Form 84-1 US Small Business Administration Export-Import Bank of t

OMB No.: 3048-0003
Expires October 31, 2008
(Ex-Im Bank Use Only)

(SBA Use Only)
U.S. SMALL BUSINESS ADMINISTRATION
Date Received

Date Received
EXPORT-IMPORT BANK OF THE UNITED STATES

C.I.D. No.
JOINT APPLICATION FOR
EXPORT WORKING CAPITAL GUARANTEE
PART A. PRINCIPAL PARTIES
1. Borrower/Exporter Please circle the appropriate answer: New to Ex-Im Bank or SBA?
Company Name
D&B No.

Yes
Telephone No.

Name and Title of Contact Person

Federal ID No.

Fax No.

Address

City

Intermediary

Gross Sales:
$

State

No. of Full-Time
Employees:

No

Zip

Primary North American Industrial
Classification System (NAIC) No.:

“Small Business Concern” as
described in SBA Guidelines?
□ Yes
□ No
Has the Borrower or its owner(s), or the Guarantor ever filed for protection under U.S. bankruptcy laws? Has either had an involuntary
bankruptcy petition filed against it? □ Yes
□ No
Is the Borrower a minority-owned business □ Yes □ No
A women-owned business? □ Yes □ No
2. Borrower’s Management (Proprietors, partners, officers, directors and holders of all outstanding stock or other ownership interests 100% of ownership must be shown. Include anyone who was a principal within the last six months.) Attach separate sheet of paper if
necessary.
Name
Complete Street Address
%
Social Security
Title/Management
Gender*
owned
Number
position
(M/F)
Race* (check one or more boxes): □ American Indian/Alaska Native; □ Black/African American; □ Asian; □ Native Hawaiian/Pacific Islander; □
White. Ethnicity:* □ Hispanic/Latino; □ Not Hispanic/Latino.
Military Service Status* (choose one): □ Non-Veteran; □ Veteran; □ Service Disabled Veteran

Race* (check one or more boxes): □ American Indian/Alaska Native; □ Black/African American; □ Asian; □ Native Hawaiian/Pacific Islander; □
White. Ethnicity:* □ Hispanic/Latino; □ Not Hispanic/Latino.
Military Service Status* (choose one): □ Non-Veteran; □ Veteran; □ Service Disabled Veteran

Race* (check one or more boxes): □ American Indian/Alaska Native; □ Black/African American; □ Asian; □ Native Hawaiian/Pacific Islander; □
White. Ethnicity:* □ Hispanic/Latino; □ Not Hispanic/Latino.
Military Service Status* (choose one): □ Non-Veteran; □ Veteran; □ Service Disabled Veteran

*This information is collected for statistical purposes only. It has no bearing on the credit decision. Disclosure is voluntary.
3. Borrower’s Affiliate(s) If more than one affiliate, please attach separate sheet of paper.
Company Name
D&B No.
Telephone No.
Name and Title of Contact Person

Federal ID No.

Fax No.

Street Address

City

State

4. Personal Guarantor(s) If more than one guarantor, please attach separate sheet of paper.
Name
Social Security No.

Street Address

EIB-SBA Form 84-1

Revised 11/2006

Telephone No.

Date of Birth and Place of Birth

Fax No.

City

State

Page 1

Zip

Zip

OMB No.: 3048-0003
Expires October 31, 2008
5. Lender Please circle the appropriate answer: New to Ex-Im Bank or SBA?
Yes (If yes, submit annual report.)
Name
Federal ID No.
Telephone No.
Fax No.
Address
City
State

No
Zip

PART B. INFORMATION ABOUT THIS TRANSACTION
1. Loan Information
Loan Amount:
$

Term of Loan:
□ 6 months
□ 1 year

Interest Rate to be Charged:
Lender Interest Rate _______% Per
Annum
If Interest Rate is to be Variable:
Base Rate:_____________
Adjustment Period:___________
(Monthly, Quarterly, Annually, etc.)
Spread:_________________
Base Rate Source:______________
(WSJ, LIBOR, etc.)

