Form EIB 18-05 EIB 18-05 Itemized Statement of Payments Long-term Guarantee and D

EIB 18-05 Itemized Statement of Payments Long-term Guarantee and Direct Loan—Local Costs

eib18-05_itemized_statement_of_payments-local_cost_form_-_final (1).xlsx

Itemized Statement of Payments Long-term Guarantee and Direct Loan-Local Costs.

OMB: 3048-0057

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ITEMIZED STATEMENT OF PAYMENTS - LOCAL COSTS FOR US EXIM LONG-TERM GUARANTEES AND DIRECT LOANS
OMB No.: XXXX-XXXX








ITEMIZED STATEMENT OF PAYMENTS - LOCAL COSTS




Long-Term Guarantees and Direct Loans












EXIM Bank Transaction No:
Transaction No: 123


Local Cost Request Number:
Request Number: 456


Local Cost Provider Name:
Exp Name BBB


Local Cost Provider Address:
Exp Addr: BBB Address


Supply Contract No(s):
Contract No(s): 789


NAICS:
222240









Acquisition List No. Invoice No. Invoice Amount Invoice Amount
Paid
Acquisition List Description of Item Remarks/Comments


0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00




0.00 0.00










TOTAL INVOICE AMOUNT 0.00 0.00 TOTAL INVOICE AMOUNT PAID INDICATE CURRENCY



0.00 LESS Other <Comments for Less Other to be entered here>










0.00 NET AMOUNT




0.0000000 EXCHANGE RATE




<MM/DD/YYYY> DATE OF CONVERSION


TOTAL GROSS AMOUNT $0.00 $0.00 TOTAL PAYMENTS IN US DOLLARS




$0.00 LESS Other <Comments for Less Other to be entered here>










$0.00 TOTAL FINANCED AMOUNT








INSTRUCTIONS AND NOTES: LINK to exim.gov








For any questions about completing this form, contact Credit Administration at credit.administration@exim.gov.








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.














EIB 18-05 5/2018





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