OPIC-form-52

	OPIC-52 OMB No.: 3420-0011 Expiration: 07/31/2011
Application for Political Risk Insurance Section I: Investor and Project Information Section II: Project Effects Section III: Signature Overseas Private Investment Corporation An Agency of the United States Government 1100 New York Avenue, N.W. Washington, DC 20527 www.opic.gov Insurance Department Tel.: (202) 336-8400 Fax: (202) 408-5142
NOTICE: This form requests from potential OPIC clients information that is required by OPIC’s governing legislation - the Foreign Assistance Act of 1961, Title IV, as amended (“FAA”) - to determine whether a project and its sponsor(s) meet eligibility criteria for OPIC political risk insurance. Complete responses to the questions on this form are required to apply for OPIC insurance benefits under the FAA. Client information contained in this questionnaire will be deemed designated as privileged or confidential in accordance with OPIC’s Freedom of Information Act (FOIA) regulations (22 CFR part 706) and will be treated as confidential to the extent permitted under FOIA. As a federal agency, OPIC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless a valid OMB Control Number with an expiration date that has not expired is displayed.
Public reporting burden for this collection of information is estimated to average 9 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to Forms Manager, OCFO – Security and Administrative Services, Overseas Private Investment Corporation, 1100 New York Avenue, N.W., Washington, D.C. 20527; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.
Application for Political Risk Insurance – Section I

The Overseas Private Investment Corporation (OPIC) requests information on this application to determine whether the Investor and the project meet eligibility requirements for insurance, specifically with regard to underwriting criteria and legislative and regulatory compliance. Information provided to OPIC must be accurate as of the date an OPIC contract is issued. Responses to questions that call for estimates or projections should take the form of good faith statements made to the best of the Investor’s knowledge and belief, after due inquiry. Misrepresentations or failure to disclose relevant information may result in the cancellation of insurance. Neither issuance of a registration letter nor acknowledgment of receipt of this application implies that the investment is eligible for political risk insurance or that a contract will be issued.

The information contained in this application will be designated as privileged or confidential in accordance with the Freedom of Information Act (FOIA) regulations (22 CFR Part 706) and will be treated as confidential to the extent permitted OPIC by FOIA.

INSTRUCTIONS:

Please contact an insurance officer at (202) 336-8400 if you have any questions about this application.

1. All applicants must fill out a complete application which is composed of Sections I and II and sign Section III.

2. All applicants must provide the certifications requested in Parts 5 and 6 of Section I.

3. If you use an attachment to answer any of the questions in this application, please write “see Attachment” in the appropriate answer block and indicate the corresponding question number on your attachment.

3. All applicants applying for OPIC insurance must sign this application in Section III. If an Investor is applying for OPIC insurance on behalf of other eligible Investors, OPIC also will require the ultimate beneficiary Investors to sign this application.

3. When completed, please submit:^

a. Completed application (Sections I-III), and

b. One (1) copy of all attachments and supporting documentation to:

Applications Officer – Insurance Department

Overseas Private Investment Corporation

1100 New York Avenue, N.W.

Washington, DC 20527

Section I - Investor and Project Information

Part 1: Investor Information (Investor to be Insured by OPIC)

1.

Name of Investor:

     

OPIC Insurance Registration Number:

     

DUNS #:      

(See OPIC registration letter for assigned number.)

Address:

     

City:

     

State:

     

Zip/Postal Code:

     

Country:

     

Telephone:

     

Fax:

     

E-Mail:

     

Website:

     

Occupation (if individual):

     

Location of registration/incorporation (if entity):

     

2.

Type of Investor (check one investor type only)

Entity Organized Under U.S. Law

a.

Is more than 50% of both the total equity interest and each class of equity interests issued by the Investor and outstanding on the date hereof beneficially owned by U.S. citizens?* (If No, please contact OPIC before proceeding.)

Yes

No

b.

Is this entity a minority-owned business?

Yes

No

c.

Is this entity a women-owned business?

Yes

No

Individual Investor

a.

Is the Investor a citizen of the United States? (If No, please contact OPIC before proceeding.)

Yes

No

Entity Organized Outside of the United States

a.

If organized other than as a corporation, is 100% of both the total equity interest and each class of shares or equity interests issued by the Investor and outstanding beneficially owned by U.S. citizens? (If No, please contact OPIC before proceeding.)

Yes

No

b.

If organized as a corporation, is 95% or more of both the total equity interest and each class of shares or equity interests issued by the Investor and outstanding beneficially owned U.S. citizens? (If No, please contact OPIC before proceeding.)

Yes

No

Non-Profit/Non-Governmental Organization organized under U.S. Law

a.

Is more than 50% of the Board of Directors composed of U.S. citizens?

Yes

No

Non-Profit/Non-Governmental Organization organized outside of the U.S.

a.

Is 100% of the Board of Directors composed of U.S. citizens?

Yes

No

3.