□ Other (specify: )

Other Fees or Charges (type and amount);
Conversion of Preliminary Commitment?
□ Yes
If yes: commitment #________
□ No

Type of Loan (check one):
□ Revolving
□ Transaction(s) Specific
Renewal?
□ Yes
□ No
Were You Assisted by an Ex-Im Bank City/State
Partner or a Small Business Development Center?
□ Yes
If yes, please identify:
Name & Address:__________________
___________________
Contact Name:_____________________
Telephone No.:____________________
□ No

2. Transaction Information
Products/Goods/Services to be exported (description):
Estimated Total Export Sales to be supported by this Loan: $ ________
Principal Countries of Export (please identify the top 3 countries):
(Ex-Im Bank applicants only) U.S. Content Percentage:

______ %

Please estimate the number of jobs to be supported by this
Loan:
Are Performance Guarantees or Standby Letters of Credit to
be issued under this Loan?

# of existing jobs maintained:
# of additional jobs created:
Yes
No
Percentage of Loan to be utilized for performance
guarantees: _________%

3. (Ex-Im Bank applicants only) Please answer the following questions about the “export items” to be exported from the U.S.
a. Military Is the buyer of the export items associated in
Yes
No
If yes, please attach a description of the buyer or
any way with the military? Are the items to be used by the
items, as applicable.
military, or are they defense articles, or do they have a
military application?
b. Nuclear Are the export items to be used in the
Yes
No
If yes, please attach a description of the items.
construction, alteration, operation, or maintenance of
nuclear power, enrichment, reprocessing, research, or heavy
water production facilities?
c. Environmental Are the export items to be used for an
Yes
No
If yes, please attach a description of the items,
environmental project or do they have perceptible
including the following information: If transaction
environmental benefits?
related to a specific project, identify the project;
project location; and project sector or industry. If
not related to a specific project, identify the sector
in which items are to be used to create an
environmental benefit.
d. Munitions Are the export items on the U.S. Munitions
Control List (Part 121 of Title 22 of the Code of Federal
Regulations), or do they require a validated export license
from the Bureau of Export Administration?
EIB-SBA Form 84-1

Revised 11/2006

Yes

Page 2

No

If yes, please attach a description of the items. If
uncertain whether a validated export license is
required, written verification from the appropriate
licensing agency may be required before loan
approval.

OMB No.: 3048-0003
Expires October 31, 2008
PART C. CERTIFICATIONS
*Please attach a signed, duplicate original of Part C for each Borrower and each Lender
1.

