Form DOT F 2326-2 DOT F 2326-2 TIFIA_RRIF Application_Form

OMB Control Number: 2105-0569; Expiration Date: [●], 2021

Application for RRIF and TIFIA Credit Assistance Fiscal Years 2018 - 2021

The Build America Bureau (the “Bureau”) was created to streamline and improve access to U.S. Department of Transportation (the “Department”) Federal credit programs. As part of its mission, the Bureau is responsible for administering the application processes for the Railroad Rehabilitation and Improvement Financing (“RRIF”) and the Transportation Infrastructure Finance and Innovation Act of 1998 (“TIFIA”) credit programs.

This form is the application (“Application”) to be used by the entity (referred to herein as the “Borrower”) seeking Federal credit assistance under the RRIF and TIFIA credit programs. 45 U.S.C. 823 and 23 U.S.C. 602. Under the Paperwork Reduction Act of 1995, a federal agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is [2105-0569]. A Borrower applying under the TIFIA credit program must submit a Letter of Interest (“LOI”) to the Bureau before submitting an Application for TIFIA credit assistance. 23 U.S.C. 602(a)(1)(A). A Borrower applying under the RRIF credit program is encouraged to submit an LOI to the Bureau before submitting an Application for RRIF credit assistance in order to describe its project, demonstrate the proposed Borrower’s ability to meet DOT’s creditworthiness requirements, detail how applicable statutory eligibility requirements are met, and outline the proposed financial plan. The Department estimates that it will generally take applicants fewer than one hundred (100) person-hours to assemble a single Application. Submitting an LOI will reduce the time spent preparing a complete RRIF Application. The LOI form for both credit programs can be located here.

The Bureau will only accept Applications from Borrowers whose projects and creditworthiness have met or are likely to meet applicable statutory eligibility requirements, including satisfying a full review of the creditworthiness of the Borrower and the project. A Borrower seeking credit assistance under both programs may submit a single Application, except in certain circumstances. The Bureau will use the information provided in a completed Application to evaluate recipients for credit assistance in accordance with the applicable RRIF and TIFIA requirements. Borrowers may be asked to provide additional supporting evidence, clarify or quantify details, or update previously submitted information during the Application review process.

Details about how to submit are included in Section F. An Application checklist is appended to the form.

DETAILED GUIDANCE WITH RESPECT TO SPECIFIC SECTIONS OF THIS APPLICATION IS AVAILABLE IN THE BUREAU CREDIT PROGRAMS GUIDE. THE CREDIT PROGRAMS GUIDE CAN BE DOWNLOADED HERE.

If you still have questions regarding this form, please contact the credit underwriter assigned to your project or the Bureau at (202) 366-2300 or BuildAmerica@dot.gov.

Summary Information

Borrower Name: Click or tap here to enter text.

Project Name: Click or tap here to enter text (the “Project”)

Project Location: Click or tap here to enter text.

☐ TIFIA Amount Requested: $ Click or tap here to enter text.

Estimate of Eligible Project Costs: $ Click or tap here to enter text.

Credit Instrument Requested: Click or tap here to enter text.

☐ RRIF Amount Requested: $ Click or tap here to enter text.

Estimate of Eligible Project Costs: $ Click or tap here to enter text.

Credit Instrument Requested: Click or tap here to enter text.

Duplicate this box as necessary for master credit agreement requests.

SECTION A: Borrower Contact Information

1. Legal Name and Principal Business Address
   Click or tap here to enter text.

2. Authorized Point of Contact. Provide the name, title, and contact information of the person authorized to be the point of contact for all matters related to this Application.
   
   

1. Name and Title: Click or tap here to enter text.

2. Email Address:Click or tap here to enter text.

3. Telephone Number:Click or tap here to enter text.

4. Mailing Address (if different from principal business address) – include for both U.S. mail and courier purposes (i.e., no P.O. Box) address:
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SECTION B: Borrower Information

This Section B should not exceed 10 pages, excluding attachments.

1. Background Information and Legal Authority

1. Describe the Borrower’s place and date of incorporation or organization and the state(s) and territory(ies) in which the Borrower does business.
   Click or tap here to enter text.

2. Describe the legal authority of the Borrower to carry out the Project activities described in Section C and to levy taxes, issue debt, charge tolls or other fees, and/or receive dedicated funding from another entity, as applicable. Include as Attachment B-1 a copy of the statutory authority under which the entity was created or its incorporation documents.
   Click or tap here to enter text.

