Form 34 HRSA Loan Guarantee Program Application

OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

HRSA LOAN GUARANTEE PROGRAM APPLICATION

Please send a complete application and all requested attachments to LGProgram@hrsa.gov. Contact the HRSA Loan Guarantee Program with questions on how to complete this application.

Part A. Borrower Information
Legal Name
D/B/A
H80 Grant Number
Street Address
State & ZIP Code
Tax ID
Contact Person
Name
Title
Telephone
E-mail
Part B. Lender Information
Lender Name
Street Address
State & Zip Code
Tax ID
Contact Person
Name
Title
Telephone
Email
Part C. Loan Information
Loan Amount		Loan Term (Years)
Interest-only Period (Months, if applicable)		Amortization Period (Years)
Proposed Interest Rate		Fixed (Y/N): Variable (Y/N):
If Variable, cite index & adjustment frequency
Collateral

Part D. Project Information

1. Project Type (check all that apply):

	New Construction
	Alteration/Renovation
	Land Acquisition
	Facility Acquisition

2. Facility Address: _______________________________________________________________

(Street) (City, State) (Zip Code)

3. Site in Scope? (Y/N):

4. Site Control (select one): Owned/To Be Purchased/Leased

Part E. Project Funding Sources & Uses

1. USES. Check all that apply and provide total amount.
Use			Amount ($)	Comments (if any)
	Land/Building Acquisition
	Hard Construction Costs
	Construction Contingency
	Environmental Remediation
	Furnishings, Fixtures & Equipment
	Soft Costs (Professional & Other Fees)
	Soft Costs Contingency
	Lender's Fees & Expense
	Other (Specify)
	Other (Specify)
Total Project Budget

2. SOURCES. Indicate amount from each source in‐hand or committed, and if the funds are restricted to a specific use.
	Amount ($)
Source	In-Hand ($)		Committed ($)	Use Restrictions (if any)
Guaranteed Loan
Borrower’s Funds
Other-Specify:
Other-Specify:
Other-Specify:
Total

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

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