RUS Form 291 (8-70)

CERTIFICATION OF NONSEGREGATED FACILITIES

An executed copy of this form is submitted as part of the loan application. It is used by the borrower to certify that it does not and will not maintain or provide segregated facilities for its employees.

This form must be completed as follows:

Fld Name / Item No.	Instruction
First Blank	Enter the complete name of the company.
Date	On the first blank provided in the second paragraph enter the month and the day, i.e. January 31. On the second blank following '20', enter two digits to indicate the year, i.e. 03.
Applicant	Enter the complete name of the company.
President	This blank is for the signature of the president of the company.
Date	Enter the date (month, day, and year) when the president signs this form, i.e. January 31, 2003.

A hard copy of this form should be sent to the General Field Representative with the completed loan application package.