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pdfOMB No.: 3048-003
Expiration Date: 04/30/2023
EXIM Bank Date Received:
EXPORT-IMPORT BANK OF THE UNITED STATES
APPLICATION FOR EXPORT WORKING CAPITAL GUARANTEE
APPLICATION INSTRUCTIONS
PART A. PRINCIPAL PARTIES
1. Borrower/Exporter. Complete this section with information on the individual or corporate borrower. Provide the
primary North American Industrial Classification System (NAICS) number of the borrower, rather than the product being
exported.
2. Borrower’s Management. Complete this section for each proprietor, partner, officer, director or other individual
owning 20% or more of the borrower, including parent companies. 100% of ownership must be shown. The following
are considered “Associates” of the borrower: a. for a sole proprietorship, the sole proprietor; b. for a partnership, all
general partners and all limited partners owning 20% or more of the equity of the firm; c. for a corporation, all owners
of 20% or more of the corporation and each officer and director; d. for limited liability companies (LLCs), all members
owning 20% or more of the company, each officer, director, and managing member; d. any person hired by the business
to manage day-to-day operations. All Associates must be shown.
3. Borrower’s Affiliate(s). Provide information about all of the Borrower’s Affiliates, including owners if Company(ies),
and entities with common ownership. See 13 CFR 121.103, 13 CFR 121.107, 13 CFR 121.301, SBA Guidelines and SBA
Small Business Compliance Guide: Size and Affiliation.
4. Personal and/or Corporate Guarantor(s). List all individuals and entities that will guarantee repayment of the loan.
The personal guarantee of the owner(s) is required in most cases.
5. Lender. Provide information about the Lender.
PART B. INFORMATION ABOUT THE TRANSACTION
Provide type of loan requested, the loan amount, and term and answer all questions in Part B. (See also Checklist item 2
below.)
PART C. CERTIFICATIONS
This section must be signed by an authorized representative of the borrower, each guarantor, and the Lender
("Applicants".)
EIB- Form 84-1, Revised 10/2021
OMB No.: 3048-003
Expiration Date: 04/30/2023
CHECKLIST OF INFORMATION TO BE ATTACHED FOR NON-DELEGATED AUTHORITY TRANSACTIONS
BACKGROUND
YES
N/A
TRANSACTION
YES
N/A
FINANCIAL INFORMATION
YES
N/A
1. Brief resume of the principals and key employees; history of business; copy of business plan, if available; identify
whether sole proprietorship, general partnership, limited liability company (LLC), corporation and/or subchapter-S
corporation.
2. Explanation of use of proceeds and benefits of the loan guarantee, including details of the underlying
transaction(s) for which the loan is needed, including country(s) where the buyers are located.
3. Attach product literature. If applicable, attach description of items if they are
nuclear, military, environmental, on the U.S. Munitions Control List, or require an export license.
4. Copy of letter of credit and/or copy of buyer’s order/contract, if required.
5. Export credit insurance-related material (policy, application, buyer credit limit), if required.
6. Copy of export license, if required.
7. Business financial statements (Balance Sheet, Income Statement, statement of Cash Flows) for the last three
years, if applicable, supported by the most recent Federal income tax return for the business.
8. Current financial statement (interim) dated within 120 days of the date of the application filing.
9. Aging of accounts receivable and accounts payable, as of the same date as #8 above, if required.
10. All Affiliated Companies – Business Financial Statements (Balance Sheet, Income Statement, Aging of
Accounts Receivable and Accounts Payable) for the last completed fiscal year end, as well as current statements no
older than 120 days from the date of application filing. In addition, submit signed Federal income tax returns for
the last fiscal year end or an extension form if not filed after the due date.
Important Requirement – Submit a combined or consolidated financial statement for the current period as well
as the last fiscal year end (combining all affiliated companies), eliminating any inter-company transactions (sales,
receivables, payables, etc.).
