![](media/image1.png){width="1.1666666666666667in"
height="1.0986111111111112in"} **EXPORT-IMPORT BANK OF THE UNITED
STATES**

**BENEFICIARY CERTIFICATE AND AGREEMENT**

**For Use With**

**Bank Letter of Credit Export Credit Insurance Policy or**

**Financial Institution Buyer Credit Export Credit Insurance Policy or**

**Medium Term Export Credit Insurance Policy**

NOTE: This form is to be used only if the beneficiary of the letter of
credit, the recipient of a funding under a direct buyer credit loan or
the recipient of payment under a reimbursement loan or a payment under a
supplier credit is not also the U.S. Exporter. In that situation the
exporter must complete those parts of the Exporter Certificate EIB94-07
required in its instructions and the beneficiary must complete this
entire certificate.

Name and Address of Policyholder: Name and Address of Beneficiary:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Policy No.\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(to be completed by the policyholder, also see No.4.e) Beneficiary\'s
Dun & Bradstreet Number \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Taxpayer ID No.:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Congressional
District:\_\_\_\_\_

Indicate (not required) if owned by a [ٱ]{dir="rtl"} woman, or an
[ٱ]{dir="rtl"} ethnic minority, describe\_\_\_\_

Upon representation that the Export‑Import Bank of the United States
("Ex-Im Bank") has issued to the policyholder identified

above an export credit insurance policy, and in consideration of either
(check one):

[ٱ]{dir="rtl"} a) the payment, acceptance or negotiation of an
irrevocable letter of credit in our favor; or,

[ٱ]{dir="rtl"} b) the financing of an export,

We, the Beneficiary, hereby certify to the policyholder and to Ex-Im
Bank as follows:

1.  The policyholder has either (check one):

> [ٱ]{dir="rtl"} a) informed us of an irrevocable letter of credit with
> Identification No.\_\_\_\_\_\_\_\_\_\_ and we have presented, or shall
> present, documents which are in compliance with the terms and
> conditions of such irrevocable letter of credit; or,
>
> [ٱ]{dir="rtl"} b) to our belief, established an obligation of the
> foreign buyer named below to make repayment of funds on a specified
> term in support of an export, for which we have received payment.
>
> 2\. The above referenced irrevocable letter of credit **or** the
> buyer\'s obligation to pay the policyholder is in support of an export
> transaction described as follows:
>
> a\) Name and address of
> buyer\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\) Description and quantity of
product(s)/service(s)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

c\) The product(s) are: [ٱ]{dir="rtl"} New, [ٱ]{dir="rtl"} Used. If
used, attach Used Equipment Questionnaire form EBD-M-25.

> d\) Place of
> Shipment\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> e) Date of
> Shipment\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

f)  Contract Price to Buyer:

\(i\) Products/Service \$\_\_\_\_\_\_\_\_\_\_

ii\) Less discounts or similar allowances \$\_\_\_\_\_\_\_\_\_\_

iii\) Plus total insurance, freight or other

delivery charges included in the transaction \$\_\_\_\_\_\_\_\_\_\_

Subtotal: \$\_\_\_\_\_\_\_\_\_\_

iv\) Less cash payment \$\_\_\_\_\_\_\_\_\_\_

(minimum 15% required for MT)

\(v\) Total final net delivered financed portion \$\_\_\_\_\_\_\_\_\_\_

3\. To the best of our knowledge and belief, the products described
above were **shipped from the United States**, in accordance with
paragraph 2 above.

4\. With respect to products

a\) which could be used for **military** purposes,

b\) which could be components of a product or equipment which could be
used for military purposes,

c\) which could be used to manufacture products or equipment which could
be used for military purposes,

d\) listed on the United States **Munitions List** (part 121 of Title 22
of the Code of Federal Regulations), or

e\) purchased by or for use by security, military or defense
organizations, [ٱ]{dir="rtl"} we \_\_\_\_ have or [ٱ]{dir="rtl"} the
policyholder \_\_\_\_

Initial Initial

has received the written approval of the Ex-Im Bank for such sale prior
to shipment of the products **and attached it** to this certificate.
Submit a Defense Product Questionnaire EIB92-61 in order to obtain such
approval.

