supplier credit (based on the applicant’s relationship with the exporter or supplier)
Is this a resubmission of a previously withdrawn, returned or denied application, or a renewal for an existing policy?
Yes
No
If yes, indicate previous transaction number: _________________
B. Primary Reason for applying for this policy
Risk Mitigation
Financing
To offer more competitive terms
C. Primary point of contact for this applicant/application
Lender
Broker
2. SPECIAL COVERAGES
Check the boxes for the special coverages that apply to this transaction. Complete and attach the requested forms,
where applicable.
Shipment to address in the U.S.

Foreign Currency Coverage
-indicate currency ________
- currency of supply contract
US dollar
foreign currency
Warehouse – Attachment IV
Required

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Services

Additional Named Insured
Attachment III - ANI required

Bulk Agriculture

Documentary Cover (question
applicable only to supplier credits)
Attachment II required

Other

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APPLICATION FOR FINANCIAL INSTITUTION, SHORT-TERM SINGLE-BUYER INSURANCE
3. PARTICIPANTS
Provide information on the additional participants to the transaction.
Exporter
The exporter is the U.S. entity that contracts with the buyer for the sale of the U.S. goods and services.
Items marked with an asterisk (*) are required fields. Under corporate ownership, provide name of ultimate parent
company, if there is a corporate owner. For number of employees and sales volume, aggregate for the company and all
its affiliates2, including corporate owners and subsidiaries.
* Exporter's legal name:
* Corporate Ownership:

Tradestyle:
* Street Address:
* City:

*State:

*Primary Industry NAICS1:

* Country:

*Does the Exporter have any affiliates2?:

Yes

* Zip + 4:

No

*Total Number of Employees:

*Annual Sales Volume:

Contact person:

E-mail:

Position title:

Phone:

* Woman-Owned:

Yes

No

'HFOLQHWR$QVZHU

* Minority-Owned:

Yes

No

'HFOLQHWR$QVZHU

* Veteran-Owned:

Yes

No

'HFOLQHWR$QVZHU

Fax:

Supplier
The supplier is the U.S. entity that manufactures the goods and/or performs the services to be exported. Check
if the
exporter is the supplier and there are no additional suppliers. Enter any additional suppliers, or check
various:
* Supplier's legal name:
*Corporate Ownership:

Tradestyle:
* Street Address:
* City:

*State:

*Primary Industry NAICS1:

* Country:

*Does the Supplier have any affiliates2?:

Yes

* Zip + 4:

No

*Total Number of Employees:

*Annual Sales Volume:

Contact person:

E-mail:

Position title:

Phone:

* Woman-Owned:

Yes

No

'HFOLQHWR$QVZHU

* Minority-Owned:

Yes

No

'HFOLQHWR$QVZHU

* Veteran-Owned:

Yes

No

'HFOLQHWR$QVZHU

Fax:

1A

company’s Primary Industry NAICS codes is the NAICS that accounts for the largest share of sales for the most recently completed fiscal year. The full
definition of “primary industry” is set forth at 13 C.F.R. § 121.107.
2Affiliations exist when one individual or entity controls or has the power to control another or when a third party or parties control or have the power to
control both. Factors such as common ownership, common management, previous relationships with or ties to another entity, and contractual relationships
may cause affiliation. The complete definition of affiliation is found at 13 C.F.R. § 121.103.

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APPLICATION FOR FINANCIAL INSTITUTION, SHORT-TERM SINGLE-BUYER INSURANCE
Buyer
The buyer is the entity that contracts with the exporter for the purchase of U.S. goods and services.
Buyer legal name:

Postal Code:

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:

Fax:

Guarantor
The guarantor is the person or entity that agrees to repay the credit if the buyer does not. Refer to the short-term credit
standards to determine in what circumstances personal or corporate guarantors are required.
Is a guarantor involved in this transaction? Yes
No
If yes, is the guarantor

an individual or

a company?