3. Include a link to the Borrower’s, or its controlling entities’, web site, if available. Click or tap here to enter text.

2. Organization and Management

1. Describe the Borrower’s management structure, identifying the legal names of key principals (e.g., director and chief financial officer) and any recent or proposed changes to the management structure. Provide a management organizational chart showing the management structure and reporting relationships among individuals as Attachment B-2.
   Click or tap here to enter text.

2. Describe the Borrower’s corporate structure, identifying the relationship between all legal entities in the corporate or quasi-corporate family, including subsidiaries. Provide a company organizational chart showing the ownership relations among legal entities as part of Exhibit B-2.
   Click or tap here to enter text.

3. Identify Other Names under which Borrower Does Business.
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3. Past Performance and Experience with Federal Assistance

1. Briefly describe three examples of projects that are similar in size, cost, and scope to the Project that the Borrower (including its parents or subsidiaries, if applicable) has successfully completed or is currently implementing. Indicate whether these projects received Federal financial assistance.
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2. Identify any prior projects for which the Borrower (including its parents or subsidiaries) has received RRIF or TIFIA credit assistance.
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3. Federal Tax Identification Number:
   Click or tap here to enter text.

4. Data Universal Numbering System (DUNS) Number: Click or tap here to enter text.

5. Status of Registration in the Federal System for Award Management (SAM):
   ☐ Active
   ☐ Inactive, or not yet registered

4. Borrower Eligibility.

1. Select the Borrower’s entity type.

1. If “Other”: Click or tap here to enter text.

2. Freight railroads only: Identify your revenue class.

TIFIA Borrowers Only

b. Private Borrowers must provide the name and a brief description of the public entity sponsoring the Project for state/local planning purposes. See also Section C-7.
Click or tap here to enter text.

RRIF Joint Venture Borrowers Only

c. If you selected “Joint Venture” in Section 2.a, provide the following information about the Joint Venture party that is eligible to apply for a RRIF loan (referred to in this section as the “JV eligible applicant”). See the Credit Programs Guide for more information.

1. Identify the legal name and principal business address of the JV eligible applicant:
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ii. Identity the JV eligible applicant’s entity type:

iii. Identify the government, state or territory under which the JV eligible applicant is organized or incorporated:
Click or tap here to enter text.

iv. Describe the overall corporate and management structure of the JV eligible applicant, as applicable. Attach a company organizational chart showing the ownership relations among legal entities as Attachment B-3:
Click or tap here to enter text.

v. Provide a link to the JV eligible applicant’s web site, if available.
Click or tap here to enter text.

vi. Provide the name, title, and contact information of the person authorized to be the point of contact for the JV eligible applicant for all matters related to this Application:
Click or tap here to enter text.

vii. Describe the nature of the Joint Venture relationship. Attach documentation supporting the existence of the Joint Venture as part of Attachment B-3.
Click or tap here to enter text.

viii. If your Joint Venture includes parties other than the Borrower and the JV eligible applicant, describe them here.
Click or tap here to enter text.

SECTION C: Project Information

This Section C should not exceed 10 pages, excluding the attachments.

☐ Check this box if requesting a master credit agreement and duplicate this Section C for each project to be covered under the master credit agreement. For information about master credit agreements, see the Credit Programs Guide.

☐ TIFIA State Infrastructure Bank Projects: Check this box if the Borrower will be a state infrastructure bank (SIB) seeking to capitalize or fund a rural projects fund with the proceeds of a secured TIFIA loan. See the Credit Programs Guide for more information about SIB projects. SIB Borrowers must provide the information required of this Section C for each project that the SIB anticipates offering a loan; the ten-page limit will apply per project.

1. Project Name. This name should match the summary information identified on page 1 of this Application.
   Click or tap here to enter text.

2. Project Location

1. Describe the location of the Project. Wherever possible, identify: each city and/or county, Metropolitan Statistical Area (MSA), if applicable, and state in which the Project is located; the cities and/or counties that the Project will serve; any major highways, rail or transit routes intersecting the Project; and the Congressional districts impacted by the Project. If the Project will cross state lines, please provide the above information for each state impacted.
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2. Attach a vicinity map showing the Project’s location, impacted cities and/or counties and states, and all major highways, rail or transit routes as Attachment C-1. Provide a high-level map of the Project showing major design elements as part of Attachment C-1.