11. Signed joint personal financial statement(s) of each major shareholder(s)/partner(s), owner(s), of the
company (with 20% or greater ownership, including assets and liabilities of both spouses) and their most recent
Federal income tax return (not required for venture capital partners). Please redact Social Security numbers.
12. Estimate of monthly cash flow for the terms of the loan, highlighting the proposed export transaction.
13. Description of type and value of proposed collateral to support the loan (company assets/export product,
i.e., inventory, accounts receivable, other).
14. Attach credit memorandum prepared by the Lender. Also attach D&B Report and Personal Credit Reports
on Principals and Guarantors.
15. Nonrefundable $100 application fee by check, or money order or wire transfer, made out to the EXIM Bank.
EIB- Form 84-1, Revised 10/2021
OMB No.: 3048-003
Expiration Date: 04/30/2023
PART A. PRINCIPAL PARTIES
Yes
New to EXIM Bank?
1. Borrower/Exporter
Company Name
No
Dba/
Date Business
Established
New to Export?
No. of Years Exporting
Telephone No.
Website Address
Name and Title of Contact Person
Address (No P.O. Boxes)
Gross Annual
Sales Last Year:
No. of Full-Time
Employees:
D&B No.
Federal ID No.
E-mail Address
County of Business
City
State
Primary North American Industrial
Classification System (NAICS) No.:
Zip+4
“Small Business Concern” as
described in SBA Guidelines:
Yes
Yes
Yes
Yes
Yes
*Is the Borrower a minority-owned business?
*Is the Borrower a women-owned business?
*Is the Borrower a veteran-owned business?
*Is the Borrower a disability-owned business?
No
No
No
No
No
Not Disclosed
Not Disclosed
Not Disclosed
Not Disclosed
2. Borrower’s Management (Proprietors, partners, officers, directors and holders of all outstanding stock or
other ownership interests, including parent companies. 100% of ownership of Borrower must be shown.
Attach separate sheet if necessary.)
* The gender/race/ethnicity/veteran data is collected for program reporting purposes only. It has no bearing on credit decision.
Disclosure is voluntary.
a) Name (Company, or last, first, middle initial)
Title/Management Position/Point of Contact
E-mail Address
Website Address (if applicable)
Complete Address
EIB- Form 84-1, Revised 10/2021
% owned
*Gender
M
F
OMB No.: 3048-003
Expiration Date: 04/30/2023
Ethnicity*
Race* (one or more boxes may be selected.)
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Pacific Islander
Asian
White
Military Service Status*
Other
Non- Veteran
Not Hispanic or Latino
Service Disabled Veteran
Veteran
b) Name (Company, or last, first, middle initial)
*Gender
F
M
% owned
Title/Management Position/Point of Contact
E-mail Address
Website Address (if applicable)
Complete Address
Race* (one or more boxes may be selected)
Ethnicity*
American Indian or Alaskan Native
Black or African American
Native Hawaiian or Pacific Islander
Asian
White
Other
Military Service Status*
Hispanic or Latino
Non-Veteran
Hispanic or Latino
Not Hispanic or Latino
Veteran
c) Name (Company, or last, first, middle initial)
Service Disabled Veteran
*Gender
M
F
% owned
Title/Management Position/Point of Contact
E-mail Address
Website Address (if applicable)
Complete Address
Race* (one or more boxes may be selected.)
Ethnicity*
American Indian or Alaskan Native
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
Asian
Not Hispanic or Latino
White
Other
Military Service Status*
EIB- Form 84-1, Revised 10/2021
Non-Veteran
Veteran
Service Disabled Veteran
OMB No.: 3048-003
Expiration Date: 04/30/2023
3. Borrower’s Affiliate(s) If more than one affiliate, please attach separate sheet.
Company Name
Telephone No.
Website Address
D&B No.
Name and Title of Contact Person
Street Address (No P.O. Boxes)
Number of Employees for
Each Affiliate
Federal ID No.
