Form CFL10 Claim for Loss

IA Form CFL10
Revised XX 202X

OMB Control No. 1076-0020
Expires: X/XX/202X

CLAIM FOR LOSS
Department of the Interior
Loan Guarantee, Insurance and Interest Subsidy Program
(Note: do NOT use this form for Bond Guarantee claims)

Date: ____________

Department Loan Guarantee Certificate Number ____________
Department Loan Insurance under Loan Insurance Agreement Number _____________

Lender:_______________________________________
Address:______________________________________
______________________________________
______________________________________
______________________________________
Borrower:_____________________________________
Address:______________________________________
______________________________________
______________________________________
______________________________________

Guarantee or Insurance Percentage:_______%
Original Loan Principal Amount:
$________________________

(Exclusive of amounts potentially added pursuant to 25 CFR §§ 103.8, 103.34, or 103.36.)

Lender’s Internal Loan Number:_________________________
Interest Subsidy awarded on loan? Yes
No

Indicate the earliest date of default, as defined by 25 CFR § 103.44: _______________________, 20______
List all bases for default: _________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

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IA Form CFL10
Revised XXXX, 20XX

OMB Control No. 1076-0020
Expires: X/XX/XXX

I. The Unpaid Debt
Please list the following:
1.
The amount of past due principal:
2.
The amount of past due interest:
3.
The amount of any late fees:
4.
The amount of any precautionary advances:
5.
Any other amounts the Lender claims:

________________
________________
________________
________________

_______________

(Identify authority in space provided below.)
TOTAL:

6.

________________

The date through which interest has been calculated:

______________________, 20____

II. Liquidation Efforts
If the Lender liquidated loan collateral prior to submitting this Claim for Loss (this is mandatory before
submitting a Claim for Loss under an Insurance Agreement), please list the following:
1.

2.
3.

4.

Total proceeds from collateral liquidation:

$________________

Administrative expenses of liquidating collateral:

$________________

Liquidation proceeds applied to debt:

$________________

(Please attach a detailed breakdown showing what
assets were sold, how and where they were sold, the
proceeds attributable to each asset, and the date(s) of sale.)
(Please attach receipts and a detailed breakdown showing
the nature and date of each expense.)
(Please attach a description of how liquidation
proceeds were allocated to principal, interest and
other fees, and the dates posted.)

Does the unpaid debt listed in Section I reflect the amount of the lender’s loss after applying
No
liquidation proceeds to the debt?
Yes

(If not, please provide an explanation.)

III. Claim Amount
For guaranteed loans, the claim amount should equal the Department’s guarantee percentage rate multiplied
by the total unpaid debt listed in Part I, after deducting any recovery from liquidation proceeds reflected in
Part II.
For insured loans, the claim amount should equal the Department’s insurance percentage rate multiplied by
the total unpaid debt listed in Part I, after deducting any recovery from liquidation proceeds reflected in Part

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IA Form CFL10
Revised XXXX, 20XX

OMB Control No. 1076-0020
Expires: X/XX/XXX

II, unless , as of the date of this Claim for Loss, the amount claimed would exceed 15% of the aggregate
outstanding principal amount of all loans – including this one – that the lender has insured under the
Program (“15% cap”). If so, then the claim amount should equal the 15% cap.
The Lender’s claim:

$_________________________

If this is an insurance claim, please list the
15% cap as of the date of this
Claim for Loss:

$_________________________

Lender:______________________________
ABA No.:____________________________

By:__________________________________
Its:__________________________________
Paperwork Reduction Act Statement: This form is covered by the Paperwork Reduction Act. It is used to establish
the nature and amount of a claim the respondent can make against the Federal government. The information is
provided by respondents to obtain or retain a benefit. In compliance with the Paperwork Reduction Act of 1995, as
amended, the collection has been reviewed by the Office of Management and Budget and assigned a number and an
expiration date. The number and expiration date are at the top right corner of the form. An agency may not sponsor or
conduct, and a person is not required to respond to, a request for information collection unless it displays a currently
valid OMB Control Number. The public reporting burden is estimated to average 2 hours per respondent . This includes the
time needed to understand the requirements, gather the information, complete the form, and submit it to the
Department. Comments regarding the burden or other aspects of the form may be directed to the Indian Affairs
Information Collection Clearance Officer, Office of Regulatory Affairs – Indian Affairs, 1001 Indian School Road NW,
Suite 229, Albuquerque, New Mexico 87104.
Privacy Act Statement (5 U.S.C. 552(a)): The authority for collecting this information is 25 U.S.C. 1511. The
information will be used to administer the Loan Guarantee, Insurance and Interest Subsidy Program, 25 U.S.C. 1481et seq.
Disclosures of this information may be made to track and record payments and unpaid balances and provide information
on payments made for paying interest subsidy, credits obtained, service loans made, and premiums paid by
Lenders, and for the other routine uses described by system of record notice, BIA-13, Loan Management and Accounting
System.

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