Name of Person OPIC should contact for information:

     

Title:

     

Company:

     

Address:

     

City:

     

State:

     

Zip/Postal Code:

     

Country:

     

Telephone:

     

Fax:

     

E-Mail:

     

*

OPIC deems a corporation organized under the laws of the U.S. or its states or territories to be beneficially owned by U.S. citizens if more than 50 percent of each class of its issued and outstanding stock is owned by U.S. citizens either directly or beneficially.

4.	How did you learn about OPIC and its services?
			conference		OPIC Web site		other government agency (SBA, TDA, EX-IM)
			insurance broker		former OPIC clients		other (please explain)	     
Part 2: Private Political Risk Insurance
	OPIC strongly encourages Investors to consider carefully the availability of private political risk insurance for their investments abroad. OPIC only offers insurance to Investors who, having investigated the possibility of obtaining insurance from private political risk insurers, decide to pursue OPIC insurance because private insurance is not available on terms sufficient to make the investment viable for the Investor, or because of specific benefits OPIC participation will bring to the investment.
5.	Have you sought political risk insurance from the U.S. private political risk insurance market for the project?*								Yes	No
6.	If private political risk insurance is available, is it in the amount necessary and on terms sufficient for the project’s viability?								Yes	No
	If Yes, please explain why political risk insurance is being sought from OPIC. If No, please explain.      
Part 3: Project Information
7.	Project Description
a.	Briefly describe the project and investment structure.      
b.	Please attach a copy of information memoranda, business plans, investment structure diagram or other descriptions of the project that would be helpful to OPIC’s understanding of the project. Also provide copies of any project documentation such as company charter, joint venture documents, loan agreements, technical assistance agreements, management service agreements, lease agreements, loan guaranties, licenses or agreements with the host government, etc. All documentation must be in English.      
c.	If entering into a contract to provide goods/services to a foreign government, please indicate total amount, date contract was/will be signed, and approximate date work will commence. Please attach a copy of the contract as well.     

8.

Please specify whether this project is:

an expansion of an existing enterprise

a new (greenfield) enterprise

a privatization of a state-owned company

other (please explain)      

9.

Where is the project located? (If in a remote location, please include GPS coordinates or attach a map showing the location.)      

10.

Name of the entity (the “Foreign Enterprise”) in the host country into which the investment will be made:

Foreign Enterprise:

     

Address:

     

City:

     

Postal Code:

     

Country:

     

Telephone:

     

Fax:

     

E-Mail:

     

11.

Please list below the name, principal address, and citizenship or jurisdiction of formation, as applicable, of all shareholders and/or individuals, who beneficially own, whether directly or indirectly, 5% or more of the Foreign Enterprise. For Non-Profit Organizations, please list the name, address, and citizenship of all members of the Board of Directors or other governing body. This information is not required for widely traded public companies.

Full Name (including first, middle, last names)

Address of Current Residence

Country of Citizenship

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

12.

Government Involvement

a.

Describe any host government involvement in the project such as any contracts, concession, or licenses from the government, any planned government purchasing or supplying, or any form of joint venture with the government.      

b.

If entering into a contract to provide goods/services to a foreign government, give the name and address of the department or agency involved. Briefly describe any previous experience the Investor has had with this foreign government.      

13.

Please identify and describe briefly any current or past disputes with respect to this project that involve any agency or instrumentality of the host government. Include all disputes that involved or currently involve the Investor, the Foreign Enterprise, or any participants in the project.      

Part 4: Investment to be Insured by OPIC

14.

Type of Investment to be Insured (Check all that apply)

Amount

Equity

$      

Leases

$      

Loans or Loan Guaranties

$      

Technical Assistance or Management Agreements

$      

Performance Guaranty/Advance Payment Guaranty/Other Guaranty/Contract Disputes

$      

Other (please explain)

$      

15.

Type of Coverage Sought (Check all that apply)

Expropriation

Political Violence for Assets

Non-Honoring of a Sovereign Guarantee*

Inconvertibility

Political Violence for Business Income

Wrongful Calling of a Guaranty (Bid bonds, advance payment, etc.)

(If seeking coverage for wrongful calling of a guaranty, please provide draft/final copy of each of the guaranties you wish to insure).

16.

Term of OPIC Contract:

      years

(OPIC can offer a minimum term of 3 years and a maximum term of 20 years)

17.

Investment Schedule

Date

Amount

a.

Initial Investment

     

$      

b.

Subsequent Investment(s)

     

$      

     

$      

     

$      

c.

Expected date that commercial operations will begin:

     

* Please consult with OPIC regarding specific eligibility requirements for this coverage before proceeding.