Borrower and Lender Certifications

The undersigned, each as authorized representative of the Borrower and the Lender (respectively) and on its behalf, each
independently make the following certifications:
Debarment/Suspension – I certify and acknowledge that neither I or my Principals have within the past 3 years been a) debarred,
suspended, declared ineligible from participating in, or voluntarily excluded from participation in, a Transaction; b) formally proposed
for debarment, with a final determination still pending; c) indicted, convicted or had a civil judgment rendered against us for any of
the offenses listed in the Regulations; d) delinquent on any amounts due and owing to the U.S. Government or its agencies or
instrumentalities as of the date of execution of this certification; or the undersigned has received a written statement of exception from
Ex-Im Bank or SBA attached to this certification, permitting participation in this Transaction despite an inability to make
certifications a) through d) in this paragraph. I further certify that I have not and will not knowingly enter into any agreements in
connection with the goods and/or services purchased with the proceeds of this loan with any individual or entity that has been
debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a Transaction. All
capitalized terms not defined herein shall have the meanings set forth in the Government-wide Non-procurement Suspension and
Debarment Regulations - Common Rule (13 CFR part 145 – SBA Regulations and 12 CFR part 413 – Ex-Im Bank Regulations). I am
not listed on any of the publicly available debarment lists of the following international financial institutions: World Bank Group,
African Development Bank, Asian Development Bank, European Bank for Reconstruction and Development and the Inter-American
Development Bank.
Compliance with Laws - In addition, I certify that neither I nor anyone acting on my behalf, such as agents, have engaged or will
engage in any activity in connection with this transaction that is a violation of a) the Foreign Corrupt Practices Act of 1977, 15
U.S.C. 78dd-1, et seq. (which provides for civil and criminal penalties against individuals who directly or indirectly make or
facilitate corrupt payments to foreign officials to obtain or keep business) Further, I have not engaged, and will not engage, in
any activity in connection with this transaction that is a violation of the Arms Export Control Act, 22 U.S.C. 2751 et seq., the
International Emergency Economic Powers Act, 50 U.S.C. 1701 et seq. or the Export Administration Act of 1979, 50 U.S.C.
2401 et seq. I have not been found by a court of the United States to be in violation of any of these statutes within the preceding
12 months and, to the best of my knowledge, the performance by the parties to this transaction of their respective obligations does
not violate any other applicable law.
Further, neither I nor anyone acting on my behalf in connection with this transaction is currently under charge or has been, within
the past 5 years, convicted in any court or subject to national administrative measures of any country for bribery of foreign public
officials.
Lobbying (applicable to Lender only) – I certify to the best of my knowledge and belief, that if any funds have been paid or will
be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an
officer or employee of Congress, or an employee of a member of Congress in connection with this commitment providing for the
United States to guarantee a loan, I will complete and submit a Standard Form-LLL, "Disclosure Form to Report Lobbying" in
accordance with its instructions. Submission of this statement is imposed by 31 U.S.C. 1352 as a prerequisite for making or
entering into this transaction. Any person who fails to file this statement when required is subject to a civil penalty of not less
than $10,000 and not more than $100,000 for each such failure.
False Statements – I certify that the representations made and the facts stated in this application and its attachments are true to the
best of my knowledge and belief, and I have not misrepresented or omitted any material facts. I understand that knowingly
making false statements or overvaluing a security to obtain a Government-guaranteed loan can subject me to a fine of up to
$250,000 and imprisonment for up to five years under 18 U.S.C. 1001.
Borrower:
Name of Borrower
Signature
Name and Title of Authorized Representative (Print or Type)

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Lender:
Name of Lender
Signature
Name and Title of Authorized Representative (Print or Type)

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2.

Guarantor and Additional Borrower Representations and Certifications (SBA applicants only)

The undersigned, each as authorized representative of the Borrower and the Guarantor(s) (respectively) and on its behalf, each
independently make the following representations and certifications:
(If any answer to any of these questions is “yes,” provide complete
information on a separate sheet of paper)
a. Are there any pending or threatened liens, tax liens, judgments or
material litigation against the:
b. Does the Borrower or Guarantor or any spouse or member of the
household of the Borrower or Guarantor, or anyone who owns, manages
or directs the Borrower’s business or their spouses or members of their
households, work for SBA, Small Business Advisory Council, SCORE,
any Federal Agency, or the Lender?
c. Has the Borrower or its owner(s), or the Guarantor ever filed for
protection under U.S. bankruptcy laws? Has either had an involuntary
bankruptcy petition filed against it?
d. Has the Borrower or its owner(s) or affiliates, or the Guarantor
ever previously requested U.S. Government financing?
e. Is the Borrower or Guarantor now, or ever have been in the past:
(a) under indictment, on parole or probation; or (b) charged with or
arrested for any criminal offense other than a minor motor vehicle
violation (including offenses which have been dismissed, discharged, or
nolle prosequi); or (c) convicted, placed on pretrial diversion, or placed
on any form of probation including adjudication withheld pending
probation for any criminal offense other than a minor vehicle violation?
f. Are all owners and Guarantors U.S. Citizens?
If no:
Are the non-U.S. Citizens lawful permanent resident aliens?
□ Yes (provide alien registration number(s): ____________)
□ No