Guarantor legal name:
Contact person:

Country:
E-mail:

Position title:

Phone:

Street Address:
City:

Postal Code:

Fax:

End-user
The end-user is the foreign entity that uses the U.S. goods and services:
Check if the end-user is also the buyer.
End-user legal name:

Province :

Contact person:
Position title:

Country:
E-mail:

Street Address:

Phone:

City:

Postal Code:

Fax:

Agent:
An agent is a business entity or individual located in the country of the borrower or buyer who has assisted in the sourcing,
packaging, and/or preparation of a request for support from Ex-Im Bank, and which will receive compensation in some form for
their services.
Is an agent involved in this transaction? yes no
If yes, add the agent information below:
Agent legal name:

Province :

Contact person:

Country:

Position title:

E-mail:

Street Address:

Phone:

City:
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Postal Code:

Fax:
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Related Parties
Describe any direct or indirect ownership or family relationship that exists between any of the participants. If none, so indicate:
None.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Primary Source of Repayment (PSOR)
The PSOR is the entity whose financial statements form the basis of Ex-Im Bank’s evaluation of reasonable assurance of
repayment, i.e. the entity whose financial statements Ex-Im Bank uses to supply calculate the ratios for short-term credit
standards compliance. For this transaction, indicate whether the PSOR is:
the buyer,
the corporate guarantor, or
business combination, (e.g. the consolidated or combined financial statements of the buyer and one or more corporate
guarantors.). If business combination, indicate which entities comprise the
combination____________________________________________________________________________________________
No

Is the PSOR a financial institution?

Yes

Select the risk category:

Private sector

Does the PSOR have a bond rating?

Yes

Public sector

No

If yes, indicate the name of the rating agency, rating, and the date of the rating.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4. TRANSACTION DESCRIPTION AND ELIGIBILITY
Provide a description of the products or service, including their NAICs code, if known:
______________________________________________________________________________________________________
Answer the following questions about the products or services.
Is each product produced or manufactured in the United States?
yes no

Are these products on the munitions control list?
Are the products new or used?

yes
new

Are the products capital goods that will be used to produce exportable products? yes

no
used
no

If yes, provide an explanation: ____________________________________________________________________________
Has this transaction been considered by any other export credit insurer?

yes

no

If yes, provide an explanation: ___________________________________________________________________________

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5. FINANCED AMOUNTS AND STRUCTURE
Enter the %s for each payment term the exporter will extend to the buyer
Payment terms requested
Payment
Sight
type
Cash

Against
Documents
Sight Draft 
Documents
Against
Payment
Sight Draft
Documents
Against
Acceptance
Open Acct.
Prom Note

Up to 30

Up to 60











(number of days)
Up to 90
Up to 120





Up to 180

Up to 270

Up to 360







Enter the details of the transaction below:
Single financing
Revolving line
the transaction is still being negotiated
Indicate whether:
the financing mandate has been received
Credit Limit requested: $ _______________________________________________________________________________

This application is for:

Requested effective date: _______________________________________________________________________________
6. CREDIT INFORMATION ON THE PSOR
The information requested in Attachment I: Credit Information is attached.
7. CERTIFICATIONS AND NOTICES
The Applicant (hereafter “Applicant” or “it”) CERTIFIES, ACKNOWLEDGES and COVENANTS to the ExportImport 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. 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 Ex-Im 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;
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APPLICATION FOR FINANCIAL INSTITUTION, SHORT-TERM SINGLE-BUYER INSURANCE
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 clauses 1) through 5) of
this section A.
B. Applicant has conducted and will conduct reasonable due diligence in connection with this transaction, including checking
the System for Award Management (https://www.sam.gov/portal/public/SAM/) (“SAM”) to determine if parties are
excluded from U.S. Government transactions, 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 SAM or the SDN List (or is otherwise prohibited from conducting business
with U.S. public and private entities pursuant to OFAC Regulations).
C.

If any funds have been paid 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 insure or guarantee a loan, the
undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” (http://
www.exim.gov/pub/ins/pdf/lll.pdf) 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.

D.

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.

E.

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.

F.

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: We estimate that it will take you about 1 hour(s) 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, OMB# 3048-0023 Washington, D.C. 20503.

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Signature

Print Name and Title

Date
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APPLICATION FOR FINANCIAL INSTITUTION, SHORT-TERM SINGLE-BUYER INSURANCE

Attachment I: Credit Information Requirements
Directions: The required credit information depends on the type of PSOR (non-financial institution or a financial institution)
and on the amount of credit support requested. Check the boxes that are applicable to your transaction.
1.