Part 5: Insurance of Exports Certification
18.	OPIC seeks to ensure that American insurance companies have an opportunity to compete for transportation insurance business associated with the export of goods to projects supported by OPIC programs. To encourage fair and open competition for this business, OPIC requires certain certifications from Investors receiving OPIC insurance. Please check the appropriate box below:
a.	No certification is required if an Investor receiving OPIC insurance does not have a controlling interest in the project in which it is investing.* If your firm does not have a controlling interest in the project, please check the box below and proceed to the next Section.
		The Investor does not have a controlling interest in the project.
b.	In those instances where the Investor does have a controlling interest in the project, OPIC requires that the Investor certify that each contract for the export of goods from the United States in connection with the establishment of the project will include a clause requiring that United States insurance companies shall have a fair and open competitive opportunity to provide insurance against risk of loss for such export of goods. If Investor is able to so certify, please check the box below.
		I certify that each contract for the export of goods from the United States in connection with the establishment of the project will include a clause requiring that U.S. insurance companies shall have a fair and open competitive opportunity to provide insurance against risk of loss for such exports.
c.	In those instances where the Investor does have a controlling interest in the project, but is unable to provide the certification requested in Question 19 (b) above, please check the appropriate box below.
		The project country prohibits use of U.S. insurance services for transportation insurance.
		There are no exports associated with the establishment of this project.
		All transportation insurance associated with the export of U.S. goods to the project is or will be arranged through the Investor’s pre-existing worldwide insurance program, for which U.S. insurance companies were given a fair and open opportunity to compete. It is not practicable to alter these arrangements for U.S. exports to the project.
		Other (please explain):	     

*	A "controlling interest" means that the Investor has a majority equity interest in the project or can exercise effective management control by agreement or otherwise.

Part 6: Investor Representations
19.	Eligibility to conduct business with the United States Government
	Is the Investor, any related party or affiliate of the Investor, or any supplier to the project currently suspended, debarred or voluntarily excluded from procurement or non-procurement dealings with the United States Government (Executive Order 12549 February 18, 1986, 51 CFR 6370)? (If Yes, please contact OPIC before proceeding.)		Yes	No
20.	Foreign Corrupt Practices Act*
a.	To the best of the Investor’s knowledge after due inquiry, has the Investor ever been the subject of an investigation under the Foreign Corrupt Practices Act of 1977, (as amended)? (If Yes, please contact OPIC before proceeding.)		Yes	No
b.	Has the Investor been convicted of, or been party to a final adverse administrative determination of, an offense under the Foreign Corrupt Practices Act of 1977, (as amended)? (If Yes, please attach explanation.)		Yes	No
c.	To the best of the Investor’s knowledge after due inquiry, has the project been established (e.g., obtained licenses, approvals, permits, etc.) in compliance with all applicable laws pertaining to corrupt practices? (If No, please attach explanation.)		Yes	No
d.	Has the Investor established and maintained internal management and accounting practices and controls that are adequate to ensure compliance with all applicable laws pertaining to corrupt practices? (If No, please attach explanation.)		Yes	No
e.	Will the Project be carried out in compliance with all applicable laws, including those pertaining to corrupt practices? (If No, please attach explanation.)		Yes	No
f.	Has the Investor, or an authorized officer of the Investor, read and understood the OPIC Anti-Corruption Policies and Strategies Handbook, dated September 2006 as amended from time to time**? (If No, please contract OPIC.)		Yes	No
g.	Has the Investor provided a copy of the Anti-Corruption Handbook to all officers of the Investor and the Foreign Enterprise directly involved in the management of the project? (If No, please explain.)      		Yes	No
21.	Is the Investor, or any officer or director of the Investor:
a.	presently under indictment? (If Yes, please contact OPIC before proceeding.)		Yes	No
b.	a party to any consent judgment or agreement with the SEC that restrains or restricts its activities? (If Yes, please contact OPIC before proceeding.)		Yes	No
22.	Has the Investor, or any officer or director of the Investor:
a.	ever been convicted for any criminal offense other than a minor motor violation? (If Yes, please contact OPIC before proceeding.)		Yes	No
b.	ever been found by a court in a civil action or by the SEC or similar U.S. state agency to have violated any U.S. Federal or U.S. state securities law? (If Yes, please contact OPIC before proceeding.)		Yes	No
	*	OPIC, as an agency of the U.S. Government, does not support projects that involve illicit payments.
	**	The OPIC Anti-Corruption Policies and Strategies Handbook is posted on OPIC’s website at: http://www.opic.gov/about/Transparency/documents/opicanticorruptionhandbook0906.pdf

Application for Political Risk Insurance – Section II

The following Section II – Project Effects (Parts 1- 4) of the application requests information which is required by OPIC’s governing legislation. The information provided will allow OPIC to determine whether a project and its investor(s) meet the eligibility criteria for OPIC insurance with regard to the effects of the project on the U.S. economy, development abroad, the environment, and worker rights and safety. Complete responses are mandatory, per the Foreign Assistance Act of 1961, as amended, Section 231(k)(2).

INSTRUCTIONS:

Please contact an insurance officer at (202) 336-8400 if you have any questions about this application.