Borrower

Guarantor

□
□
□
□

Yes
No
Yes
No

□
□
□
□

Yes
No
Yes
No

□
□

Yes
No

□
□

Yes
No

□
□
□
□

Yes
No
Yes
No

□
□
□
□

Yes
No
Yes
No

□
□

Yes
No

□
□

Yes
No

Authorization - I authorize SBA and/or the Lender to make inquiries as necessary to verify the accuracy of the statements made
and to determine my creditworthiness. I authorize the SBA’s Office of Inspector General to request criminal record information
about me from criminal justice agencies for the purpose of determining my eligibility for programs authorized by the Small
Business Act, as amended.
Agreements - I agree that if SBA approves this application I will not, for at least two years after the date of SBA’s approval, hire
as an employee or consultant anyone that was employed by the SBA during the one-year period prior to the disbursement of the
loan. I further agree that as consideration for any management, technical, and business development assistance that may be
provided to me by SBA or on its behalf, I waive all claims against SBA and its consultants. I understand and agree that I need not
pay anybody to deal with SBA, and that I have read and understand SBA Form 159, which explains SBA policy on Borrower and
Lender representatives and their fees. By my signature, I certify that I have received a copy and read a copy of the “Statements
Required by Law and Executive Order” (SBA Form 1261) that was attached to this application, and that I agree to comply with
all such laws and executive orders.
False Statements - I certify that the representations made and the facts stated in this application and its attachments are true, to the
best of my knowledge and belief, and I have not misrepresented or omitted any material facts. I understand that knowingly
making false statements or overvaluing a security to obtain a Government-guaranteed loan can subject me to a fine of up to
$250,000 and imprisonment for up to five years under 18 U.S.C. 1001, and to the civil remedies available under the False Claims
Act, 31 U.S.C. 3729 et seq. I further understand that knowingly making false statements or overvaluing a security to a Federally
insured institution can subject me to a fine of up to $1,000,000 and imprisonment for up to 20 years under 18 U.S.C. 1014.

EIB-SBA Form 84-1

Revised 11/2006

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OMB No.: 3048-0003
Expires October 31, 2008
Borrower:
Name of Borrower
Signature
Name and Title of Authorized Representative (Print or Type)
Guarantor:
Name of Guarantor
Signature
Name and Title of Authorized Representative (Print or Type)

3.

Date

Date

Additional Lender Certifications (SBA applicants only)

The undersigned, as authorized representative of the Lender and on its behalf, make the following certifications:
I submit this application to SBA for approval subject to the terms and conditions outlined above. Without the participation of
SBA as described in the application, I would not be willing to make this loan, and in my opinion this financial assistance is not
otherwise available on reasonable terms.
I certify that none of the Lender’s employees, officers, directors, or substantial stockholders (more than 10%) have a financial
interest in the applicant.
I certify that the representations made and the facts stated in this application and its attachments are true, to the best of my
knowledge and belief, and I have not misrepresented or omitted any material facts. I understand that knowingly making false
statements or overvaluing a security to obtain a Government-guaranteed loan can subject me to a fine of up to $250,000 and
imprisonment for up to five years under 18 U.S.C. 1001, and to the civil remedies available under the False Claims Act, 31 U.S.C.
3729 et seq.
Name of Lender
Signature
Name and Title of Authorized Representative (Print or Type)

EIB-SBA Form 84-1

Revised 11/2006

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OMB No.: 3048-0003
Expires October 31, 2008