E-mail Address
County of Business City
Annual Sales
State
Describe Nature of Affiliation
4. Personal and/or Corporate Guarantor(s) Please attach separate sheet if there are more guarantors.
a) Name (Company, or last, first, middle initial)
Federal ID No. (if applicable)
Years in Business (if applicable)
Telephone No.
Street Address
E-mail Address and/or Website Address
County of Business
State
City
Zip+4
Describe Nature of Affiliation with Borrower
b) Name (Company, or last, first middle initial)
Federal ID No. (if applicable)
Years in Business (if applicable)
Telephone No.
Street Address
E-mail Address and/or Website Address
Describe Nature of Affiliation with Borrower
EIB- Form 84-1, Revised 10/2021
County of Business
City
State
Zip+4
Zip+4
OMB No.: 3048-003
Expiration Date: 04/30/2023
c) Name (Company, or last, first middle initial)
Federal ID No. (if applicable)
Years in Business (if applicable)
Telephone No.
Street Address
County of Business
E-mail Address and/or Website Address
State
City
Zip+4
Describe Nature of Affiliation with Borrower
5. Lender
Lender Name
Federal ID No.
New to EXIM?
Yes
(If new to EXIM, submit annual report)
Name and Title of Contact Person (last, first middle initial)
Street Address
State
Telephone No.
City
Zip+4
EIB- Form 84-1, Revised 10/2021
E-mail Address
Fax No.
No
OMB No.: 3048-003
Expiration Date: 04/30/2023
PART B. INFORMATION ABOUT THIS TRANSACTION
1.
Loan Information
Loan Amount:
Type of Loan:
Term of Loan:
1 year
2 years
3 years
4 years
5 years
Other: (specify)
Renewal?
Yes
Revolving
Transaction Specific
Transaction Specific Revolving
Fast Track
Supply Chain
Interest Rate to be charged (% per annum):
6 months
No
If yes, maximum amount of existing Loan
Facility:
If yes, amount currently outstanding:
Other Fees or Charges (please enter type and amount):
If Interest Rate is to be Variable:
Adjustment Period:
Base Rate:
Base Rate Source:
Spread:
Were you assisted by a City/State entity or a Small Business Development Center? (If yes, please identify: )
Yes
Name
Telephone No.
Website Address
Street Address
City
State
Name and Title of Contact Person
2.
Transaction Information
Products (Goods and/or Services) to be exported (description):
EIB- Form 84-1, Revised 10/2021
Email Address
No
Zip + 4
OMB No.: 3048-003
Expiration Date: 04/30/2023
Principle Countries of Export (please identify the top 3
countries):
Estimated Total Export Sales per annum to be
supported by this loan:
U.S. Content Percentage:
Please estimate the number of jobs to be supported by this Loan:
No. of existing jobs maintained:
Are Performance Guarantees or Standby LCs to be issued
under this Loan:
Yes
Percentage of Loan to be utilized for Performance
Guarantees:
No
Will Local Costs be included under this Loan?
(Costs incurred in the buyer's country (i.e. local delivery, installation, taxes) eligible for
EXIM cover, provided that: U.S. content requirements are met; included within the
contracts; do not exceed 15% of export contract; and no local goods are included.)
Yes
No. of additional jobs created:
No
%
If Yes, what is the USD amount and/or percentage
of Local Costs in each invoice or contract?
$
%
What is the nature of Local Costs to be supported?
3. Please answer the following questions about the “export items” to be exported from the U.S.
a. Military – Is the buyer or the end user of the export items associated in any way
with the military? Are the items to be used by the military, or are they defense
articles, or do they have a military application? If yes, please attach a description
of the buyer or items as applicable and contact EXIM Bank for approval.
Yes
No
b. Nuclear – Are the export items to be used in the construction, alteration,
operation, or maintenance of the nuclear power, enrichment, reprocessing,
research, heavy water production facilities, nuclear fuel reloads, radioisotopes
for medical and other use, or the handling, treatment, transportation, or
storage of radioactive waste? If yes, please attach a description of the items,
and contact EXIM Bank for approval.