3. ☐ Check this box if the Project is a surface transportation project located wholly or partially outside of an urbanized area with a population greater than 150,000 individuals, as determined by the U.S. Census Bureau. Provide information about the area in which the Project will be implemented and the population, as determined in the latest Census. Click or tap here to enter text.

3. Project Description

1. Describe the Project scope, inclusive of all major work activities and design elements, consistent with the detailed Project budget to be provided in Section D. Describe all features to be constructed and construction phases. Identify the anticipated useful life of the Project, the method of Project delivery (e.g., design-bid-build, design-build, etc.), and the key Project agreements. Click or tap here to enter text.

2. ☐ Public-private partnerships. Provide as Attachment C-2 the value-for-money (or comparable) analysis undertaken by the Project sponsor before deciding to advance the Project as a public-private partnership.

3. Provide as Attachment C-3 concise conceptual design plans that identify all elements of Project scope.

3. Project Schedule

1. Anticipated Revenue Service Commencement Date: Click or tap to enter a date.

2. Anticipated date to commence procurement of construction contractors for the Project: Click or tap to enter a date.

3. Identify the start and completion dates for each major phase or milestone of the Project including, as applicable: preliminary engineering and environmental documentation, final design, right-of-way acquisition, procurement of construction contracts, construction, vehicle acquisition, start-up and testing, and revenue service. Also, identify the anticipated dates for securing anticipated Federal financial assistance (including closing of the Bureau credit agreement).
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4. Provide as Attachment C-4 a detailed project schedule showing, as a minimum, the milestones identified in Section 4.c.
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5. If you are requesting expedited processing, explain why your Application and Project are suitable candidates for expedited processing. See the Credit Programs Guide for more information.
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3. Project Team

1. Describe the relevant Project parties to include the Borrower, the Project sponsor (if different), the Borrower’s equity sponsors (as applicable), principal project contractors, material subcontractors (e.g., for engineering, rolling stock, tunnel boring, systems, operations and maintenance), financial and legal advisors (as applicable), and lenders.
   Click or tap here to enter text.

2. Provide as Attachment C-5 an organizational chart identifying the relationships between the parties identified in Section 5.a.

3. Local Funding Partners. Identify any local entities that are anticipated to contribute funding, real property, design or construction of discrete elements of Project work, or other valuable consideration to the Project (other than permits or land use approvals, etc.) and the status of such contributions. Provide documentation and evidence of such contributions as part of Attachment C-6.
   Click or tap here to enter text.

3. Transportation Planning and Programming Approvals. If applicable, provide as Attachment C-7 evidence of the Project’s inclusion in the long-range transportation plan, the metropolitan transportation improvement program (TIP), and the approved statewide transportation improvement program (STIP) of each state affected by the Project. Information relating to state freight plans and state rail plans should also be included, if applicable. Only the cover page and applicable page of each document should be provided.

3. Environmental Review

1. Describe the status of the Project’s environmental review and any steps remaining for Project to obtain a final agency decision. If final agency decision(s) have already been received, provide a copy of the decision(s) as Attachment C-8.
   Click or tap here to enter text.

2. Identify and explain any differences between the Project as analyzed in the applicable environmental document(s) and the Project scope provided in this Application.
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3. Summarize the quantitative or qualitative details of benefits to the public that the Project will achieve, particularly as analyzed in the environmental review document(s).
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3. Project Management and Compliance Monitoring Plan

1. Describe, at a level of detail appropriate to the size and scope of the Project, how the Borrower will ensure delivery of the Project as planned, within budget, and in accordance with Project commitments, terms of any credit agreement, and applicable Federal regulations and provisions of Federal law. This description should include: (a) information on the roles and responsibilities of all entities with decision-making authority for the Project; (b) reporting processes that document status, changes, delays, and potential risks to the Project; and (c) coordination processes that provide for advance notification of potential issues to appropriate agencies (including the Bureau, as required by any credit agreement) and timely resolution of issues.
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2. Provide any technical or independent engineering reports prepared for the Project as Attachment C-9.