1. All applicants must fill out a complete application which is composed of Sections I and II.

2. All Parts of the form must be filled out completely. For Part 2, Investors are only required to fill out either Section 2A or Section 2B, depending on the nature of the Foreign Enterprise.

3. If you use an attachment to answer any of the questions in this application, please write “see Attachment” in the appropriate answer block and indicate the corresponding question number on your attachment

Section II – Project Effects
Part 1: Effects of the Project on the U.S. Economy (For All Projects)
1.	Project Affiliates
	For each shareholder listed in Section 1, Question #13 (i.e., all shareholders and/or individuals, who beneficially own, whether directly or indirectly, 5% or more of the Foreign Enterprise), please list any other entities in which these shareholders have a controlling interest, whether or not you consider these entities to be related to the Foreign Enterprise or project (such entities herein shall be referred to as “Foreign Enterprise Affiliates”).
	Shareholder Name (from Section 1, Question #13)		Name of Foreign Enterprise Affiliate			Country Location
	     		     			     
	     		     			     
	     		     			     
	     		     			     
	     		     			     
2.	Project Category
	If your project falls into one of the categories listed below, please check the appropriate box and proceed to Question #5. If not, check the “Not Applicable” box to the right and proceed to Question #3.						Not Applicable
	Financial services (e.g., a branch bank, leasing company, etc.) intended to serve predominantly host country or regional markets. Telecommunications services intended to serve predominantly host country or regional markets. Oil and/or gas exploration. Tourism services (e.g., a hotel, restaurant or resort). Power supply or transmission for host country or regional markets. Mining of minerals or ores not mined in the U.S.. Host country or regional sales, service, distribution or transportation (no production involved).
3.	Production of Comparable Products
a.	Does the Investor or any Foreign Enterprise affiliate identified in Question #1 produce goods or services in the U.S., which are comparable to goods or services produced or to be produced by the Foreign Enterprise?						Yes	No
b.	If you answered “No” to Question #3a, please proceed to Question #4. If you answered “Yes” to Question #3a, will the project’s production compete with or replace such comparable U.S. production?						Yes	No
c.	If you answered “No” to Question #3b, please explain below why the Foreign Enterprise’s production will not compete with or replace such U.S.-based production.      
d.	For each Investor and Foreign Enterprise Affiliate identified in Question #3a above that is producing goods in the U.S. that are comparable to the goods or services that are or will be produced by the project, please indicate the number of U.S. employees engaged in the production of such goods or services: currently, one year ago, and projected one year from now.
	Name of Foreign Enterprise Affiliate	Current U.S. Employment		U.S. Employment One Year Ago	Projected U.S. Employment One Year From Now
	     	     		     	     
	     	     		     	     
	     	     		     	     
	     	     		     	     
	     	     		     	     

4.	Effects on U.S. Operations
	Has any Investor or Foreign Enterprise Affiliate identified in Question #1 above reduced or expect to reduce the number of its U.S. employees or the level of operations in the U.S. either 1) in order to devote resources to the project, or 2) because the project’s production enables them to do so? If “Yes”, please explain below.      				Yes	No
5.	Sources of Project Funding (Total Project Cost)
		Equity	Debt	Other*
a.	From OPIC		$     
b.	From the investor(s) to be insured by OPIC	$     	$     	$     
c.	From other U.S. sources	$     	$     	$     
d.	From host country sources	$     	$     	$     
e.	From third country sources (specify countr(ies)):	$     	$     	$     
f.	From other international institutions (specify):	$     	$     	$     
g.	Other (specify):	$     	$     	$     
h.	FUNDING TOTAL: $	$     	$     	$     
	*e.g., technical assistance or management service agreements, leases, consigned equipment, reinvested retained earnings, etc.
6.	Offshore Funds
	Of the project funding listed in #5b and #5c above, what amount, if any, is from an offshore source (i.e., what amount of U.S. funds will not flow from the U.S. to the host country, but rather from another country, for example, a foreign bank account owned by the U.S. entity)?			$     

7.	Uses of Project Funds
Start-up/Construction Project Expenditures refers to the total sources of project funding included in Question #5h above, including land, buildings, raw materials, equipment, labor, services, working capital and other costs. Also indicate below how long the start-up/construction phase is projected to last (that is, how long until the project will be operational). If the project is an expansion, this question refers to initial expenditures related to the expansion. Subsequent Operational Expenditures refers to the average annual value of procurement over the first five years of full operations necessary for the project’s continued operation, including raw materials, labor, services, working capital and other costs. Subsequent Operational Expenditures do not include the expenditures listed in Start-up/Construction Project Expenditures and are generally funded by the project’s revenues. If the project is an expansion, this question refers to operational expenditures related to the expansion.
		Start-up/Construction Project Expenditures (Column 1)	Average Annual Subsequent Operational Expenditures (Column 2)
	Time period for start-up/construction (number of months)	     
a.	Purchased or spent in the host country	$     	$     
b.	Purchased from the U.S.*	$     	$     
c.	Purchased from other developing countries (specify):	$     	$     
d.	Purchased from other industrialized countries (specify):	$     	$     
e.	Miscellaneous project costs included in #5 above not related to the procurement of assets/services (i.e., interest during construction, debt service reserve account, etc.) NOTE: financing, consulting and legal fees/expenses are paid services which should be included in (a) – (d) above, as applicable.	$     	     
f.	TOTAL: $	$     **	$     
*OPIC considers U.S. procurement to be equipment manufactured by, or services provided by, U.S. workers. Equipment or services sourced from U.S. subsidiaries overseas should be listed in #7c or #7d above. **Note: Column 1 total should equal total figure (equity+debt+other) given for #5h above

