TITLE XVI HEALTH CENTER LOAN GUARANTEE
PROGRAM APPLICATION
Please answer all questions as completely and accurately as possible and provide all requested attachments. Only shaded regions are required for pre-application.
| Legal Name of Borrower: |
| Current Address: |
| Address of Project: |
| Executive Director: |
Contact Name (if different):
Title:
Telephone:
Fax: |
Legal Counsel (Firm):
Address:
Telephone:
Fax: |
Attorney's Name:
Telephone:
Fax:
Borrower's Accountant: |
A) |
Attachment 1: Please provide a complete list of your Board of Directors and officers, including names, |
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addresses, employer and position . |
B) |
Attachment 2: Please provide a list of all Senior Management personnel and resumes. |
A) |
Are you corporately integrated with (e.g., a subsidiary of) any other organization? Yes |
No |
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If yes, please indicate name, address, type of legal relationship, and nature of integration. |
B) Are you involved in any joint ventures? Yes No If yes, please indicate names, addresses, and types of legal relationships.
C) Is there a developing or operating Health Center managed care network in your marketplace? Yes No If yes, is your health center involved? Yes No
D) How is the health center collaborating with other entities to integrate service delivery?
A) |
(Note: For the following program information, please note any projected changes due to the facility project. Mission of Borrower: |
B) |
Please circle each of the medical/dental services offered: Adult Medicine Ambulatory Surgery Dental Home Care Laboratory Mental Health Occupational Health Pediatrics Pharmacy Substance abuse Urgent Care Vision Care Other medical/dental services offered (please list): |
Elder care Family Planning Nutrition OB/GYN Podiatry Radiology |
C) |
Description of any other programs offered: |
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D) |
Geographic Service Area: (please name census tracts/counties/towns served) |
E) |
Population of Service Area: |
F) |
In the table below, please indicate the daily hours of operation of the health center. |
Hours of Operation |
Sun. |
Mon. |
Tues. |
Wed. |
Thurs. |
Fri. |
Sat. |
Total: |
Existing |
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Planned |
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G) What percentage of users fall: below 100% of poverty between 100% and 200% of poverty between 200% and 400% of poverty
A) Purpose of loan (circle all that apply):
- Facility Acquisition
- New Construction
- Renovation
- Land Acquisition
- Equipment Purchase
- Refinance Existing Debt
- Modernization
B) Permanent financing will be needed: From:___ to ___
Construction financing will be needed: From:____ to____
C) The facility housing the project to be financed is: Owned To Be Purchased If you currently own, is your facility mortgaged? Yes__ No__
D) Site Control:
If you do not presently own the site, please describe the status of your plans to purchase the site (i.e. what needs to be done for you to control the site). Indicate the estimated acquisition price for the proposed site.
E) Site Location:
Describe what presently exists on the site as well as in the immediate surrounding area (empty lot, vacant/occupied buildings, residential/commercial uses). Describe whether the location of planned facility is conducive to successfully providing primary care, in terms of its access to public transportation and other transportation routes, commercial activity and residential concentrations.
F) Facility Square Footage: In the table below, please indicate the total square footage of your current facility and the projected total square footage following the project.
Description of Area |
Current Site (Sq. ft.) |
Projected Site (Sq. ft.) |
Medical |
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Dental |
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Laboratory |
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Administrative |
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Other (specify) |
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Total Sq. Footage |
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G) Will any other organization occupy space at this facility? Yes No If yes, list organizations, amount of space to be occupied, and terms of lease.
H) In the table below, please indicate the total number of existing and new examination rooms.
Description of area |
Current |
Projected |
Medical Exam Rooms |
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Dental Operatories |
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I) Please provide the following pieces of project information:
Attachment 3: Description of capital project .
Attachment 4: Please provide a detailed capital project budget.
Attachment 5: Please complete Attachment 5 to detail the sources and uses of project funding.
Attachment 6: Business Plan or a financial/operational justification for the project. This statement should include the following types of information:
Project Justification: Discuss the need for services in your targeted service area. What unmet public health needs will the project help to meet? How will this project help you address changes in the health care environment in your area? Why is this project important to your health center? How will this project influence your ability to serve patients?
Demand: Provide an analysis of current demand for primary care services in the target community, and how the planned project will respond to that demand. If a formal demand analysis has been conducted for this site, include that analysis as an attachment. Is the health center's patient population growing or changing in composition? What effect will those changes have on the health center's services or volume? Include information on the location and capacity of competing health care providers.
