Form EIB 92-34 EIB 92-34 Application for Short-Term Letter of Credit Export Credi

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OMB No. 3048-0009
Expires: Pending

APPLICATION
FOR SHORT-TERM LETTER OF CREDIT
EXPORT CREDIT INSURANCE POLICY
App. Number (EXIM Bank Use Only)

This application is to be completed by a financial institution (or a broker acting on its behalf) in order to obtain a short-term letter
of credit insurance policy. An online version of this application is available on EXIM Bank’s web site. EXIM Bank encourages
customers to apply online, as it will facilitate our review and allow customers a faster response time. Additional information on
how to apply for EXIM Bank insurance can be found at EXIM’s web site http://www.exim.gov.
Send this completed application to EXIM Bank, 811 Vermont Ave NW, Washington, D.C. 20571. EXIM Bank will also accept emailed pdf and faxed applications. EXIM Bank will not require the originals of these applications to be mailed. The application
must be PDF scans of original applications and all required attachments. (Fax number 202.565.3675, e-mail
exim.applications@exim.gov)
APPLICANT
Applicant Name:

Phone #:

Contact Person:

Fax #:

Position Title:

E-mail:

Street Address:

Duns #:

City:

State/Province:

NAICS code:
Website:

Nine-digit zip code:

Does the applicant have a market rating?

Yes

No

Country:

If yes, indicate the name of the rating agency, rating, and the date of the rating.

Please provide the following information from the applicant’s most recent audited financial statements.
Statement period (fiscal or interim):

Are the financial statements combined or consolidated?

Financial Statement Dates:

Auditor:

Opinion:

Net Income:

Net Loans:

Total Assets

Equity:

Broker: If Applicable
Name of Broker:

Phone #:

Ex-Im Bank Broker #:

Fax #:

Contact Person:

E-mail:

Affiliate(s) (if applicable)
Please provide the following information for any subsidiaries, branches, or affiliates that the applicant would like us to consider
adding as Additional Named Insureds under the policy.
Legal Name:

Phone #:

Contact Person:

Fax #:

Position Title:

E-mail:

Street Address:

Nine-digit zip code:

City:
EIB 92-34
Revised 10/2017

State/Province:

Country:

1. General Questions
Insurance
A. Indicate the EXIM Bank programs the applicant has used.
Local
State
B. What type of charter does the applicant hold?
C. Indicate the name of the applicant’s regulatory authority.
D. Does the applicant have any foreign government ownership?
If yes, please indicate the country and the percentage owned:

OMB No. 3048-0009
Expires: Pending

Working Capital

Loan Guarantee

E. Letter of Credit Experience
• In what year did the applicant’s letter of credit business begin?
• What was the total amount of letter of credit transactions in the last 12 months?
• What was the total number of letter of credit transactions in the last 12 months?
• Please provide the following information on the individuals responsible for administering the letter of credit policy:
Name

Title

Years of Trade Finance Experience

Years of Letter of Credit Experience

2. Letter of Credit Portfolio
What is the expected maximum value of letters of credit outstanding at any time over the next 12 months?
Please provide the following details regarding projected transactions to be insured over the next 12 months.
Country

Number of Issuing Banks

Total Letters of Credit

Total Letters of Credit #

3. Attachments
Please provide any information (e.g., the applicant’s most recent annual report) that would be helpful in evaluating this
application.

EIB 92-34
Revised 10/2017

CERTIFICATIONS AND NOTICES

OMB No. 3048-0009
Expires: Pending

The Applicant (hereafter “Applicant” or “it”) CERTIFIES, ACKNOWLEDGES and COVENANTS to the Export-Import Bank of the United
States (hereafter “EXIM 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 EXIM 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 publicly 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 EXIM 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 EXIM Bank of such change. Applicant further understands that in accepting or approving this
application, EXIM Bank is relying upon Applicant’s statements set forth in the application and on the foregoing certifications, and all statements and
certifications to EXIM 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 EXIM 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 EXIM 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. EXIM 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). EXIM 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 per response 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 # 3048-0009 Washington, D.C. 20503.

EIB 92-34
Revised 10/2017

(Signature)

(Print Name and Title)

(Date)