Yes
No
c. Environmental – Are the export items to be used for an environmental
project or do they have a perceptible environmental benefit? If yes, please
attach a description of the items and identify the sector in which the items are
to be used, or the sector of the project. If related to a specific project, identify
the project and project location.
Yes
No
d. Munitions – Are the export items on the U.S. Munitions Control List (Part 121 of
Title 22 of the Code of Federal Regulations), or do they require a validated export
license from the Bureau of Export Administration? If yes, please attach a
description of the items and contact EXIM Bank for approval. If uncertain whether
a validated export license is required, written verification from the appropriate
licensing agency may be required before loan approval.
Yes
No
EIB- Form 84-1, Revised 10/2021
OMB No.: 3048-003
Expiration Date: 04/30/2023
PART C. CERTIFICATIONS
Please sign duplicates of Part C for each Borrower and each Lender.
1. Certifications and Signature
Please refer to the “Standard Certifications and Covenants for EXIM Bank Applications” set forth in Form EIB18-cn, posted
on the EXIM Bank website at [https://www.exim.gov/sites/default/files/forms/eib18-cn.pdf] (the “Standard
Certifications”). THE STANDARD CERTIFICATIONS ARE INCORPORATED INTO THIS APPLICATION AS IF FULLY AND
DIRECTLY SET FORTH HEREIN. When signing this application in the space provided below, the undersigned authorized
officer signing on the applicant’s behalf certifies and represents that he or she is fully authorized to sign on the applicant’s
behalf, and that HE OR SHE HAS READ the Standard Certifications referenced above AND IS CERTIFYING AND
COVENANTING, as appropriate, to all of the certifications, acknowledgements and covenants set forth in the Standard
Certifications.
Applicant further certifies that 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 set forth in this application or in the Standard Certifications, becomes untrue, or is discovered to have been
untrue when made, Applicant will promptly inform EXIM Bank of all such changes or discoveries. Applicant further
understands that in accepting or approving this application, EXIM Bank is relying upon Applicant’s statements set forth in
the application and in the Standard 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.).
I,
of
, do hereby certify that I am the duly appointed and qualified
of
[Name of Applicant] and that as such I am authorized to execute this application on behalf
[Name of Applicant].
In witness whereof, I have hereunto signed my name this
day of
, 202_.
Borrower:
Name of Borrower
Name and Title of Authorized Representative (Print)
Signature
I,
Date
, do hereby certify that I am the duly appointed and qualified
of
[Name of Applicant] and that as such I am authorized to execute this application on behalf of
[Name of Applicant].
In witness whereof, I have hereunto signed my name this
day of
, 202_.
Lender:
Name of Lender
Signature
EIB- Form 84-1, Revised 10/2021
Name and Title of Authorized Representative (Print)
Date
OMB No.: 3048-003
Expiration Date: 04/30/2023
2. Guarantor and Additional Borrower Representations and Certifications
The undersigned, each as authorized representative of the Borrower and the Guarantor(s)
(respectively) and on its behalf, each independently make the following certifications:
ALL QUESTIONS MUST BE ANSWERED AND ARE SUBJECT TO VERIFICATION. (If any answer to any of
these questions below, except for “g”, is “yes,” provide complete information separately.)
Borrower/Associate(s)
of Borrower
a. Are there any pending or threatened liens, tax liens judgments or material
litigation against the:
Guarantor(s)
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Yes
No
If yes to c., is any of the financing currently delinquent?
Yes
No
Yes
If yes to c., did any of this financing ever default and cause a loss to the
Government?
Yes
No
Yes
No
d.1. Is the Borrower or any of its Associates or the Guarantor(s) presently
subject to an indictment, criminal information, arraignment, or other means by
which formal charges are brought in any jurisdiction?
Yes
No
Yes
No
d.2. Has the Borrower or any of its Associates or the Guarantor(s) been arrested
in the past six months for any criminal offense?