The PSOR is not a financial institution
a) Provide details of the applicant’s experience with the buyer
yes
Does the applicant have any experience with the buyer?

no

If yes, provide the following information:
Date of first transaction with the buyer: _______________________________________________________________
Date of first credit transaction with the buyer: __________________________________________________________
Has the applicant visited the buyer?

yes

no

If yes, indicate the date of the last visit and provide a call report.___________________________________________
Describe the credit facilities extended to the buyer:

short-term
medium-term
long-term
security
none

Total credit limit available to the buyer/corporate guarantor ________________________________________________
Total outstanding short-term balances ________________________________________________________________
Total outstanding medium-term or long-term balances ___________________________________________________
Credit performance

satisfactory

unsatisfactory

Has the applicant ever had credit insurance for the buyer or corporate guarantor before?

yes

no

If yes, enter the name of the insurer, and coverage dates and amounts _______________________________________
_______________________________________________________________________________________________
b) Provide the below supporting financial information on the PSOR.
x
x
x
x
x
x

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A credit report on the PSOR dated within six months of the application
Two trade references on the PSOR of similar amounts and payment terms and dated within six months of the
application
A bank reference on the PSOR not older than 6 months from the date of application
the applicant’s credit memorandum on the PSOR
the applicant’s call report on the PSOR (if applicable)
Three fiscal year end audited financial statements with notes and the most recent interim statements with
notes if the last fiscal year end is more than nine months prior to application

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PSOR is a financial institution

2.

a) Provide details of the applicant’s experience with the financial institution guarantor. Include dates and amounts of
none
previous transactions with the PSOR or indicate
_____________________________________________________________________________________________
b) Provide the applicable supporting financial information on the PSOR:
Check the box that applies to your transaction and provide the information noted below the box
The transaction is for an amount up to $1 million:
x One short-term debt rating of the PSOR from S&P, Moody’s or Fitch. Rating must be B, P-3 or F3 or better.
The transaction is for between $1,000,001 and $10,000,000
x One short-term debt rating of the PSOR from S&P, Moody’s or Fitch. Rating must be B, P-3 orF3 or better.
x

If the PSOR does not have an acceptable current market rating, provide most recently publishe d audited financial
statements that ade quately disclose financial condition a nd were prepared in acc ordance with accounting princi ples
that afford a reasonable basis for reliance on the information provided.

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Attachment II. Documentary Cover Attachment
If the credit is a supplier credit, and documentary cover is requested, provide the following:
x A bank reference on the exporter dated within six months of the application
x Two trade references on the exporter dated six months of the application
x Financial statements on the exporter as follows
$500,000 or less signed by an authorized office for the exporter
$500,001 - $999,999 reviewed by a CPA with notes attached
$1,000,000 or more audited by a CPA with opinion and notes attached
Note that typically documentary cover is only provided for a supplier credit when the exporter/supplier is a small
business. Call Ex-Im Bank’s Trade Finance and Insurance Division at 202-565-3400 with further questions.

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Attachment III: Additional Named Insured Questionnaire
Indicate the name of the additional named insured as follows:
Legal Name:________________________________________________________________________________
Address: ___________________________________________________________________________________
City: ______________________________________________________________________________________
State: ______________________________________________________________________________________
Country: ___________________________________________________________________________________
Zip/ Postal Code: ____________________________________________________________________________
Relationship to Applicant: ______________________________________________________________________
Role in the transaction: ________________________________________________________________________
Contact: ___________________________________________________________________________________

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Attachment IV – Warehouse Information
If you requested the Special Coverage – Warehouse, answer the following questions about the warehouse
Warehouse Type:

Owned or controlled by exporter
Bonded warehouse
Neither, provide details

Warehouse Location:

City ___________________________
State/Province __________________
Country________________________

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Attachment V
Anti-Lobbying Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid 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 insure or guarantee a loan, the
undersigned shall complete and submit Standard Form-LLL, ``Disclosure Form to Report Lobbying,'' (available at
www.exim.gov/pub/ins/pdf/lll.pdf) 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.

Signature

Title

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