OPIC Form 115 with DUNS inclusion - 2011

OPIC APPLICATION FOR FINANCING

Application Instructions

By completing Part I of the OPIC Application for Financing (the “Application”) you will initiate the process to be considered for an OPIC loan or loan guaranty. The application consists of three sections, but you are asked to complete and submit only Section I for OPIC’s initial review, and to proceed to complete the rest of the form only after you have been contacted by an OPIC staff member.

Throughout the process of completing the on-line application there are web page links to helpful definitions, a description of the OPIC application process, a list of frequently asked questions (or FAQs), etc. to help guide you through the process. However, should you have questions, please contact the OPIC Information Officer at 202-336-8799 or email [email protected].

The Application’s four parts consist of the following:

Section IA: Initial Loan Request Information Sheet

Section IB: Business Plan and Attachments

Section II (1-4): OPIC Investment Policy Questions

Section III: Signature

Responses to questions, which call for estimates or projections, should take the form of good faith statements made to the best of the applicant’s knowledge and belief. All information furnished in the Application is treated as privileged business information, to the fullest extent permitted by law.

NOTE: NEITHER SUBMISSION NOR ACCEPTANCE OF THIS APPLICATION IMPLIES THAT THE PROJECT IS ELIGIBLE FOR FINANCING OR THAT FINANCING WILL BE PROVIDED.

OPIC 115

OMB No. 3420-0015

Exp. 7/31/2011

FINANCE APPLICATION SECTION IA: LOAN REQUEST

• Submit only Section IA to begin the loan request process. OPIC will review your submission and advise when to proceed to complete Parts II, III and IV of the application.

• Contact [email protected] or (202) 336-8627 with any questions or to follow up on your submission.

1. PROJECT COMPANY (Overseas entity that will be the beneficiary of the OPIC financing for the purpose of undertaking the proposed overseas investment (the “Project”) in an OPIC eligible country (the “Project Country”) (click on web link to see country list).)

Project Company Name:

Project Company Address (including city and country):

Office Phone Number(s):

Fax Number(s):

E-mail(s):

Specific Project Location (if different from above):

2. Authorized Representative (Individual signing the application; i.e. shareholder in or executive of Project Company, financial advisor, legal counsel, etc.)

Name and Title of Representative:

Relationship to the Project Company:

Address:

Office Phone Number(s):

Cell/Mobile Phone Number(s):

Fax Number(s):

E-mails(s):

3. Ownership (Please list all ultimate beneficial owners of the Project Company. (If the Project Company is privately held please list every individual owning shares in the Project Company, including the percentage ownership and nationality of each individual. If the Project Company is wholly or partly owned by one or more publicly traded companies, please indicate the name of each company and the place of incorporation. If you have a complete ownership chart please attach with the link provided.)

Shareholder Name Country of Citizenship or Incorporation Percent Owned

1)

2)

3) ___________

100%

4. SME or Woman or Minority-Owned DESIGNATION Is any U.S. shareholder identified above a (i) ___ Small or Medium Enterprise with revenues ≤ $250 million, (ii) ___ an individual with net worth ≤ $67 million, (iii) ___ woman-owned business, (iv) ___ minority-owned business (check all that apply)

5. Project Summary (Please summarize the Project, describing the identified market opportunity; the location of the Project; what products or services will be produced and whether for the local market or for export (and if for export, to which countries); and whether the Project is a start up, expansion, or privatization.

6. Project Costs (Below please list estimated Project costs; for expansions, include only the costs associated with the expansion; alter categories as necessary to accurately reflect uses of funds.)
	US$	%
Pre-Operating Expenses	$	%
Land	$	%
Building/Improvements	$	%
Equipment	$	%
Working Capital	$	%
Contingency	$	%
General Development Fees	$	%
Debt Service Reserve	$	%
Financing/Legal Fees	$	%
Interest During Construction	$	%
Other	$	%
Total Project Costs	$	100%

7. Project Funding (Below please summarize the sources of funding for the Project costs; alter categories as necessary to accurately reflect sources of funds.)
	US$	%
Debt:	$	%
OPIC loan (indicate proposed term)	$	%
Other term debt (indicate proposed term and collateral)	$	%
Supplier financing	$	%
Subordinated Debt:
Shareholder subordinated loans	$	%
Third party subordinated debt	$	%
Equity:	$	%
Cash equity in the form of capital	$	%
In-kind contribution
Other	$	%
Total Project Funding	$	100%
8. Collateral and Credit Enhancements (Please specify collateral and guaranties proposed to secure or support the OPIC loan such as pledge of shares; liens on Project Company or U.S. assets; debt service reserve accounts; personal or corporate guaranties; keyman life insurance; bank letters of credit; or other Project support.)
-9. Management Experience and Track Record (Briefly describe relevant experience in the Project’s business sector of the shareholders and key Project management. For each individual listed below please specify that person’s relationship to the Project (i.e. shareholder, CEO, etc.)