Yes
No
Yes
No
d.3. For any criminal offense (other than a minor vehicle violation) has the
Borrower or any of its Associates or the Guarantor(s) : 1) been convicted; 2)
plead guilty; 3) plead nolo contendere; 4) been placed on pretrial diversion; 5) or
been placed on any form of parole or probation (including probation before
judgment)?
Yes
No
Yes
No
e. Is the Borrower, any of its Associates, or the Guarantor(s) presently debarred,
suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any Federal department or agency?
Yes
No
Yes
No
f. Is any 50% or more owner of the Borrower more than 60 days delinquent on
any obligation to pay child support arising under an administrative order, court
order, repayment agreement between the holder and a custodial parent, or
repayment agreement between the holder and a state agency providing child
support enforcement services?
Yes
No
Yes
No
b. Has the Borrower or its Associates(s), or the Guarantor(s) ever filed for
protection under U.S. bankruptcy laws? Has either had an involuntary
bankruptcy petition filed against it?
c. Has the Borrower or its Associates(s) or its affiliates, or the Guarantor(s) ever
previously requested U.S. Government financing? (This includes student loans
and disaster loans.)
g. Are the Borrower and all of its Associates and Guarantors U.S. Citizens?
If no: Are the non-U.S. citizens lawful permanent resident aliens?
Yes Provide alien registration #(s)
EIB- Form 84-1, Revised 10/2021
Yes
No
No
Yes
No
No
No
OMB No.: 3048-003
Expiration Date: 04/30/2023
3. Certifications and Signature
Please refer to the “Standard Certifications and Covenants for EXIM Bank Applications” set forth in Form EIB18-cn,
posted on the EXIM Bank website at [https://www.exim.gov/sites/default/files/forms/eib18-cn.pdf] (the “Standard
Certifications”). THE STANDARD CERTIFICATIONS ARE INCORPORATED INTO THIS APPLICATION AS IF FULLY AND
DIRECTLY SET FORTH HEREIN. When signing this application in the space provided below, the undersigned authorized
officer signing on the applicant’s behalf certifies and represents that he or she is fully authorized to sign on the
applicant’s behalf, and that HE OR SHE HAS READ the Standard Certifications referenced above AND IS CERTIFYING
AND COVENANTING, as appropriate, to all of the certifications, acknowledgements and covenants set forth in the
Standard Certifications.
Applicant further certifies that 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 set forth in this application or in the Standard Certifications, becomes untrue, or is discovered to have been
untrue when made, Applicant will promptly inform EXIM Bank of all such changes or discoveries. Applicant further
understands that in accepting or approving this application, EXIM Bank is relying upon Applicant’s statements set forth
in the application and in the Standard 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.).
I,
, do hereby certify that I am the duly appointed and qualified
of
[Name of Applicant] and that as such I am authorized to execute this application on behalf of
[Name of Applicant].
In witness whereof, I have hereunto signed my name this
day of
, 202_.
Borrower:
Name of Borrower
Signature
Name and Title of Authorized Representative (Print)
Date
I,
, do hereby certify that I am the duly appointed and qualified
[Name of Applicant] and that as such I am authorized to execute this application on behalf of
of Applicant].
In witness whereof, I have hereunto signed my name this
day of
of
, 202_.
Guarantor:
Name of Guarantor
Name and Title of Authorized Representative (Print)
Signature
Date
EIB- Form 84-1, Revised 10/2021
[Name
OMB No.: 3048-003
Expiration Date: 04/30/2023
NOTICE TO APPLICANTS
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 2 hours 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 Bank and the Office of Management and Budget, Paperwork
Reduction Project, OMB # 3048-0013 Washington, D.C. 20503.
EIB- Form 84-1, Revised 10/2021
| File Type | application/pdf |
| File Title | Joint Application for Export Working Capital Guarantee |
| Author | Export-Import Bank of the United States |
| File Modified | 2021-10-29 |
| File Created | 2021-10-29 |