Form EIB 10-04 EIB 10-04 NOTICE OF CLAIM AND PROOF OF LOSS – WORKING CAPITAL GUAR

OMB No. 3048-0035 EXPIRES:
PENDING 2023

Export-Import
Bank of the
United States

NOTICE OF CLAIM AND
PROOF OF LOSS –
WORKING CAPITAL
GUARANTEE

This Notice of Claim and Proof of Loss – Working Capital Guarantee application is for requesting a claim payment under
the Working Capital Guarantee program. An on-line version of this Notice of Claim and Proof of Loss is available on
EXIM’s website. EXIM encourages customers to submit in EXIM Online, https://eximonline.exim.gov/apps/bap, as it will
facilitate EXIM’s review and provide customers a faster response time.

SECTION A. Name and Address (Please provide full names and address).
GUARANTEED LENDER MAKING DEMAND FOR PAYMENT
EXIM Transaction No.
Master Guarantee Agreement (MGA) No.
Name
Address
City
State/Province
Postal Code
Country
Contact Name
Email
Phone Number
Current Holder of Original Promissory Note
BORROWER - For additional parties, add a separate page
Name
Address
City
State/Province
Postal Code
Country
Contact Name
Email
Phone Number
GUARANTOR - For additional parties, add a separate page
Name
Address
City
State/Province
Postal Code
Country
Contact Name
Email
Phone Number
EIB 10-04 (Rev. 09/23)

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OMB No. 3048-0035
EXPIRES: PENDING 2023

SECTION B. General Information
EXIM LOAN FACILITY
Reason for claim filing

Was this guarantee approved under Lender's delegated
authority?
Is this a transaction-specific loan?
Is there a Forbearance Agreement?
Type of loan facility

Is this loan under a fast-track lender program?
Is this a loan under city/state program?
Is this loan under a trade association partnership program?

Yes No
Yes No
Yes No
If yes, Agreement Date(s): MM/DD/YYYY
revolving loan facility
transaction-specific loan facility
transaction-specific revolving loan facility
Supply Chain facility
Yes No
Yes No
Yes No

Effective date of the Facility
Last date Facility was renewed
Facility extension(s) granted (please
list all extensions)

MM/DD/YYYY
MM/DD/YYYY

Maximum amount of Facility approved
Final Disbursement Date approved

$

Advance rate of collateral

MM/DD/YYYY

MM/DD/YYYY
% inventory
% receivables
% Other

What are the products provided by the Borrower?
Date of the last disbursement
Outstanding Principal balance of the EXIM loan
Claim filing extension granted by EXIM?

MM/DD/YYYY
$
Yes No
Date(s):

Indirect export(s) included?
Date of default
Note approval date
Demand Letter to Borrower
Demand Letter to Guarantor(s)

Yes No

EIB 10-04 (Rev. 09/23)

MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY

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OMB No. 3048-0035
EXPIRES: PENDING 2023

DOMESTIC LINES AND COLLATERALIZATION
Is there a domestic loan
Outstanding amount of the domestic line
Is the domestic line current?
Is the Domestic line collateralized?
Is there cross-collateralization?
Other loan facilities extended to the Borrower (list the
Facilities and amounts outstanding)

Yes No
$
Yes No
Yes No
Yes No

Collateral of the domestic line and other credit facilities
extended

LOAN INSURANCE
Is there a related insurance policy from EXIM?
If “YES”, EXIM Policy number(s)

Yes No

Is there a related insurance policy from another insurer?

Yes No

If 'Yes”, policy number(s), name and address of the
insurer(s) etc.

SECTION C. BUSINESS STRUCTURE INFORMATION
NAICS Code

Status of Borrower’s operation

Business structure of the Borrower

Proprietorship
Corporation
Partnership
Limited Partnership
Government Non-Sovereign
Government Sovereign

Borrower’s type of business

Wholesale
Manufacturing
Retail
Processing
Contractor
Service
Government
Other

EIB 10-04 (Rev. 09/23)

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OMB No. 3048-0035
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SECTION D. DOCUMENTATION AS PER MGA ARTICLE 5.01
Were all Disbursements made after receipt of a
Borrowing Base Certificate and its supporting
documentation as per MGA?