8.		U.S. Suppliers Information
Please provide a detailed list of U.S. suppliers providing key goods and services for the project.
a.		Initial Procurement: Please list items to be procured from the United States for start up project expenditures from Question #7b, Column 1, above. Also ensure that the total in #7b, Column 1, equals the total in #8a, below.
		Supplier, City and State	Supplier Description		Product Description				Procurement Amount ($)
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		TOTAL							     
b.		Average Annual Subsequent Operational Expenditures (Over 5 Years): Please list items to be procured from the United States for subsequent annual project operations from Question #7b, Column 2, above. Also ensure that the total in #7b, Column 2, equals the total in #8b, below.
		Supplier, City and State	Supplier Description		Product Description				Procurement Amount ($)
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		     	SME? Yes No Don’t Know Minority Owned? Yes No Don’t Know Women Owned? Yes No Don’t Know		      New Used				     
		TOTAL							     
9.	Destination of Project Sales and Production
Please estimate the project’s average annual direct sales revenue by country over the first five years of operations (after the construction or expansion of the project has been completed.) If project production involves more than one product, please list all products on an attachment and specify a percentage breakdown by product. If the project is an expansion of an existing enterprise, or otherwise only part of an enterprise, provide only the incremental revenues related to and resulting from the new investment.
AVERAGE ANNUAL REVENUES FOR FIRST 5 YEARS OF PROJECT OPERATIONS
				Total Revenues ($)
Sold in Host Country:				$     
Exported to the United States:				$     
Exported to other countries (list countries and amounts below)
Country:				$     
Country:				$     
Country:				$     
Country:				$     
Country:				$     
TOTAL:				$     
10.	Import Substitution
a.	Will the Foreign Enterprise’s production that is sold in the host country replace current imports?						Yes			No
b.	If yes, estimate the average annual value of the imports replaced.						$     
11.	Exports to the United States
a.	Will project exports to the U.S. replace products currently exported from the host or other countries to the U.S. market?						Yes			No
b.	If yes, estimate the average annual value of the exports replaced:						$     
12.	Financial Outflow
	In each column, estimate the project’s five year average annual financial outflow from the host country (measured from the commencement of the construction or expansion phase) to the U.S. or other countries resulting from the project financing in Question #5.					Remittance to the United States		Remittance to Other Countries
a.	OPIC Loan Principal, Interest, and Fees:					$     		$     
b.	Other Loan Principal and Interest (from U.S. or other lenders):					$     		$     
c.	Lease Payment:					$     		$     
d.	Dividends or Profits:					$     		$     
e.	Return of Initial Capital Investment:					$     		$     
f.	Fees (other than OPIC fees):					$     		$     
g.	Other:					$     		$     

13.	U.S. Export Substitution
a.	Will any of the foreign enterprise’s production sold within the host country or to third-country markets replace U.S. exports?		Yes	No
b.	I.	If yes, estimate the average annual amount of displaced exports previously exported to the host country:	$     
	II.	If yes, estimate the average annual amount of displaced exports previously exported to third countries:	$     
c.	In the absence of this investment, would other factors have caused this displacement of U.S. exports? If yes, please explain.      		Yes	No
14.	Performance Requirements
	Describe any host government decrees, laws, directives or agreements with the Foreign Enterprise that might affect project imports, exports, or employment (e.g., local content or export requirements, trade balancing or local hiring requirements, etc.).      

Part 2A: Host Country Developmental Questions (For All Projects except Financial

Services/Intermediaries)

The term “financial intermediary” relates to the Foreign Enterprise only and refers to, but is not limited to, general lending banks, specialized lending institutions, mortgage facilities, microfinance institutions, private equity funds, and other capital market transactions. If the Foreign Enterprise falls under the above financial intermediary definition, please go to Part 2B.

1.

Estimate the number of persons the project will directly employ during construction (if applicable) and by the fifth year of operation. If the project is an expansion, include only employment resulting from the expansion.

Managerial

Professional/Technical

Unskilled Labor

Construction/Start-Up

5th Year

Construction/Start-Up

5th Year

Construction/Start-Up

5th Year

Local

     

     

     

     

     

     

Expatriate

     

     

     

     

     

     

Total

     

     

     

     

     

     

For the non-construction jobs identified above, what percentage of these employees will receive formal training?

