Form EIB 10-05 EIB 10-05 Notice of Claim and Proof of Loss – Medium- and Long-Ter

OMB No. 3048-0034
PENDING 2024

NOTICE OF CLAIM PROOF OF LOSS MEDIUM TERM LONG - TERM GUARANTEE

This Notice of Claim and Proof of Loss – Medium- and Long-Term Guarantee application is for requesting a claim payment under the EXIM
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 - NAMES AND ADDRESS (please provide full names and addresses)
Guaranteed Lender Making Demand for Payment
Master Guarantee Agreement (MGA) No.:

EXIM Transaction No. (AP No.):

Name:

Contact Name:

Address:
City:

State:

Email:

Zip Code:

Country:

Phone No:

Current Holder of Original Note

Who is the current holder of the original note?

Same as the Guaranteed Lender

If PEFCO, does the guarantee fall under the 1971 Agreement?

Borrower:

Contact:

City:

State:

Zip Code:

Email:

Country:

First Guarantor:

Phone No.:
Name:

Click here if not applicable:

City:

State:

Zip Code:

Email:

Country:

Second Guarantor:

Phone No.:
Name:

Address:
State:

Zip Code:

Not Applicable

Click here if not applicable:

Not Applicable

Click here if not applicable:

Not Applicable

Email:
Phone No.:

Country:
Name:

Address:

Contact:

City:

State:

Zip Code:

Email:
Phone No.:

Country:
Name:

Address:

Contact:
State:

Zip Code:

Email:
Phone No.:

Country:

EIB 10-05
Revised 04/2024

Click here if not applicable:
Contact:

City:

Third Guarantor:

Not Applicable

Contact:

Address:

City:

check if Yes

Name:

Address:

Assignee:

PEFCO

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Expires: xx/xx/xxxx

Exporter:

Name:

Click here if not applicable:

Address:

Not Applicable

Contact:

City:

State:

Zip Code:

Email:
Phone No.:

Country:

Note: If there are more parties for this transaction than noted above, please attach the name, address, and contact information on these additional participants
and send to EXIM along with the other required documentation. To expedite your claim, we recommend online claim filing. However, if you choose to submit
your claim by mail, it is advisable to send it via overnight mail: Claims/ CACP, Export-Import Bank of the U.S., 811 Vermont Avenue, NW, Washington, DC
20571.

SECTION C - CLAIM INFORMATION

SECTION B - GUARANTEE INFORMATION
What are the goods and/or services?

First Disbursement:

Fourth Disbursement:

Second Disbursement:

Fifth Disbursement:

Third Disbursement:

Sixth Disbursement:

What is the U.S. content percentage?
What is the total contract price?
What is the amount of the cash payment?
Exposure fee paid date:

Exposure fee paid, $

Is your guarantee Medium-Term or LongTerm?

Long-Term

Medium-Term

What is the first default date?
What is the reason for the claim filing?

SECTION D1 - PROMISSORY NOTE ONE
Note Information

Check here if not applicable:

Have in Possession?
Date of Promissory Note:

Yes

No

Frequency of payments:
Fixed
Floating
Interest Rate:
Interest - Method of Calculation: 360/360

Total Principal Amount:
Number of Installments:

Principal:

First Due Dates:
Date 1st Principal Due:

365/360
Days

365/365
Days

Days

Date Ordinary Interest Paid Through:

Interest:

Have partial payments been applied to defaulted
installments?

Date 1st Interest Due:

Yes

No

Installment Information
Installment
Number(s)

Outstanding
Principal

From Date

To Date

Number of
Days

Principal Due Principal Paid

Additional Comments:

EIB 10-05
Revised 04/2024

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Interest Rate
(%)

Interest Due

Interest Paid

OMB No. 3048-0034
Expires: xx/xx/xxxx

SECTION D2 - PROMISSORY NOTE 2
Note Information

Check here if not applicable

Have in Possession?
Date of Promissory Note:

Yes

No

Number of Installments:

Frequency of payments:
Interest Rate:

Total Principal Amount:

Fixed

Floating

Rate - Method of Calculation:
Principal:

360/360
Days

365/365
Days

365/360
Days

Date Ordinary Interest Paid Through:

Interest:

First Due Dates:
Date 1st Principal Due:



Date 1st Interest Due:

Installment Information
Installment
Number(s)

Outstanding
Principal

From
Date

To
Date

Number of
Days

Principal Due

Additional Comments:

SECTION E - CLAIM - ESTIMATED ELIGIBLE LOSS
Estimated Claim Payment Amount
a) Total face value of Note(s) from Section D1 through D2.

(+)

b) Total principal payment(s) received.

(-)

c) Loss (principal only)
d) Interest Outstanding
e) Subtotal Estimated Claim Payment
f) % of Guarantee Coverage

(%)

g) Total Estimated Claim Payment

SECTION F - WIRE INSTRUCTIONS
Routing Bank Name
Recipient Bank Name
Recipient Bank’s Address:
ABA #
Account Name:
Account #:
Attention:

EIB 10-05
Revised 04/2024

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Principal
Paid

Interest Rate
(%)

Interest
Due

Interest
Paid

OMB No. 3048-0034
Expires: xx/xx/xxxx

SECTION G – CLAIM SUPPORTING DOCUMENTATION & CERTIFICATIONS
Demand Letter to Borrower:

 Enclosed  Not required

Date of the Demand Letter:

Demand Letter(s) to Guarantor(s):

 Enclosed  Not required

Date of the Demand Letter:

Lender Credit Agreement:

 Enclosed  Not required

Annex B:

 Enclosed Not required

Promissory Note(s):

 Enclosed

Assignment:

 Enclosed  Not required

Security Interest documentation if required:

 Enclosed  Not required

Other:
Other:
Other:

SECTION H – NOTICES AND SIGNATURE
Name of Lender’s Authorized Representative:
Title:
Name of Lender:
Street Address:
City:
State/Province:

Postal Code:

Email:
Phone Number:
Signature:

NOTICES
Please refer to the Lender Certifications for Notice of Claim and Proof of Loss – Medium-Term and Long-Term Guarantee posted on EXIM’s
website as document EIB 22-01. THE CERTIFICATIONS ARE INCORPORATED INTO THIS NOTICE OF CLAIM AND PROOF OF
LOSS – MEDIUM-TERM AND LONG-TERM GUARANTEE AS IF FULLY SET FORTH HEREIN. When signing this Notice of Claim and
Proof of Loss in the space provided below, the undersigned authorized representative signing on the Lender’s behalf certifies and represents
that the undersigned is fully authorized to sign on the Lender’s behalf, and that THE UNDERSIGNED HAS READ the Lender Certifications
for Notice of Claim and Proof of Loss – Medium-Term and Long-Term Guarantee referenced above AND IS CERTIFYING, as appropriate,
to all of the certifications set forth in that document.

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 90 minutes per response, that 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 #
3048-0034, Washington, DC 20503.

EIB 10-05
Revised 04/2024

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