Financial Feasibility: Discuss your organization's ability to assume the debt involved in financing the planned facility. How will the project affect annual operating revenues and expenses? How will you fund initial operating deficits, working capital needs, and start-up costs, if any? How does your organization plan to meet the equity needs of the project?
Market and Staffing : What plans do you have to market your services? How will you reach your target markets? Please discuss your recruitment and retention plan for the clinical staffing of the proposed facility. Describe your capacity for achieving this objective (e.g. your past record of recruitment and retention, linkages to medical institutions that will assist, participation in special programs, etc.)
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Attachment 7: Consistent with your stated plan (detailed in Attachment 6), please provide budget projections to cover the period from the present through completion of construction, plus three additional years after occupancy. Include those assumptions and projections covered in the following three attachments (8, 9, & 10), as well as the operational and financial changes created by the new building project.
Attachment 8: Please complete Attachment 8 detailing utilization and reimbursement information. Please include any changes created by the facility project.
Attachment 9: Please complete Attachment 9 detailing grants and contract information for the health center. Please include any changes created by the facility project.
Attachment 10: Please complete Attachment 10 detailing employment information for the health center. Please indicate any changes created by the facility project.
Please include the following as attachments to this application:
Audited financial statements for your last three fiscal years, including Management Letters.
Year-to-date internal financial statements with comparisons to the same period in the previous fiscal year. Budget (income and expense projections) for the current fiscal year. If your health center is in the final quarter of its current fiscal year, also include the budget for the next fiscal year. |
Your most recent annual report. If you do not have an annual report, please provide a brief history and
description of your organization.
Bank letter stating preliminary terms and conditions
Building plans and materials specifications (or at least at a 30% design review phase of development).
A) Please provide the following information on any outstanding debt:
Date of Loan: |
Original Amount: |
Lender: |
Outstanding: |
Interest Rate: |
Expiration of term: |
Fixed? |
Floating? |
Amortization: |
Purpose of Loan: |
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Collateral:
2. Date of Loan: Original Amount: Lender: Outstanding: Interest Rate: Expiration of term: Fixed? Floating? Amortization: Purpose of Loan:
Collateral:
Please attach additional pages with above information for any additional debt.
B) Does your health center have a working capital line of credit? Yes__ No__
If yes, what is the maximum amount of credit availability under your line? $ _____
What is the current amount outstanding under the line of credit? $ _____
What is used to secure the line of credit?
Is the line extendable to at least 1 year after receipt of loan guarantee?
C) Has the health center ever defaulted on a loan or filed for bankruptcy or protection against creditors? Yes__ No__
If yes, please include an explanation as an attachment to this application (Attachment 11) .
Are you aware of any litigation pending against the health center that might materially affect the health center's ability to borrow funds or to repay them? Yes_ No_
If yes, please attach an explanation to this application (Attachment 12) .
The undersigned hereby represents and certifies to the best of his/her knowledge and belief that the information contained in this application and exhibits or attachments hereto is true and complete and accurately describes the nature of the health center and the proposed project, and agrees to promptly inform the Health Resources and Services Administration's Bureau of Primary Health Care of any relevant changes in the proposed/actual project or the information contained herein.
Applicant:
Signature:
Title:
Date:
APPLICATION ATTACHMENTS AND CHECKLIST
These attachments are a required part of the application. Those in bold are required for the pre-application. If an item is not available, please so indicate and note plans for obtaining the item. Please attach the following and mark the first page of each with its corresponding number:
• A complete list of your Board of Directors and officers, including addresses, employer & position.
• Resumes of all senior management personnel.
• Description of capital project(s) to be funded by this loan. If refinancing, describe project that was originally financed.
• Detailed capital project budget. Include a timetable, cost estimates, itemized equipment list, and architectural drawings or plans, if available.
• Detailed sources and uses (see attached chart).
• Business plan or a financial/operational justification for the project.
• Budget projections to cover the period from present through completion of construction, plus three additional years after occupancy. The budget projections should include the operational and financial changes created by the building project and the projections included in Attachments 8, 9, & 10.
• Utilization and Reimbursement information (see attached chart).
• Historical and Projected Grant / Contract Revenue (see attached chart).
• Employment information (see attached chart).
• Information on any loan defaults, if applicable.
• Litigation pending against the health center, if applicable.
• Audited financial statements for your last three fiscal years, including Management Letters.
• Year-to-date internal financial statements with comparisons to the same period in the previous fiscal year.