5\. The products do not consist of technology, fuel, equipment,
materials or goods and services to be used in the construction,
alteration, operation or maintenance of **nuclear** power, enrichment,
reprocessing, research or heavy water production facilities.

6\. To the best of our knowledge and belief the products are **for use
only in** **countries** in accordance with Ex-Im Bank's [Country
Limitation Schedule]{.underline} in effect on the date of shipment. See
Ex-Im Bank's Internet Website \<[www.exim.gov]{.underline}\> Country and
Fee Information.

7\. Neither we, nor our Principals, have within the past 3 years been:

1)  debarred, suspended, declared ineligible from participating in, or
    voluntarily excluded from participation in, a Transaction;

2)  formally proposed for debarment, with a final determination still
    pending;

3)  indicted, convicted or had a civil judgment rendered against us for
    any of the offenses listed in the Regulations;

4)  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]{.underline}

5)  the undersigned has received a written statement of exception from
    Ex-Im Bank attached to this certification, permitting participation
    in this Transaction despite an inability to make certifications 1)
    through 4) in this paragraph.

8\. We have not and will not knowingly enter into any agreements in
connection with the goods and/or services covered by this policy 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**
(Regulations).

9\. We will complete and submit **Form-LLL (**the Anti-Lobbying
Declaration/Disclosure forms available at
<http://www.exim.gov/pub/pdf/95-10apd.pdf>), Disclosure Form to Report
Lobbying if, to the best of our knowledge and belief, **any funds have
been paid or will be paid** to any person in connection with this
application for influencing or attempting to influence:

\(1\) an officer or employee of any U.S. Government agency, or

\(2\) a Member of Congress or a Member's employee, or

\(3\) an officer or employee of Congress. *This does not apply to
commissions paid by the Bank to insurance brokers.*

10\. We have not, and will not, engage in any activity in connection
with this transaction that is a violation of 1) 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), 2) the **Arms Export Control Act**, 22 U.S.C.
2751 et seq., 3) the **International Emergency Economic Powers Act**, 50
U.S.C. 1701 et seq., or 4) the **Export Administration Act of 1979**, 50
U.S.C. 2401 et seq.; nor has it 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 its knowledge, the performance by the
parties to this transaction of their respective obligations does not
violate any other applicable law.

11\. The representations made and the facts stated by us in these
certifications and its attachments **are true, to the best of our
knowledge and belief, and we have not misrepresented or omitted any
material facts**. We further understand that these certifications are
subject to the penalties for fraud against the U.S. Government (18 USC
1001).

By:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Signature:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Print Name (Authorized Representative of the Beneficiary)

Title:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**If the beneficiary can not make any or all of the required
certifications as they are presented here, Ex-Im Bank must be contacted
to request written permission to delete or alter the certification,
without which the insurance policy may not be valid.**

##### Notices

The applicant 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 Ex-Im Bank being unable to determine
eligibility for support. The information provided will be reviewed to
determine the participants' ability to perform and pay under the
transaction referenced in this application. Ex-Im Bank 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).

**Public Burden Statement**: Reporting for this collection of
information is estimated to average 1 hour per response, including
reviewing instructions, searching data sources, gathering information,
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.

The information provided will be held confidential subject to the
**Freedom of Information Act** (5 USC 552) the **Privacy Act of 1974**
(5 USC 552a), and the **Right to Financial Privacy Act of 1978** (12 USC
3401), except as otherwise required by law. Note that the Right to
Financial Privacy Act of 1978 provides that Ex-Im Bank may transfer
financial records included in an application for an insurance policy, or
concerning a previously approved insurance policy, to another Government
authority as necessary to process, service or foreclose on an insurance
policy, or collect on a defaulted insurance policy.