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Ministerial Loan Guarantee Application (Individual and Band)
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PROTECTED A
For DIAND Use Only
Region
File No.
CIDM No.
Privacy Act Statement
The information requested on this document is collected under the authority of the Department of Indian Affairs and Northern Development Act in order to facilitate the operation of a housing loan guarantee program. This information will be stored in Personal Information Bank No. INA PPU-011. Personal information that you provide is protected under the provisions of the Privacy Act.
Applicant Information Applicant Name (First Nation Name)
Reserve Name
(If applicable)
(If applicable)
Band No.
(If applicable)
(If applicable)
Reserve No.
(If applicable)
(If applicable)
Ο Band as per Indian Act or Cree/Naskapi (or Québec) Act
Ο Self Governing First Nation
Type of Housing Program
Ο Ministerial Loan Guarantee - Individual First Nation Member
Ο Ministerial Loan Guarantee - First Nation
Ο MLG for CMHC On-Reserve Non-Profit Housing Program Project
Ο MLG for CMHC Shelter Enhancement Program Project
Borrower Information (Only required if the application is for an individual.)
Borrower Name
Title (Mrs., Mr.)
Municipality
Province / Territory
Postal Code
Business Phone No.
Extension
Cell Phone No.
(If applicable)
(If applicable)
Facsimile No.
Email Address
Type ► Ο Status Ο Non-Status
Registration No. ►
Equity Information
Application Loan Amount
$________________________________
Department Contribution
$________________________________
Borrower Funds
$________________________________
Other Funds (Specify)
$________________________________
Total Project Cost
$________________________________
Lender Information Name/Branch
Address
Contact Person
Municipality
Province / Territory
Postal Code
Lender Loan No.
Amortization Period (YY / MM)
Term (YY / MM)
Installment Amount
Installment Frequency
Ο Monthly Ο Semi-Monthly
Ο Weekly Ο Accelerated Weekly
Ο Bi-Weekly Ο Accelerated Bi-Weekly
Ο Yearly
Ο Monthly Ο Semi-Monthly
Ο Weekly Ο Accelerated Weekly
Ο Bi-Weekly Ο Accelerated Bi-Weekly
Ο Yearly
Interest Type (If Fixed)
Interest Rate __________________ %
Interest Rate __________________ %
Interest Type (If Variable)
Ο At Prime ______________________ %
Ο Below Prime - __________________ %
Ο Above Prime + __________________ %
Ο At Prime ______________________ %
Ο Below Prime - __________________ %
Ο Above Prime + __________________ %
Project Information Project Name
Project Type ► Ο Acquisition Ο Construction Ο Renovation
Number of Units
Cost
$___________________
$___________________
Size
Municipality
Province / Territory
Postal Code
Township
Plan No.
Block No.
Lot No.
Range No.
Legal Subdivision No.
Latitude/GPS
Longitude/GPS
Utility Servicing
| Planned | Actual | Service |
| ∀ | ∀ | Piped Water |
| ∀ | ∀ | Trucked Water |
| ∀ | ∀ | Well Water |
| ∀ | ∀ | Piped Sewage |
| ∀ | ∀ | Trucked Sewage |
| ∀ | ∀ | Septic Tank |
| ∀ | ∀ | Heating Fuel(Specify Source) _________________________ |
1. Band Council Resolution (BCR) or equivalent authorizing document
∀ Attached
2. Site map of project
∀ Attached
3. Letter of Intent, Commitment Letter or Loan Agreement from Lender or Approved and Signed CMHC Agreement
∀ Attached
4. Project description for the purposes of Environmental Assessment
∀ Attached
5. Any other document required by your regional office
∀ Attached
The information provided is accurate to the best of my knowledge.
Applicant Name
Signature
X
X
Date (YYYYMMDD)
The information provided is accurate to the best of my knowledge.
First Nation Authorizing Signator Name
Title
Signature
X
X
Date (YYYYMMDD)
The information provided is accurate to the best of my knowledge.
Authorizing Signator Name
Title
Signature
X
X
Date (YYYYMMDD)
DCI No: 2948843(2012-2013)