• Budget (income and expense projections) for the current fiscal year. If your health center is in the final quarter of its current fiscal year, also include the budget for the next fiscal year.
• Your most recent annual report. If you do not have an annual report, please provide a brief history and description of your organization.
• Bank letter stating preliminary terms and conditions Building plans and materials specifications (or at least at a 30% design review phase of development).
Attachment 9 - Grants and Contracts
(historical and projected)
Please list major sources and dollar amounts of grant and contract revenue for
three previous and three projected years.
Grant / Contract Revenue |
FY94 |
FY95 |
FY96 |
FY97 |
FY98 |
FY99 |
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Total Grants and Contracts: |
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Attachment 10
Employment Information
Historical and Projected
Please list the following staffing information for the health center during the past three fiscal years and
project staffing needs for next three fiscal years.
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FY94 |
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FY95 |
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FY96 |
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FY97 |
FY98 |
FY99 |
Service Provider: |
FTEs |
Salaries |
FTEs |
Salaries |
FTEs |
Salaries |
FTEs |
Salaries |
FTEs |
Salaries |
FTEs |
Salaries |
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Physician |
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Midlevel (PA, NP) |
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Nurses (RN, LPN) |
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Mental Hlth Prvdrs |
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Substance Abuse Prvdrs |
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Dental Providers |
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Provider Support* |
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Administration |
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Other |
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Total: |
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* Provider support - Clinical support staff, outreach workers, etc.
Attachment 4
Proposed Capital Budget
Please use the following format as a guide for developing a detailed budget for your capital project.
( Total Sq. Footage ) |
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Costs |
Cost/ Sq.Foot |
Hard Costs: |
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Real Estate Acquisition: |
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Land (acres) |
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Site Preparation |
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Existing Building (sq.ft.) |
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Construction/Renovation: |
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Construction of New Building (sq.ft.) |
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Rehab of Existing Building (sq.ft.) |
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Addition to Existing Bldg. (sq.ft.) |
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Construction Contingency
Interest Costs during Construction
Total Hard Costs:
Equipment Costs:
Furniture
Medical Equipment
Telephone
Computers
Artwork/Plants
Security Systems
Signage
Installation Costs
Total Equipment Costs:
Soft Costs:
Architectural
- Engineering
- Geotechnical
- Environmental
- Civil
- Structural
- Plumbing and Fire Protection
- Electrical
Bonding
Surveying
Owner's Representative
Construction Testing
Insurance
Permits and Fees
Legal - Health Center Attorney
Legal - Financing Entity Attorney
Legal - Title Insurance
Financing Fees
Appraisal
Moving
Rent
Soft Costs Contingency
Total Soft Costs:
Total Project Costs:
Attachment 5
SOURCES AND USES OF PROJECT FUNDS - SUMMARY
USES:
Total Hard Costs :
(See hard costs total, Attachment 4)
Equipment Acquisition :
(See equipment total, Attachment 4 )
Total Soft Costs :
(See soft costs total, Attachment 4 )
Refinancing Existing Debt :
Other Project Costs (please list) :
TOTAL USES OF FUNDS: $ _____
SOURCES: Cash reserves for this purpose: $
Capital campaign contributions:
1) Cash received to date:
2) Capital campaign pledges (pledges that have a firm commitment):
a) Cash from existing pledges to be received within 1 year:
b) Cash from existing pledges to be received within 2 years:
c) Cash from existing pledges to be received within 3 years:
d) Other pledges receivable:
Total pledge amount:
3) Additional amounts to be raised / expected to be raised:
Total capital campaign amounts:
Grants not included in section above (please list):
Other amounts (please describe)
Amount of this loan request:
TOTAL SOURCES OF FUNDS $ _____
(Total Uses of Funds should equal Total Sources of Funds.)
Attachment 8, page 1 - Utilization and Reimbursement Information - Medica l
(historical and projected )
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FY95 |
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FY96 |
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FY97 |
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FY98 |
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FY99 |
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Payor |
Users |
Enc.s |
Rev. Net |
Users |
Enc.s |
Rev. Net |
Users |
Enc.s |
Rev. Net |
Users |
Enc.s |
Rev. Net |
Users |
Enc.s |
Rev. Net |
Medicaid |
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Medicare |
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Self Pay |
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Free Care |
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(UCC reimb) |
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Commercial |
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FFS: (Name) |
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BC/BS |
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Capitation: |
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(Name) |
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Medicaid |
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Other |
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Payors: |
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Total: |
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