NOTICE TO APPLICANT:
Authority for Requiring Submission of Information in Application - The applicant is hereby notified that Ex-Im Bank and SBA
request the information in this application under the authority of the Export-Import Bank Act of 1945, as amended (12 U.S.C. 635 et
seq.) and section 7(a)(14) of the Small Business Act (“SB Act”), (15 U.S.C. 636(a)(14)), respectively. Providing the requested
information is mandatory (except, see Privacy Act notice below concerning social security number), and failure to provide the
requested information may result in SBA/Ex-Im Bank being unable to determine the applicant’s eligibility for financial assistance.
Unless a currently valid OMB control number is displayed on this form (see upper right of each page), SBA/Ex-Im Bank may not
require the information requested in this application, and applicants are not required to provide such information.
Submission of Social Security Number (Privacy Act notice) - Under the Privacy Act, the applicant is not required to provide social
security number information, and failure to provide social security number may not affect any right, benefit, or privilege to which
applicant is entitled. Disclosures of name and other personal identifiers are required for a benefit, however, and SBA requires an
applicant seeking financial assistance to provide sufficient information to allow SBA to make a character and credit determination
concerning individuals that are borrowers, principals, and guarantors. In determining whether an individual is of good character, SBA
considers the person’s integrity, candor, and disposition toward criminal actions. In making loans pursuant to section 7(a) of the SB
Act (15 U.S.C. 636(a)(6)), SBA is required to have reasonable assurance that the loan is of sound value and will be repaid, or that it is
in the best interest of the Government to grant the financial assistance requested. Additionally, SBA is specifically authorized to
verify the applicant’s criminal history, or lack thereof, pursuant to section 7(a)(1) of the SB Act (15 U.S.C. 636(a)(1)(B)). Further, for
all forms of assistance, SBA is authorized to make all investigations necessary to ensure that a person has not engaged in acts that
violate or will violate the SB Act or the Small Business Investment Act (15 U.S.C. 634 and 687b(a)). For these purposes, applicant is
asked to voluntarily provide social security numbers to assist SBA in making character determinations and to distinguish the
individuals listed in this application from other individuals with the same or similar name or other personal identifier.
The Privacy Act authorizes SBA to make certain “routine uses” of information protected by that Act. One such routine use is that
when this information indicates a violation or potential violation of law, whether civil, criminal, or administrative in nature, SBA may
refer it to the appropriate agency, whether Federal, State , local or foreign, charged with responsibility for or otherwise involved in
investigation, prosecution, enforcement or prevention of such violations. Another routine use is to assist in obtaining credit bureau
reports, including business credit reports on the small business borrower and consumer credit reports and scores on the principals of
the small business and guarantors on the loan for purposes of originating, servicing, and liquidating small business loans and for
purposes of routine periodic loan portfolio management and lender monitoring. See 69 F.R. 58598, 58617 (and any subsequently
published notices) for additional background and other routine uses.
Disclosure – Ex-Im Bank and SBA will hold confidential all information provided in the application, subject only to disclosure as
required under the Freedom of Information Act (5 USC 552), the Privacy Act of 1974 (5 USC 552a), the Right to Financial Privacy
Act of 1978 (12 USC 3401), or any other law or court order.
Public Burden Statement - Reporting for this collection of information is estimated to average 7.5 hours per response, including
reviewing instructions, searching data sources, gathering information, and completing and reviewing the application. Send comments
regarding the burden estimate, including suggestions for reducing it, to Office of Management and Budget, Paperwork Reduction
Project OMB# 3048-0009, Washington, D.C. 20503.