Yes
No
Add Comment:

Were all Disbursements made prior to the Final
Disbursement Date?

Yes
No
Add Comment:

Was the Borrower current under the Working Capital
loan facility at time of disbursement(s)?

Yes
No
Add Comment:

Were all disbursements under the Working Capital loan
facility less than or equal to the borrowing base?

Yes
No
Add Comment:

Were Disbursements made in agreement with the
conditions and prohibitions stated in the Loan
Authorization Agreement, the Borrower Agreement,
and the Master Guarantee Agreement?

Yes
No
Add Comment:

Are the items financed those identified in the Loan
Authorization Agreement?

Yes
No
Add Comment:

Is the transaction in compliance with all special
conditions?

Yes
No
Add Comment:

Is the transaction in compliance with requirements of
the Country Limitation Schedule in force at time of
approval?

Yes
No
Add Comment:

Is the Loan Authorization Agreement or Notice (Annex
A) signed by an authorized officer of Lender or affiliate
and EXIM?

Yes
No
Add Comment:

Is the Borrower Agreement signed by all relevant
parties?

Yes
No
Add Comment:

To the best of the Lenders knowledge, all terms and
conditions of the Borrower Agreement have been met.

Yes
No
Add Comment:

Are the loan documents free of any binding alternative
dispute resolution provisions?

Yes
No
Add Comment:

If required, has the Borrower provided all financial
statements to the Lender?

Yes
No
Add Comment:

Have the field examinations been conducted if required
by the MGA?

Yes
No
Add Comment:

EIB 10-04 (Rev. 09/23)

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OMB No. 3048-0035
EXPIRES: PENDING 2023

If required, has a valid, enforceable, and perfected
security interest been obtained and maintained?
Was the facility fee(s) paid in full and on time?
Was this delinquency on the part of the borrower and
guarantors reported to credit agencies?

Yes
No
Add Comment:
Yes
No
Add Comment:
Yes
No
Add Comment:

All documents must be submitted with the claim filing.
Promissory Note
Evidence of Payment of the Facility Fee

 Attached
 Attached
Executed copy of Loan Authorization Notice or Loan Authorization  Attached
Agreement (Annex A of the MGA)
Executed copy of Borrower Agreement
 Attached
Executed copy of the Loan Agreement
 Attached
Executed copy of Fast Track Lender Agreement, if applicable
 Attached
Delegated Authority Letter Agreement
 Attached
Security Agreement
Subordination Agreement, if required
All filed UCC financing statement(s)
Evidence of a lien search of UCC records which indicates a
perfected security interest
Field examination reports
Financial statements, if required

 Attached
 Attached
 Attached
 Attached
 Attached
 Attached

Borrowing Base Certificate(s) for the six- month period preceding
the date of the Payment Default (MGA Article 5.01(b)(vii))
Supporting Accounts Receivable Aging Reports and sample
copies of Invoices or export orders (MGA Article 5.01(b)(vii))

 Attached

Export orders or summaries of export order and inventory
schedules if applicable (MGA Article 5.01(b)(viii))

 Attached

 Attached

Records of final foreign purchase if indirect exports are included in  Attached
Loan Facility (MGA Article 5.01(b)(x))
Lender's records regarding disbursements and application of
payments to the loan (loan transaction history)

 Attached

Assignment of EXIM or other insurance policy (If insurance is
used)
Material records regarding satisfaction of the Special Conditions

 Attached

Demand Letter to Borrower
Demand Letter to Guarantor(s)
4.06 Compliance certifications
Economic Impact certifications
Bankruptcy notice or court order in the event demand is prohibited
under the bankruptcy law
Copies of communication to and from EXIM regarding Events of
Default
Copies of correspondence to and from EXIM concerning waivers,
modifications or extensions granted
EIB 10-04 (Rev. 09/23)

 Attached
 Attached
 Attached
 Attached
 Attached
 Attached
 Attached
 Attached
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Other

 Attached

Other

 Attached

SECTION E – CLAIM PAYMENT CALCULATION
PROMISSORY NOTE
Note amount
Note date
Frequency of interest payment
Method of interest calculation
Note repayment terms
Type of interest
Interest rate basis