3. Risks and Mitigation Strategies. Identify risks to Project completion and sufficiency of revenues in operations (as applicable). Sample risks might include cost escalation, approvals, litigation, construction schedules, ridership and traffic levels, risk related to availability payments, availability of grant funding, and market access and operations. Identify all mitigation strategies and any proposed cost-containment approaches (e.g., design-build, value engineering, guaranteed maximum price and/or completion date, warranties, or other incentive/disincentive clauses).
   Click or tap here to enter text.

3. Litigation. Disclose any current, threatened, or pending litigation that could, if successful, have a material adverse effect on the Project.
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3. Operations and Maintenance Plan

1. Describe the maintenance and operations plan for the Project to be implemented to ensure that the Project assets will be kept in a state of good repair and operated in accordance with Project commitments, terms of the credit agreement, and applicable regulations and provisions of law. The description should address routine maintenance, planned major maintenance, handback provisions (as applicable), and anticipated annual (YOE) costs of maintenance.
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2. Identify any third party that is anticipated to perform operations and maintenance.
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3. Identify all entities currently entitled or anticipated to be entitled to utilize the Project after operations commence and describe the anticipated level of usage and maintenance responsibilities for each entity. Describe legal or contractual arrangements governing such usage.
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3. Benefits of Credit Assistance

1. The Bureau credit assistance requested will (check all that apply):

☐ Foster private investment in the Project

☐ Reduce the contribution of Federal grant assistance for the Project

☐ Reduce the lifecycle costs, including debt service costs, of the Project

☐ Enable the Project to proceed at an earlier date

☐ Enable the Project to proceed at all, since the cost of traditional financing options would constrain the sponsor’s ability to deliver the Project

☐ Enable the Project sponsor to deliver a group of related projects or a full capital program earlier or with lowered costs

☐ Other (please describe): Click or tap here to enter text.

2. Discuss how the Project would be impacted if the requested financial assistance were unavailable or available in lowered amounts.
   Click or tap here to enter text.

SECTION D: Financial Plan

Information furnished under Section D may cross-reference materials provided in Section E (Creditworthiness) and, in all instances, must be consistent with those materials.

☐ Check if requesting a master credit agreement and modify each response accordingly to address all projects proposed to be covered under the master credit agreement.

1. Amount and Type of Credit Assistance Requested. Specify the type of Bureau credit assistance (RRIF, TIFIA or both), total dollar value of credit assistance, and the type of credit instrument requested.
   Click or tap here to enter text.

2. Credit Amount as Percentage of Eligible Project Costs. Specify the value of Bureau credit assistance requested as a percentage of the total eligible Project costs. See the Credit Programs Guide for a discussion of eligible project costs under each credit program. Click or tap here to enter text.%

3. Other Federal Assistance. Identify the value of other Federal financial assistance requested (e.g., grants or other loans), separately identifying the non-Federal share for such assistance. $ Click or tap here to enter text.

4. Combined Federal Assistance as a Total Percentage of Eligible Project Costs. Identify the total value of all anticipated Federal financial assistance, including Bureau credit assistance requested, as a percentage of the total eligible Project costs.
   Click or tap here to enter text.%

5. Sources and Uses of Funds

1. Provide a detailed statement of the yearly sources and uses for the Project as Attachment D-1. All estimates should be expressed in year-of-expenditure dollars and should include a narrative describing assumptions used to arrive at such estimates.

2. Sources should include separate line items, as applicable, for revenues, bond proceeds (general obligation, revenue, and others), other borrowing (specify), investment income, private investment (equity or debt), market value of right-of-way dedications, grants, and Federal credit assistance proceeds. For each line item, describe the status of the source (e.g., approved, budgeted, appropriated, applied for, etc.). If funding or financing is not committed, explain why.

3. Uses should include separate line items for, as applicable, feasibility studies, preliminary engineering and environmental reviews, final design, right-of-way-acquisition, vehicle acquisition, unallocated contingency, and capitalized financing costs (including debt service reserve funds, capitalized interest and capital issuance costs). Include other categories as necessary.

2. Uses should distinguish between total Project costs and eligible Project costs and any differences between these two cost estimates must be explained. See the Credit Programs Guide for a discussion of eligible costs for each credit program. Provide a similar breakdown for any eligible costs incurred prior to the date of this Application.

6. Proposed Terms for the Requested Credit Instrument. Identify the proposed terms for the credit instrument with respect to: assumed priority, interest rate, timing of disbursements, coverages, pledged security, repayment sources, amortization schedule, and lien position. The proposed terms and conditions should be submitted in the form of a term sheet as Attachment D-2.