Managerial

Professional/Technical

Unskilled Labor

     %

     %

     %

2.

Will the project provide training outside the host country? If yes, please indicate countries and type of training provided.      

Yes

No

3.

Local Ownership

a.

What will be the percentage of local ownership of the project at the start of operations?

     %

b.

If there will be local ownership, is the local owner a Small & Medium Enterprise (SME) (defined by the IFC as a firm with total employees of up to 300 employees, total assets of up to $15 million, and total annual sales of up to $15 million)?

Yes

No

4.

Will the project involve other development finance institutions (DFIs)? If yes, please indicate which organizations below:

Yes

No

Multilateral (e.g., World Bank, IFC):      

Regional (e.g., IDB, ADB):      

Bilateral (e.g., USAID, FMO):      

Other:      

5.

Will the project involve a public-private partnership? If yes, please indicate what type of party is involved below:

Yes

No

Host government entity:      

International Non Governmental Organization:      

Local Non Governmental Organization:      

Other:      

6.

Will the Foreign Enterprise have (or will it adopt) a written equal employment policy? If yes, please indicate below which areas are covered by the policy.

Yes

No

Race

Sex

Color

Political opinion

Religion

National extraction

Social origin

Other:      

7.	Will there be any benefits or policies in place that specifically address the needs of women at the workplace? If yes, please indicate below:							Yes		No
	Child care				Maternity leave
	Non-harassment policies				Other:      
8.	Will the project benefit a poor region of the host country? If yes, please indicate where below:							Yes		No
	Rural region of host country				Poor urban area in host country
9.	Will the project extend company benefits to its employees? If yes, please select all benefits that apply:							Yes		No
	Health coverage				Educational assistance
	Daily meals				Bonus or incentive plan
	Transportation				Private pension plan
	Housing assistance				Other:      
10.	Will the project provide benefits to the local community? If yes, please select all benefits that apply:							Yes		No
	Recreational facilities				Scholarship programs
	Schools				Other:      
	Medical clinics
11.	Will the project strengthen the physical, financial, or social infrastructure of the host country? If yes, please select from the list of infrastructure impacts below:							Yes		No
	Water & Sanitation				Health
	Energy				Housing
	Telecommunications				Food & Nutrition
	Education				Financial Services (e.g., financial market development, mortgage lending, or microfinance)
If you answered yes to the above question, what is the economic status of the user population, as compared to the overall host country income level?
Low income		Middle income					High income
12.	Will the project directly restore or preserve the environment? If Yes, please explain. (e.g., pollution reduction, eco-tourism, reforestation, water treatment (clean-up), or wildlife conservation).      							Yes		No
13.	Will the project develop a new sector of economic activity or strengthen an underdeveloped sector of the host country’s economy? If Yes, please explain.      							Yes		No
14.	Host government fiscal impact:
a.	Estimate the average annual revenues (duties, taxes or other payments) paid to the host government as a result of the project’s first five years of operations:							$      
b.	If the project is eligible for a tax holiday, indicate the duration of the tax holiday:							     
c.	If duties and/or tax payments to the host government will be reduced as a result of the investment (e.g., because the project will substitute for imports subject to tariffs), estimate the amount lost:							$      
15.	Are you entering this market as a result of any reforms, new legislation or new regulations in the host country? If yes, please explain.      							Yes		No
16.	Will there be new reforms, legislation, or regulations that will occur as a result of the project? If yes, please explain.      							Yes		No
17.	Please indicate whether the following technology and knowledge transfer factors are evident in the project in the host country. If new or uncommon in host country, please provide details.      
a.	Innovative management practices:		New			Uncommon			No
b.	Marketing and distribution expertise:		New			Uncommon			No
c.	Production or processing technologies:		New			Uncommon			No
18.	Will the project market products available for the first time in the host country? If yes, please explain.      							Yes		No
19.	Will the project lower local prices? If yes, please explain.      							Yes		No

Part 2B: Host Country Developmental Questions for Financial Services/Intermediaries

Projects Only (Applicant should only complete Section 2B if directed by OPIC staff to do so.)

The term “financial intermediary” relates to the Foreign Enterprise only and refers to, but is not limited to, general lending banks, specialized lending institutions, mortgage facilities, microfinance institutions, private equity funds, and other capital market transactions. If you have completed Part 2A, please continue to Part 3. Where available, please provide information only for OPIC-supported activities – not for the institution as a whole.

1.

Type of financial intermediary (FI) organization

Microfinance Institution: Non-profit

Commercial Bank: Government-owned

Microfinance Institution: For-profit

Commercial Bank: Private sector

Cooperative or Credit Union

Development Bank

Non-Bank Financial Institution (NBFI)

Other:      

2.

How long has the FI been in operation?

      Years

3.

How many new employees will the FI hire to support the increased lending activities made possible by the OPIC support?