"This is a voluntary information collection.  The estimated burden for completing Section IA of this form is 45 minutes. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number.  Comments on the burden should be sent to: Essie Bryant, Agency Clearance Officer, 1100 New York Ave., NW, Washington, DC, and David Rostker, Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503." 

OPIC 115

OMB No. 3420-0015

Exp. 12/31/2010

SECTION IB: BUSINESS PLAN AND ATTACHMENTS

If requested to do so, please submit the following complete application information package (note that less than a complete package may result in delays in OPIC’s consideration of the financing request):

1. Financial Statements

Submit financial statements of each of the primary shareholders contributing equity or debt to the Project Company. Financial statements should include a balance sheet, income statement, and cash flow statement (preferably prepared in accordance with U.S. Generally Accepted Accounting Principles (“U.S. GAAP”) or International Financial Reporting Standards (“IFRS”). Financial Statements must be prepared in English or accompanied by a certified English translation. Please submit financial statements electronically, following the guidance for your form of organization below. If these are not available, consult with OPIC before completing this application.

For an existing Project Company: - Annual Financial Statements (audited, if available; most recent 3 years)

- Quarterly Financial Statements (most recent quarter)

For a public corporation: - 10K (most recent 3 years)

- 10Q (most recent quarter)

For a private corporation: - Annual Financial Statements (audited, if available; most recent 3 years)

- Quarterly Financial Statements (most recent quarter)

- Tax Returns (most recent 3 years)

For a partnership: - Annual Financial Statements (audited, if available; most recent 3 years)

- General Partner information, including (i) current signed Statement of Net Worth (assets, liabilities, net worth) and (ii) ownership

For an individual: - Current Signed Statement of Net Worth (assets, liabilities, net worth)

- Bank Statements (most recent 3 months)

- Tax Returns (most recent 3 years)

2. Bank and Trade References (For each private corporation, partnership or individual, please provide three bank references and three trade references.)

3. Complete Business Plan/Preliminary Information Memorandum

The following checklist lists the items to include in the business plan. The checklist is intended to provide a framework for the business plan – please provide as complete a business plan as possible.

Business Plan Checklist

(a) Project Summary

OPIC Loan/Project Description (describe the amount and term of the OPIC loan, for what purpose it is to be used and a Project description/location)

Current Status (describe the Project Company’s date of incorporation, investment made to date, market or feasibility studies performed, status of documentation/permits/government consents/land acquisition, etc.)

(b) Project Ownership and Management

Project Company Ownership (provide complete Project Company ownership as described in question 3 in Part I of the Application, including all holding companies or intermediary operating companies, and electronically attach an ownership chart, if available)

Project Developers (list primary shareholders developing the Project and the professional expertise of such individuals, including experience in the Project country)

Project Management (describe Project Company management structure and professional expertise of individuals in key management positions)

Consultants/Advisors (list consultants or advisors to the Project Company, detailing the addresses, contact and role of such consultants or advisors and work or reports completed to date)

(c) Project Sector/Market/Economics

Sector/Industry (describe history, sector reform, recent market trends, competition, supply and demand, pricing, market position of Project Company (at time of market entry and long-term), etc.)

Product/Services (describe the products or services the Project will produce, in what quantity, and whether for the local market or for export (and if for export, to which countries)

Project Economic/Technical Specifications (describe Project economics, technical parameters, construction plans/schedule, equipment/land to be procured, off-take arrangements, etc.)

