5001-11A Guaranteed Loan Report Of Loss - Estimated Loss

USDA
Form RD 5001-11A
(00-00)
1. STATE - COUNTY - GLS BORROWER ID

FORM APPROVED
OMB NO.0572-0155

GUARANTEED LOAN REPORT OF LOSS
ESTIMATED LOSS
3. LOAN TYPE

2. AGENCY
LOAN NO.

Community Facilities ____
Water and Waste Disposal ____
Business and Industry ____
Rural Energy for America Program _____

4. BORROWER NAME

5. LENDER TAX ID
NO.

6. AGENCY’S LENDER
BRANCH NO.

7. LENDER ROUTING NUMBER

8. LENDER ACCOUNT NUMBER

9. ACCOUNT TYPE
___Savings ___Checking

GUARANTEED LOAN ITEMS:

$ DOLLARS

LOSS GUARANTEED:

10. DATE OF SETTLEMENT
Mo
Da
Yr.

$ DOLLARS

29. PERCENT OF LOSS GUARANTEED

11. PRINCIPAL BALANCE

30. AMOUNT TO BE PAID
(Item 28 X item 29)
31. Sum of
(Prin. Advance on Loan + Item 12) X Item 29
32. MAXIMUM LOSS ALLOWED

12. ACCRUED INTEREST OWED
13. TOTAL (Add Items 11-12)

(Lesser of Items 30 or 31)

33. PERCENT OF GUARANTEED PORTION
HELD BY LENDER
34. LOSS ON GUARANTEED PORTION
HELD BY LENDER (Item 32 X Item 33)

15. PERSONAL PROPERTY DEBTS

$0.00
$0.00
$0.00

ADJUSTMENTS TO PROTECTIVE ADVANCES &
INTEREST:

PRIOR LIEN AMOUNTS OWED AT SETTLEMENT DATE:
14. REAL ESTATE DEBTS

(Percent)

16. UNPAID TAXES, ASSESSMENTS, GROUND
RENTS, ETC.

(Percent)

35. UNPAID ANNUAL/LATE FEES

17. TOTAL PRIOR LIENS

36. AMOUNT DUE TO/FROM LENDER
FOR ESTIMATED LOSS (Item 35- Item 36)

(Add Items 14-16)

COLLATERAL:
18. REAL PROPERTY VALUE

AMOUNT DUE LENDER OR USDA: (If Applicable)

19. CHATTEL PROPERTY VALUE
20. VALUE OF PERSONAL AND
CORPORATE GUARANTEES

37. NAME OF LENDER

21. TOTAL (Add Items 18 – 20)
22. NET COLLATERAL

38. LENDER SIGNATURE

(Item 21 minus Item 17)

$0.00

23. BASIC LOSS
(Item 13 minus Item 22)

39. LENDER REP. TITLE

ADJUSTMENT TO BASIC LOSS:

40. DATE

24. FUNDS BEING HELD

$0.00

41. NAME OF USDA REPRESENTATIVE
44

25. INCOME TO BE APPLIED TO DEBT
42. USDA SIGNATURE
26. BORROWER’S DEBT PAYMENT ABILITY PRESENT VALUE

43. USDA REPRESENTATIVE TITLE

27. TOTAL DEDUCTIONS

44. DATE

(Add Items 24 - 26)

28. ADJUSTED BASIC LOSS ESTIMATE
(Item 23 minus Item 27)

$0.00
FINANCE OFFICE ONLY

45. CHECK ISSUE CODE

1 = SYSTEM GENERATED
2 = MANUAL CHECK
3 = NO CHECK ISSUED
4 = REFUND
5 = EFT

46. PAYMENT DATE
Mo
Da
Yr.

47. DATE OF DEPOSIT
Mo

Da

Yr.

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