Bond Counsel Fee Subsidy Application
Rural Health Care Support Program
Borrower Name
*
Borrower Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Borrower Contact
*
First Name
Last Name
Contact Title
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Borrower Status
*
Critical Access Hospital
Rural Emergency Hospital
Federally Qualified Health Center
Other
Description of Financing
*
Briefly describe how the proceeds of your financing will be used.
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