Instructions for RD4274-0001

Application for Loan (Intermediary Re-lending Program)

Organizations complete this form. Organizations use this form to apply for an Intermediary Re-lending Program loan.

Submit the original of the completed form in hard copy or facsimile to the appropriate Rural Development servicing office.

The organization’s representative must complete all of the items specified in the following table.

Fld Name / Item No.	Instruction
1 Name	Enter your complete legal name. (Name of the applicant organization).
2 Street	Enter your street address.
3 City	Enter the name of the city or town from your mailing address.
4 County	Enter the name of the county where your main office is located.
5 State	Enter the name of the state from your mailing address.
6 Zip Code	Enter your zip code.
7 Telephone Number	Enter your complete telephone number.
8 Amount of loan required	Enter the amount of loan you are applying for.
9 Applicant’s Tax Identification Number	Enter your organization’s tax identification number.

Fld Name / Item No.	Instruction
10 Date Established	Enter the date of your charter or certificate of incorporation.
11 Citizenship	What percentage of your organization’s members are either citizens of the United States or have been legally admitted to the United States for permanent residence?.
12 History of Intermediary	Write a brief description of your organization and what it does. Include any experience the organization has had in making and servicing commercial loans.
13 Litigation	Describe any lawsuits or other legal action against your organization or its members or directors.
14 Names of Attorneys, Accountantsand Other Parties	Enter the name and address of anyone (such as a lawyer, accountant, or packager) you hired to help you prepare this application.
15 Description of Service Rendered with Complete Justification	Describe what kind of work the person did or is going to do. Tell us why you needed to hire someone to do it.
16 Total Compensation Agreed to be Paid	How much did you agree to pay the person for his or her work?.
17 Compensation Already Paid	How much have you actually paid the person so far?.
18 Subsidiaries and Affiliates	If your organization has any subsidiary, parent, or affiliate, list the name and address and describe how that organization is related to your organization.

Fld Name / Item No.	Instruction
19 Purchase and Sales Relationships with Others	Do any of your organization’s officers, directors, or members have a substantial interest in another organization or business that you do business with? Check yes or no. If the answer is yes, list the name of the officer, director, or member and the name of the other organization or business, and explain the situation.
20 Receivership Bankruptcy	Has your organization, your affiliate, or any officer or director of your organization or your affiliate ever been in receivership or bankruptcy? Check yes or no. If the answer is yes, describe the situation.
21 Disclosure of Special Information Regarding Principals	Enter the name and address of any RBS employee who has, or has had, any kind of association with your organization.
22 Details of Relationship or Interest	Explain the details of the association.
23 Management Name	Enter the names of your board members, key officers, key hired managers, and directors.
24 Position or Title	Enter the person’s title or name of his or her position.
25 Annual Compensation	Enter the total annual salary and any other money you pay or give to the person.
26 Regulatory Agencies	Enter any federal, state or local government agencies that supervise or regulate your activities. Explain any pending matters those agencies have raised with you. Explain whether any permits, licenses, or clearances are required for your operations and whether you have all the permits, licenses, and clearances you should have.

Fld Name / Item No.	Instruction
27 Is your organization, any of its members, officers, or directors, or anyone else directly involved in your operation and management, delinquent on any federal debt?	Check yes or no. If yes, explain the involvement.
28 What is the service area for your proposed Intermediary Re-lending Program revolving loan program?	Enter the area where you will operate your revolving loan program. For example: the City of Rutland; Clark, Knox, Lewis, and Scotland counties; or the State of Nevada.
29 Intermediary Name	Enter the name of your organization.
30 By	Someone authorized to sign on behalf of the organization should sign here.

Fld Name / Item No.	Instruction
31 Title	Enter the title of the person who signed on the line above.
32 Date Signed	Enter the date the application was signed.
33 Intermediary Contact Person	Name, address, and telephone number of the person you would prefer for us to contact to discuss your application.
34 Corporate Seal	Imprint your corporate seal.
35 Attest	A second representative of your organization that normally has custody of your corporate seal should sign here.
36 Title	Enter the title of the person who signed on the “Attest” line.