ITEMIZED STATEMENT OF PAYMENTS - LOCAL COSTS FOR US EXIM LONG-TERM GUARANTEES AND DIRECT LOANS |
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OMB No.: XXXX-XXXX |
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ITEMIZED STATEMENT OF PAYMENTS - LOCAL COSTS |
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Long-Term Guarantees and Direct Loans |
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EXIM Bank Transaction No: |
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Transaction No: 123 |
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Local Cost Request Number: |
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Request Number: 456 |
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Local Cost Provider Name: |
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Exp Name BBB |
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Local Cost Provider Address: |
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Exp Addr: BBB Address |
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Supply Contract No(s): |
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Contract No(s): 789 |
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NAICS: |
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222240 |
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Acquisition List No. |
Invoice No. |
Invoice Amount |
Invoice Amount Paid |
Acquisition List Description of Item |
Remarks/Comments |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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0.00 |
0.00 |
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TOTAL INVOICE AMOUNT |
0.00 |
0.00 |
TOTAL INVOICE AMOUNT PAID |
INDICATE CURRENCY |
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0.00 |
LESS Other |
<Comments for Less Other to be entered here> |
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0.00 |
NET AMOUNT |
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0.0000000 |
EXCHANGE RATE |
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<MM/DD/YYYY> |
DATE OF CONVERSION |
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TOTAL GROSS AMOUNT |
$0.00 |
$0.00 |
TOTAL PAYMENTS IN US DOLLARS |
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$0.00 |
LESS Other |
<Comments for Less Other to be entered here> |
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$0.00 |
TOTAL FINANCED AMOUNT |
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INSTRUCTIONS AND NOTES: LINK to exim.gov |
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For any questions about completing this form, contact Credit Administration at credit.administration@exim.gov. |
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Paperwork Reduction Act Statement: We estimate that it will take you about 30 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 EXIM and the Office of Management and Budget, Paperwork Reduction Project OMB # XXXX-XXXX Washington, D.C. 20503. |
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EIB 18-05 5/2018 |
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