Appendix A to Part 240 - Application for Compensation

Appendix A to Part 240 - Application for Compensation

United States Agency for International Development

Washington, DC 20523

Ref: Guarantee dated as of ______, 20__:

Gentlemen: You are hereby advised that payment of $______(consisting of $ ______ of principal, $______ of interest and $______ in Further Guaranteed Payments, as defined in § 240.02 of the Standard Terms and Conditions of the above-mentioned Guarantee) was due on ______, 20__, on $______ Principal Amount of Notes issued by Ukraine (the “Borrower”) held by the undersigned. Of such amount $______ was not received on such date and has not been received by the undersigned at the date hereof. In accordance with the terms and provisions of the above-mentioned Guarantee, the undersigned hereby applies, under § 240.08 of said Guarantee, for payment of $______, representing $______, the Principal Amount of the presently outstanding Note(s) of the Borrower held by the undersigned that was due and payable on ______ and that remains unpaid, and $______, the Interest Amount on such Note(s) that was due and payable by the Borrower on ______ and that remains unpaid, and $______ in Further Guaranteed Payments,^[1] plus accrued and unpaid interest thereon from the date of default with respect to such payments to and including the date payment in full is made by you pursuant to said Guarantee, at the rate of ______ % per annum, being the rate for such interest accrual specified in such Note. Such payment is to be made at [state payment instructions of Noteholder or Fiscal Agent, as applicable].

All capitalized terms herein that are not otherwise defined shall have the meanings assigned to such terms in the Standard Terms and Conditions of the above-mentioned Guarantee.

[Name of Applicant]

By:

Name:

Title:

Dated:

Footnotes - Appendix A to Part 240

^[1] In the event the Application for Compensation relates to Further Guaranteed Payments, such Application must also contain a statement of the nature and circumstances of the related loss.