☐ Check this box if the Borrower requests that DOT waive the non-subordination requirements associated with Bureau credit programs. Explain how the legal requirements for such a waiver are satisfied. See the Credit Programs Guide for more information on non-subordination requirements.
Click or tap here to enter text.

7. Financial Model. Attach the financial model as Attachment D-3. The financial model should include at the minimum:

1. Project sources and uses statement consistent with the sources and uses provided in Section D.5(a) above. The statement should project cash flows monthly or quarterly.

2. Semiannual projected cash flows through such time as all Project debt is repaid, including separate line items for each category of revenue (such as sales tax proceeds, fares, toll receipts, freight revenues) and expenditure (at a minimum, construction expenditures, operations and maintenance, contributions to reserves and capital replacement funds, debt service, repayments of the RRIF or TIFIA credit instrument, and repayment of other borrowed funds as well as equity dividends or proceeds (as applicable), if any);

2. Estimated debt service coverage ratios, for each tier of debt, separated into Federal, non-Federal (addressing, as applicable, senior and junior lien debt), and illustrating projected combined coverage, as applicable; and

3. Amortization schedule for all Project debt, separated into Federal, non-Federal (addressing, as applicable, senior- and junior-lien debt), and combined components.

The model should be projected on a cash (year-of-expenditure) basis with inflation assumptions described.

SECTION E: Creditworthiness

Total narrative supporting this Section E should not exceed 10 pages, excluding the attachments.

☐ Check if requesting a master credit agreement and modify each response accordingly to address all projects proposed to be covered under the master credit agreement.

1. Financial Statements. Provide financial statements, balance sheets or income statements for the past five years as Attachment E-1. All such documents should be audited or otherwise complied or reviewed by an independent Certified Public Accountant).

2. Pledged Revenue Source

1. Describe all revenue sources to be pledged to repay the credit instrument and other Project debt. Specify the nature of the revenue source (dedicated or not dedicated), the expected rate(s), the base to which such rates will be applied (e.g., retail sales, average daily traffic), historical and projected revenues from each source, and projected increases or decreases in such revenues over time.
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2. Detail any proposed flow of funds and any accompanying escrow or trust agreements that would govern the repayment of requested credit instrument and other Project debt.
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3. List existing or anticipated pledges/claims on revenues and summarize all claims on the flow of funds.
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4. Attach documentation (e.g., revenue studies, feasibility studies, traffic studies, and economic forecasts) as Attachment E-2 to provide the basis for projected revenues.

5. Provide the net present value calculation of the proposed repayment stream and material assumptions used in the calculation (e.g., growth rate, discount rate, terminal multiple, etc.)
   Click or tap here to enter text.

3. Physical Collateral. To the extent applicable, provide information concerning any physical collateral offered as security for requested Bureau credit assistance.
   
   

   Collateral Description	Value	Basis of Evaluation	Date of Evaluation
   Click or tap here to enter text.	$ Click or tap here to enter text.	Click or tap here to enter text.	Click or tap to enter a date.
   Click or tap here to enter text.	$ Click or tap here to enter text.	Click or tap here to enter text.	Click or tap to enter a date.
   Click or tap here to enter text.	$ Click or tap here to enter text.	Click or tap here to enter text.	Click or tap to enter a date.

4. Rating Letter (TIFIA Borrowers). Provide as Attachment E-3 one preliminary rating opinion letter that indicates all debt obligations funding the Project, as well as other obligations that will be paid from the same source of repayment for the requested TIFIA credit assistance, have the potential to achieve an investment-grade rating. The preliminary rating must include a preliminary rating opinion on the TIFIA credit instrument.

5. Rating Letter (RRIF Borrowers). If the Borrower intends to provide a rating as a basis for determining the credit risk premium, provide as Attachment E-3 one preliminary rating that indicates all debt obligations funding the Project, as well as other obligations that will be paid from the same source of repayment for the requested RRIF credit assistance, have the potential to achieve an investment-grade rating. The preliminary rating must include a preliminary rating opinion on the RRIF credit instrument. See the Credit Programs Guide for more information about the credit risk premium.

6. Other Supporting Information. Provide any other information that supports creditworthiness of the Borrower or the Project, as applicable, such as any proposed rate covenant, coverage requirements, market position, history of user-based repayments for other obligations, the economic outlook for related commerce.
   Click or tap here to enter text.