Managerial

Professional/Technical

Unskilled Labor

Local

     

     

     

Expatriate

     

     

     

4.

What percentage of these employees will receive training?

Managerial

Professional/Technical

Unskilled Labor

     %

     %

     %

5.

What benefits does (or will) the FI provide to its employees? Check all that apply.

Medical coverage

Transportation

Pension plans

Subsidized meal

Concessional loans

Other:      

6.

Will the FI have (or will it adopt) a written equal employment policy? If yes, please indicate below which bases are covered by the policy.

Yes

No

Race

Sex

Color

Political opinion

Religion

National extraction

Social origin

Other:      

7.

Will there be any benefits or policies in place that specifically address the needs of women at the workplace? If yes, please indicate below:

Yes

No

Child care

Maternity leave

Non-harassment policies

Other:      

8.

Will the FI be involved in any community outreach initiatives? If yes, please indicate below:

Yes

No

Recreation facilities

Scholarship programs

Schools

Other:      

Medical clinics

9.

Does the FI involve other development finance institution (DFI) participation? If yes, please indicate below type of DFI and specify the name of the institution(s):

Yes

No

Multilateral (e.g. World Bank, IFC):      

Regional (e.g. IDB, ADB):      

Bilateral (e.g. USAID, FMO):      

Other:      

10.

Will the FI be involved in any public-private partnerships? If yes, please indicate below:

Yes

No

Local government ministry:      

International NGO:      

Local NGO:      

Other:      

11.

Is there any innovative product or service that helps the FI gain a competitive edge in the market? If yes, please describe.      

Yes

No

12.

Please indicate whether the following technology and knowledge transfer factors are evident in the FI’s activities in the host country. If new or uncommon in host country, please provide details.

a.

Innovative management practices:

New

Uncommon

No

b.

Marketing and distribution expertise:

New

Uncommon

No

c.

Production or processing technologies:

New

Uncommon

No

13.

Does the FI adhere to the following good corporate governance measures? Please check all that apply.

Governed by board

Accounting standard used:

Regulated by:      

Local Standard

Audited by:      

GAAP

Rated by:      

IFRS

Other:      

Other:      

Please use the investment strategies of the FI to be employed for lending activities made possible by the OPIC support in answering the following questions:

14.

Projected average annual revenue

$     

15.

Projected number of loans

     

16.

Projected number of borrowers

     

17.

Projected average annual taxes, duties, and fees paid to the host government over the first 5 years

$     

18.

Projected average outstanding loan size per borrower

$     

19.

Projected maximum loan size to a single borrower

$     

20.

Projected minimum loan size to a single borrower

$     

21.

Projected median loan size to a single borrower

$     

22.

Projected percentage of borrowers that will be women (or women-managed businesses)

     %

23.

Projected type of clients as a percentage of the portfolio

     %

Micro-entrepreneurs (defined as an enterprise with total employees of up to 10, total assets of up to $10,000, and total annual sales of up to $100,000)

     %

Consumers (defined as a borrower of consumer loan product that is not a mortgage, such as a car, credit card, home equity loan, home equity line of credit, signature loan, signature line of credit, or Certificate of Deposit loan)

     %

Small & Medium Enterprises (defined by the IFC as a firm with total employees of up to 300 employees, total assets of up to $15 million, and total annual sales of up to $15 million)

     %

Large Corporations

     %

Other:      

24.

A. Projected loan tenors as a percentage of the portfolio for commercial lenders

B. Projected mortgage maturity period as a percentage of the portfolio for mortgage lenders

     %

< 6 months

     %

< 5 years

     %

7 – 12 months

     %

6 - 10 years

     %

13 – 24 months

     %

11 - 15 years

     %

25 – 36 months:

     %

16 – 20 years

     %

> 36 months

     %

> 20 years

25.

A. Projected purpose of the loans as a percentage of the portfolio for commercial lenders

B. Projected purpose of the mortgages as a percentage of the portfolio for mortgage lenders

     %

Working capital

     %

New mortgages

     %

Start-up capital

     %

Mortgage refinancing

     %

Expansion capital

     %

Mortgage-backed securities

     %

Equipment purchase

     %

Home improvement loans

     %

Other:      

     %

Other:      

26.

A. Projected business activities/sectors of borrowers as a percentage of portfolio for commercial lenders

B. Projected target of mortgages as a percentage of portfolio for mortgage lenders

     %

Manufacturing

     %

Low-income homes

     %

Agriculture

     %

Middle-income homes

     %

Construction

     %

High-income homes

     %

Transportation and Communication

     %

Residential rental properties

     %

Tourism

     %

Commercial properties

     %

Trade/Retail

     %

Other:      

     %

Service

     %

Other:      

27.

Projected geographic distribution of borrowers as a percentage of portfolio

     %

Urban

     %

Rural

     %

Other:

28.