$
MM/DD/YYYY

Daily
Monthly
Quarterly
Other
360/360 360/365 365/365
Fixed
Prime

Floating
 SOFR  LIBOR

 OTHER

Guaranteed interest rate.
(list all interest rates and the time period they apply)

Principal outstanding
Interest paid to
Last interest payment date

$
MM/DD/YYYY
MM/DD/YYYY

OTHER ELIGIBLE OUT-OF-POCKET COSTS CLAIMED
Enforcement Costs
Collateral Protection Costs
Realization Costs

$
$
$

CALCULATION OF ESTIMATED LOSS
Principal Outstanding
(+) Interest
(+) Enforcement Costs
(+) Collateral Protection
(+) Realization costs
Total claimed loss

$
$
$
$
$
$

SECTION F - WIRE INSTRUCTIONS AND TAX ID
Routing Bank Name: ________________________________________________________________
Routing Bank Address: ______________________________________________________________
Recipient Bank Name: ______________________________________________________________
Recipient Bank Address: ____________________________________________________________
EIB 10-04 (Rev. 09/23)

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OMB No. 3048-0035 EXPIRES:
PENDING 2023

ABA No. _________________________________________________________________________
Account Name: ____________________________________________________________________
Account No. ______________________________________________________________________
Tax ID No. ________________________________________________________________________
Attention: _________________________________________________________________________
Reference No., if any: _______________________________________________________________
Additional Comments: _______________________________________________________________
SECTION G – CERTIFICATIONS AND SIGNATURE
Please refer to the “Certifications for Notice of Claim Proof of Loss – Working Capital Guarantee” set forth in Form E I B
23- 0 1 posted on the EXIM website at https://img.exim.gov/s3fs-public/documents/eib-23-01-certifications-for-wcgclaim.pdf?VersionId=AzMWbNUCHXpXqR4OvBMK5Bg2mxxt45Vc (the “Certifications”). THE CERTIFICATIONS ARE
INCORPORATED INTO THIS NOTICE OF CLAIM PROOF OF LOSS AS IF FULLY AND DIRECTLY SET FORTH
HEREIN. When signing this Notice of Claim Proof of Loss – Working Capital Guarantee in the space provided below, the
undersigned authorized representative signing on the Lenders behalf certifies and represents that he or she is fully
authorized to sign on the Lender's behalf, and that HE OR SHE HAS READ the Certifications referenced above AND IS
CERTIFYING to all the certifications set forth in the Certifications.
The Lender further certifies that the representations made, and the facts stated in this Notice of Claim Proof of Loss –
Working Capital Guarantee and its attachments are, true and the Lender has not misrepresented or omitted any
material facts. The Lender further covenants that if any statement set forth in this application or in the Certifications,
becomes untrue, or is discovered to have been untrue when made, the Lender will promptly inform EXIM of all such
changes or discoveries. The Lender further understands that in accepting or approving this application, EXIM is relying
upon the Lender's statements set forth in the application and in the Certifications, and all statements and certifications to
EXIM are subject to the penalties for false or misleading statements to the U.S. Government (18 USC § 1001, et. seq.).
I,
of
on behalf of

, do hereby certify that I am the duly appointed and qualified
(Name of Lender)

(Title)

and that as such I am authorized to execute this application

(Name of Lender)

.

In witness whereof, I have hereunto signed my name this

day of

. 20

.

Signature of Lender’s Authorized Representative
_______________________________________________________________________
Date: ___________________________

EIB 10-04 (Rev. 09/23)

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OMB No. 3048-0035 EXPIRES:
PENDING 2023

Name of Lender’s Authorized Representative: ____________________________________________________
Title: _____________________________________________________________________________________
Name of Lender: ___________________________________________________________________________
Street Address: ____________________________________________________________________________
City: ___________________________________________
State/Province: ___________________________________

Postal Code: _________________

Email: ____________________________________________________________________________________
Phone Number: ____________________________________________________________________________

NOTICES
The Lender 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 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 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 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 reserves
the right to decline to process or to discontinue processing any application.
Paperwork Reduction Act Statement: We estimate that it will take you about 6 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 and the Office of Management and Budget, Paperwork Reduction Project, OMB# 3048-0035 Washington, D.C. 20503

EIB 10-04 (Rev. 09/23)

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