SECTION F: General Terms and Borrower Certifications

DETAILED GUIDANCE WITH RESPECT TO THE SPECIFIC SECTIONS OF THIS APPLICATION IS AVAILABLE IN THE BUREAU CREDIT PROGRAMS GUIDE. THE CREDIT PROGRAMS GUIDE CAN BE DOWNLOADED HERE.

The following items require certification by an authorized representative of the Borrower requesting credit assistance. The Department may require that Borrowers provide documentation in support of these certifications.

1. Format and Submission

1. An Application checklist is appended to this Application to assist Borrowers in preparing their Applications. The checklist should be submitted with the completed Application as Attachment F-1.

2. One original Application should be provided in three-hole punch binders with sections and tabs following the sequence shown in the Application checklist. The original set should include only the completed Application, without attachments, and must be sent to the attention of the Director of Credit Programs, Build America Bureau, Room W12-426, 1200 New Jersey Avenue, SE, Washington, DC, 20590. Borrowers are advised to utilize an express mail or courier delivery service to ensure delivery confirmation of the package.

3. The Application must also be transmitted to the Bureau electronically. When appropriate, the Bureau will provide Borrowers detailed instructions on how to electronically transmit the Application files, including attachments.

2. Information Requests. If a Borrower desires that any information submitted in its Application or any supplement thereto not be released by the Department upon request from a member of the public or otherwise be made publicly available, the Borrower must so state and set forth any reasons why such information is confidential and should not be released, including details as to any competitive harm which would potentially result from the release of such information. The Department will keep such information confidential to the extent permitted by law.

3. Application Approvals. The provision of credit assistance is subject to the approval of an Application in accordance with the Department’s approval processes and successful negotiation of a credit agreement on terms and conditions satisfactory in all respects to the Department. Please see the Credit Programs Guide for detailed information with respect to the Application approval and credit agreement negotiation process.

4. Fees. Except in certain circumstances, the Borrower will be responsible to pay costs incurred for services duly provided by the Department’s legal, financial or other third-party advisors involved with the evaluation of the LOI, evaluation of this Application, and negotiation of any TIFIA/RRIF credit agreement and related transactional documentation, in each case as applicable, irrespective of whether a credit agreement is executed. Please refer to the Credit Programs Guide for further information with respect to exceptions to this requirement as well time and method of payment for such services.

5. Lobbying. The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement; (2) if any funds other than Federal appropriated 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 Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. (3) the undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. See 31 U.S.C. § 1352; 49 C.F.R. part 20; Appendix A to Part 20.

6. Debarment and Suspension. Check the applicable box:

☐ By signature below, the undersigned certifies that, to the best of his or her knowledge and belief, the Borrower and its principals: 1) are not presently excluded or disqualified; 2) have not been convicted within the preceding three years of any of the offenses listed in 2 C.F.R. §180.800(a) or had a civil judgment rendered against it for one of those offenses within that time period; 3) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses listed in 2 C.F.R. §180.800(a); or 4) have not had one or more public transactions (Federal, State, or local) terminated within the preceding three years for cause or default. 2 C.F.R. § 180.335.

☐ The undersigned is unable to make the certification requested and has included an explanation on Attachment F-2.

7. Default/Delinquency. The undersigned certifies that none of the Borrower nor any of its parents, equity sponsors, subsidiaries, or affiliates, as applicable (i) is not currently in default or delinquent on any debt or loans provided or guaranteed by the Federal Government, and (ii) does not have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted, or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

8. Reporting Subaward and Executive Compensation. The undersigned certifies that the Borrower has or will have the necessary processes and systems in place to comply with the reporting requirements under the Federal Funding Accountability and Transparency Act of 2006 (Pub. L. 109-282; 31 U.S.C. § 6101 note), as amended by the Government Funding and Transparency Act (Pub. L. 110-252, title VI, § 6202(a)), and the related regulations at 2 C.F.R. Part 170, should the undersigned be approved to receive credit assistance from the Department.

9. No False or Misleading Information. It is a crime to knowingly make false statements to a Federal agency. Penalties upon conviction can include a fine and imprisonment per 18 U.S.C. 1001. Misrepresentation of material facts may also be the basis for denial of financial assistance by the Department.

