Rural Hospital Loan Program Statement of Interest

Rural Hospital Loan Program

Statement of Interest

The Mississippi Rural Hospital Loan Program (“RHLP” or the “Program”) is administered by the Mississippi State Department of Health, Mississippi Office of Rural Health and Primary Care (“MORHPC"). The Program provides loans to rural hospitals to assist hospitals in providing needed direct health care services for Mississippi citizens. A rural hospital may apply for and use the loan for the following purposes:

1. Maintaining or upgrading the rural hospital’s facilities;

2. Maintaining or increasing the current staff of the rural hospital; or

3. Providing health care services that are not currently available to citizens.

What is a statement of interest?

A statement of interest is an opportunity for potential applicants to express their hospital’s need for a loan and desire to receive a loan from the RHLP. Submission of your statement of interest is the only way to initiate the application process for this Program. Once you submit your statement of interest, a MORHPC staff member will contact you via email with additional information and guidance on next steps.

Serious inquiries only.

Contact Information

Please contact RHLP@msdh.ms.gov with any questions or technical assistance needs.

STATEMENT OF INTEREST FORM

Name of Mississippi Licensed Rural Hospital*

“Rural Hospital” means a licensed Mississippi hospital that has fifty (50) or fewer licensed general acute, non-specialty beds as defined in House Bill 365, adopted by the Mississippi Legislature in its regular 2022 session.

License Number*

Street Address (Physical Location)*

City (Physical Location)*

Zip Code*

Point of Contact Name*

(Last Name, First Name)

Point of Contact Email Address*

Point of Contact Phone Number*

Phone

CEO/Administrator Name*

(Last Name, First Name)

CEO/Administrator Email (Authorized Signatory for Institution)*

Street Address (Mailing Address)*

The mailing address must match the Hospital's W-9 form for payment processing.

P.O. Box Number (Mailing Address)*

City (Mailing Address)*

State (Mailing Address)*

Zip Code (Mailing Address)*

Federal Unique Entity Identifier (UEI)*

Any entity receiving funding from the Mississippi State Department of Health must be registered in SAM.gov. The Unique Entity ID is the 12-character alphanumeric ID assigned to an entity by SAM.gov after the registration process is complete.

Federal Tax ID Number*

DO YOU HAVE A QUALIFYING PROJECT FOR THE RURAL HOSPITAL LOAN PROGRAM?*

Maintaining or upgrading the hospital’s facilities

Maintaining or increasing the current staff of the rural hospital

Providing health care services that are not currently available to citizens

Pre-Application Requirements

Attachment 1 Letter of Intent: The Letter of Intent should include a detailed description of the project and purpose for applying for the loan to determine program eligibility, the proposed financing structure and collateral requirements, and any other terms of the applicant’s proposed project.
Attachment 2 Letter of Good Standing: A Letter of Good Standing refers to a certificate issued by the Mississippi Secretary of State Office verifying that a registered business entity has complied with all requirements for conducting business in the State of Mississippi. To request an official letter, please visit https://www.sos.ms.gov/business-services/order-documents
Attachment 3 Current Financial Audit: The financial audit should show good financial condition.

Please contact RHLP@msdh.ms.gov with any questions or technical assistance needs.

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CERTIFICATION*

On behalf of the licensed rural hospital, I certify that I will follow and comply with the guidelines, guidance, rules, regulations and/or other criteria regarding the use of monies under this Program.

Please answer yes to initiate the application process.

Yes

E-signature*

(First Name Last Name)

By signing electronically, you agree your electronic signature is the legal equivalent of your manual/handwritten signature. By using any device, means or action, you consent to the legally binding terms and conditions of this document. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

Completion Date*

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