If the FI’s projected lending activities will be global, please provide an estimate of the asset allocation of the FI’s portfolio either by country or region. If space is inadequate, please supply additional information on separate sheets of paper and attach them to this form.

     

     %

     

     %

     

     %

     

     %

     

     %

29.

Using financial projections please provide one or more of the following repayment performance measures that are applicable to the FI. If portfolio at risk ratio and write-off ratio are not available, please report other indicators, if any, that are used to measure repayment performance (for example, arrears rate, repayment rate). Indicate as precisely as possible how this performance indicator is calculated.

     %

Portfolio At Risk (PAR) Ratio

     %

Write-off Ratio

     %

Other:      

30.

For your latest fiscal year, please provide one of the following profitability measures that is applicable to the FI. If return on investment and operational self-sufficiency ratio are not available, please report other indicators, if any, that are used to measure profitability (for example, financial rate of return). Indicate as precisely as possible how this profitability indicator is calculated.

     %

Return on Investment

     %

Operational Self-Sufficiency Ratio

     %

Other:      

Part 3 – Environmental Effects Questions (For All Projects)
1.	Will the project involve any physical modification of the project site or construction? If yes, please explain:      	Yes	No
2.	Will the project use natural resources, particularly any resources that are non-renewable or in short supply (water, energy)? If yes, please explain:      	Yes	No
3.	Will the project involve the storage, use, transport, handling or production of potentially hazardous materials, including fuel? If yes, please explain:      	Yes	No
4.	Will the project produce solid wastes during construction or operation? If yes, how will the solid wastes be handled?      	Yes	No
5.	Will the project release pollutants including any toxic or noxious substances to the air? If yes, how will the pollutants be handled?      	Yes	No
6.	Will the project release pollutants to the groundwater or surface waters including the marine environment? If yes, how will the pollutants be handled?      	Yes	No
7.	Does the project pose a risk of accidents during construction or operation that could adversely impact human health or the environment? If yes, please explain:      	Yes	No
8.	Is the project located in or near an internationally recognized protected area or sensitive environment (wetland, coastal zone)? If yes, please describe further:      	Yes	No
9.	Is the project located in or near areas vulnerable to natural hazards (earthquake, landslides, flooding)? If yes, please describe further:      	Yes	No
10.	Does the Foreign Enterprise have an environmental, health or safety management system in place? If yes, please describe the system in detail:      	Yes	No
11.	Are there environmental reports, assessment or permits available for OPIC review? If so, please list below and attach.      	Yes	No

Part 4: Worker Rights Questions (For All Projects)
1.	Does the project involve investing in, lending to, or acquiring an existing enterprise?		Yes	No
	If no, proceed to Question #3. If yes, answer the following: a. Are any parts of the work force organized in a legally recognized trade union? b. If yes, is the trade union recognized by management? If no, briefly explain.      		Yes Yes	No No
2.	Answer only if the project involves an existing enterprise: Have there been any strikes at the project site or directly related to the existing project? If yes, briefly describe the nature of the strike, and list the start and end dates of the strike.      		Yes	No
3.	Does the project directly or indirectly employ, or plan to employ, workers under 18 years of age? If yes, briefly describe the duties and approximate age of the youngest worker(s).      		Yes	No
4.	Will the project involve physical construction? If yes, briefly describe the nature of the construction and list the approximate start and end dates of the construction below.      		Yes	No
Start Construction Month/Yr:      		End Construction Month/Yr:      
5.	Will all workers at the project site be directly employed by the foreign enterprise, during the construction (if any) and operational phases of the project? If no, briefly describe the on-site contractors’ and/or subcontractors’ duties. Examples: “Engineering, Procurement, and Construction contractors will be used during the construction phase” or “Operations and Maintenance contractors will be used when the project is operational”, or “The majority of on-site duties during construction and operations will be performed by third-party contractors and subcontractors.”      		Yes	No
6.	Will the project be located in a Free Trade Zone (FTZ) or Export Processing Zone (EPZ) or a similar special designated area in the project country? If yes, do project country labor laws apply to businesses in such a zone?		Yes Yes	No No

Section III – Signature
	Each Investor must sign this application. The signature applies to Section I and II.
	Applicant (Investor):	     	Applicant (Investor):	     
	By:	     	By:	     
	Name & Title (print):	     	Name & Title (print):	     
	Date:	     	Date:	     
By signing this form, the Investor(s) hereby represents and warrants that (a) this form is identical in all material and substantive respects to OMB form No. 3420 0011 sent to the Investor by OPIC and (b) that the Investor understands that OPIC shall regard the Investor’s answers to the questions on this form to be answers to the questions as asked on OMB form No. 3420 0011.

 Signed applications may be submitted by fax to (202) 408-5142. Alternatively, signed electronic applications (for example in Adobe PDF or other readable formats) may be submitted by electronic mail to [email protected]. Supporting documentation may be submitted by fax to (202) 408-5142 or by electronic mail to [email protected].