EIB-SBA Form 84-1

Revised 11/2006

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OMB No.: 3048-0003
Expires October 31, 2008
APPLICATION INSTRUCTIONS
PART A. PRINCIPAL PARTIES
1. Borrower/Exporter. Complete this section with information on the individual or corporate borrower. Provide the
preliminary North American Industrial Classification System No. (NAIC) of the borrower, rather than the product
being exported.
2. Management. Complete this section for each proprietor, partner, officer, director or other individual owning 20%
or more of the borrower. 100% of ownership must be shown.
3. Personal Guarantor(s). List all individuals and entities that will guarantee repayment of the loan. The personal
guarantee of the owner(s) is required in most cases.
4. Lender. Leave blank if you are applying for a Preliminary Commitment and a prospective lender has not been identified.
PART B. INFORMATION ABOUT THE TRANSACTION
Provide the loan amount, term and type of loan requested, and answer all questions in Part B. (See also Checklist item 2 below.)
PART C. CERTIFICATIONS
This section must be signed by an authorized representative of the borrower, each guarantor, and, if this is a request for a final
commitment, the Lender.
CHECKLIST OF INFORMATION TO BE ATTACHED
(Note: All Attachments must be signed and dated by all person(s) signing this form.)
BACKGROUND
1. Brief resume of principals and key employees, History of business; copy of business plan, if available;
identify whether sole proprietorship, general partnership, limited liability company (LLC), corporation
and/or subchapter-S corporation.
2. Explanation of use of proceeds and benefits of the loan guarantee, including details of the underlying
transaction(s) for which the loan is needed, including country(s) where the buyers are located.
TRANSACTION
3. Attach product literature. (Ex-Im Bank applicants only): If applicable, attach description of items if
they are nuclear, military, environmental, on the U.S. Munitions Control List, or require an export license.
4. Copy of letter of credit and/or copy of buyer's order/contract, if available.
5. Export credit insurance-related material (policy, application, buyer credit limit), if applicable.
6. Copy of export license, if required.
FINANCIAL INFORMATION
7. Business financial statements (Balance Sheet, Income Statement, statement of Cash Flows) for the last
three years, if applicable, supported by the most recent Federal income tax return for the business. (SBA
applicants only): Also submit the last three years of signed Federal income tax returns for the business.
8. Current financial statement (interim) dated within 90 days of the date of application filing.
9. Aging of accounts receivable and accounts payable.
10. Schedule of all principal officer/owner's compensation for the past three years, and current year to date
[if none, please indicate].
11. Signed joint personal financial statements(s) of each major shareholder(s)/partner(s), owner(s), of the
company (with 20% or greater ownership, including assets and liabilities of both spouses) and their most
recent Federal income tax return (not required for venture capital partners).
12. Estimate of monthly cash flow for the term of the loan, highlighting the proposed export transaction.
13. Description of type and value of proposed collateral to support the loan (company assets/export
product, i.e., inventory, accounts receivable, other).
14. Attach credit memorandum prepared by the Lender. (SBA applicants only): Also attach D&B Report
and Personal Credit Reports on Principals and Guarantors.
15. (Ex-Im Bank applicants only): Nonrefundable $500 application fee for a Preliminary Commitment or
nonrefundable $100 application fee for a Final Commitment, whichever is applicable, by check or money
order made out to the Ex-Im Bank.
16. (SBA applicants only): SBA Form 1261
17. (SBA applicants only): Copy of IRS Form 4506-T (original to be submitted to IRS by the Lender).

EIB-SBA Form 84-1

Revised 11/2006

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N/A

Yes

N/A

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MAILING/FORWARDING INSTRUCTIONS
Please circle the appropriate answer.
1.

If application is submitted by a Borrower/Exporter:
a.

Is Borrower/Exporter's requested loan amount in Part B $1,666,666 or less?

b. Is Borrower/Exporter a small business, as defined by 13 CFR 121.105?

□ Yes

□ No

□ Yes

□ No

If answer to both of the above is YES, send entire set of materials to the SBA Representative in the U.S. Export
Assistance Center nearest you. Call (800) 827-5722 for the address.
If answer to both of the above is NO, send entire set of materials to:
Export-Import Bank of the U.S.
Office of Credit Applications and Processing
811 Vermont Avenue, NW
Washington, DC 20571
2.

If application is submitted by a Lender.
a.

Is Lender an SBA 7(a) Participating Lender?
□ Yes □ No
If YES, and if the loan will have a maturity of twelve (12) months or less, submit with this application a Lender’s
check equal to 0.25% of the guaranteed amount of the loan.

b.

Is Lender using its Ex-Im Bank Delegated Authority?
□ Yes
□ No
If YES, send the application, the Loan Authorization Notice (two originals), the appropriate facility fee, and the
$100 application fee to the Ex-Im Bank address above, regardless of the guarantee amount.

Loan Officer’s Recommendation:

□ Approve

OR SBA USE ONLY
□ Decline
State Reason(s):

Signature

Title

Other Recommendation if required:

□ Approve

□ Decline

Signature

Title

Date
State Reason(s):
Date

THIS BLOCK TO BE COMPLETED BY SBA OFFICIAL TAKING FINAL ACTION
□ Approve

□ Decline

State Reason(s):

Signature

EIB-SBA Form 84-1

Title

Revised 11/2006

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