Signature. By signature below, the undersigned: (i) acknowledges and agrees to the general terms and conditions identified in this Section F; (ii) certifies that the facts stated and the certifications and representations made in this application are, to the best of the his or her knowledge and belief after due inquiry, true, and the Borrower has not omitted any material facts; and (iii) certifies that he or she is authorized by the Borrower to submit this Application, bind the Borrower to the terms and conditions acknowledged and agreed, and make the certifications made by submission of this Application.

Legal Name of Borrower: Click or tap here to enter text.

By: _____________________________________________________________

Name and Title: Click or tap here to enter text.

Date: Click or tap to enter a date.

APPENDIX 1 – APPLICATION CHECKLIST

An Application must include the items identified in this checklist. A completed checklist should be included in the Application packet.

Item	Page Limit
☐ Summary Information Table	N/A
☐ Section A: Borrower Contact Information	N/A
Section B: Borrower Information ☐ 1. Background Information and Legal Authority ☐ 2. Organization and Management ☐ Attachment B-2: Organizational Charts - Management Organizational Chart and Corporate Organization Chart ☐ 3. Borrower Eligibility ☐ 4. Past Performance and Experience with Federal Assistance ☐ 5. Borrower Eligibility ☐ Attachment B-3: RRIF Joint Venture Eligible Applicant Information (if applicable)	10 (excluding attachments)
Section C: Project Information ☐ Master Credit Agreement Applicants: Duplicate Section C for each project ☐ TIFIA State Infrastructure Bank Applicants: Duplicate Section C for each project ☐ 1. Project Name ☐ 2. Project Location ☐ Attachment C-1: Vicinity Map and Project Map ☐ 3. Project Description ☐ Attachment C-2: Conceptual Drawings ☐ Attachment C-3: Value-For-Money Analysis for Public-Private Partnerships ☐ 4. Project Schedule ☐ Attachment C-4: Detailed Project Schedule ☐ 5. Project Team ☐ Attachment C-5: Project Team Organizational Chart ☐ 6. Local Funding Partners ☐ Attachment C-6: Documentation of Local Funding Partner Contributions ☐ 7. Transportation Planning and Programming Approvals ☐ Attachment C-7: Relevant Pages from the Long-Range Plan, TIP and STIP (as applicable) ☐ 8. Environmental Review ☐ Attachment C-8: Environmental Decision Documents (as available) ☐ 9. Project Management and Compliance Monitoring Plan ☐ Attachment C-9: Available Project Reports ☐ 10. Risks and Mitigation Strategies ☐ 11. Litigation ☐ 12. Maintenance and Operations Plan ☐ 13. Benefits of Credit Assistance	10 (excluding attachments)
Section D: Financial Plan ☐ 1. Amount and Type of Credit Assistance Requested ☐ 2. Credit Amount as Percentage of Eligible Project Costs ☐ 3. Other Federal Assistance ☐ 4. Combined Federal Assistance as a Total Percentage of Eligible Project Costs ☐ 5. Sources and Uses of Funds ☐ Attachment D-1: Detailed Sources of Uses Statement ☐ 6. Proposed Terms for the Requested Credit Instrument ☐ Attachment D-2: Proposed Terms ☐ 7. Financial Model ☐ Attachment D-3: Financial Model	N/A
Section E: Creditworthiness ☐ 1. Financial Statements ☐ Attachment E-1: Financial Statements, balance sheets or income statements ☐ 2. Pledged Revenue Source ☐ Attachment E-2: Documentation Supporting Projected Revenues ☐ 3. Physical Collateral ☐ 4. TIFIA Borrowers Only: Rating Letter ☐ Attachment E-3: TIFIA Indicative Rating Letter ☐ 5. RRIF Borrowers Only: Rating Letter ☐ Attachment E-3: RRIF Indicative Rating Letter ☐ 6. Other Supporting Information	10
Section F: Terms and Borrower Certifications ☐ 1. Format and Submission ☐ Attachment F-1: Application Checklist ☐ 2. Information Requests ☐ 3. Application Approvals ☐ 4. Fees ☐ 5. Lobbying ☐ 6. Debarment and Suspension ☐ Attachment F-2: Explanation as to why Borrower Is Unable To Submit Certification as to Debarment and Suspension ☐ 7. Default/Delinquency ☐ 8. Reporting Subaward and Executive Compensation ☐ 9. No False or Misleading Information ☐ 10. Signature	N/A

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