Agreements (list all key operating agreements necessary to undertake the Project such as concession agreement(s), construction contract(s), offtake agreement(s), environmental impact studies, feasibility studies, marketing studies, technical assistance agreement(s), management services agreement(s), lease(s), etc. (and attach electronically if possible)

(d) Project Financial Plan and Collateral

Project Financial Plan (include financial plan as illustrated in questions #6 and #7 of Part I of the Application)

Debt/Equity (describe proposed OPIC and other lender debt (loan amount, tenor, grace period) and source, timing and amount of equity contributions)

Collateral and Credit Enhancements (describe proposed collateral and credit enhancements, such as guarantees or letters of credit, that will be provided for the borrowing of the OPIC Loan)

(e) Legal, Economic, Political Environment and Government Participation

Licenses/Permits (list all licenses, permits, consents, approvals, environmental requirements etc. required by the Project Country government and the status of such documentation)

Legal Regime (list Project country laws, regulations or pending reforms that will impact the Project or the sector)

Economic/Political Climate (describe the economic and political climate of the Project Country and the specific region in which the Project is located)

Government/Multilateral Participation (describe any government or multilateral involvement in the Project or the sector and any government incentives such as tax holidays)

Current or Pending Litigation (describe all current or pending disputes or litigation involving the Project or the Project Company, or shareholders)

(f) Project Strengths/Risks and Mitigants

Strengths (describe those factors that strengthen the Project economics and contribute to the long-term viability of the Project)

Risks (describe Project risks such as credit risks, sector/market risks and competition, operational and management risks, political/economic risks, legal/regulatory risks and what steps the Project Company will take to mitigate such risks)

4. Financial Model (Please electronically attach a detailed model of financial projections of the Project over the requested term of the OPIC loan. Describe the primary financial model assumptions and justification for such assumptions. If the Project is an expansion please ensure that the model includes that last two fiscal years of operations as the basis for the projections.)

The model should include detailed assumptions as to the Project’s budget, revenue, expenses, financing terms, timing of equity contributions, loan disbursement schedule, etc. The model must include an income statement, balance sheet and cash flow statement projecting the financial performance of the Project over the life of the OPIC loan. The model must also include the calculation of the following ratios Cash Flow to Debt Service, Current Assets to Current Liabilities, Total Indebtedness to Tangible Net Worth, Return on Assets, and Internal Rate of Return.

5. Sponsor Disclosure Reports

The following must complete a Sponsor Disclosure Report: (i) every Project Company shareholder beneficially owning, directly or indirectly, 5% or more of the Project Company, and (ii) subject to OPIC’s review of the Application, any individual or entity providing credit support to the Project or having a significant managerial relationship to the Project. Please click on the web link to locate this form, and once completed submit this form electronically by attaching it to this application.

SECTION II: OPIC INVESTMENT POLICY QUESTIONS

PART 1 – Effects of the Project on the U.S. Economy

In completing the form below, recall that the “Project” is the proposed overseas investment and “Project Company” is the overseas entity that will be the beneficiary of the OPIC financing for the purpose of undertaking the Project in the Project Country.

1. PROJECT AFFILIATES

Please list for each shareholder directly or indirectly owing 5% or more of the Project Company, any other entity in which such shareholder has a controlling interest, whether or not such entity is related to the Project Company (each such entity is an ‘affiliate’ of the Project Company for the purposes of the questions below).

Shareholder Name	Name of Project 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 (Sources of Project Financing). 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 Project Country or regional markets

 Telecommunications services intended to serve predominantly Project Country or regional markets.

 Oil and/or gas exploration

 Tourism services (e.g., a hotel, restaurant or resort).

 Power supply or transmission for Project Country or regional markets

 Mining of minerals or ores not mined in the U.S.

 Project Country or regional sales, service, distribution or transportation (no production involved).

3. PRODUCTION OF COMPARABLE PRODUCTS

(a) Do any Project Company affiliates identified in #1 above produce goods or services in the U.S. which are comparable to goods or services produced or to be produced by the Project Company?

 Yes

 No

(b) If you answered “No” to Question #3(a), please proceed to Question #4. If you answered “Yes” to Question #3(a), will the Project’s production compete with or replace such comparable U.S. production?

 Yes

 No

(c) If you answered “No” to Question #3(b), please explain below why the Project Company’s production will not compete with or replace such U.S.-based production.

(d) Employment in Comparable Production
For each Project Company affiliate identified in #3(a) 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 one year from now.
Name of 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 Project Company affiliate identified in #1 above reduced or expect to reduce the number of 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.				 Yes  No

5. SOURCES OF PROJECT FUNDING (TOTAL PROJECT COST)
		Equity	Debt	Other*
(a)	From OPIC	$	$	$
(b)	From the primary U.S. shareholder(s) developing the Project	$	$	$
(c)	From other U.S. sources	$	$	$
(d)	From Project Country sources	$	$	$
(e)	From third country sources (specify countries)	$	$	$
(f)	From international institutions (specify)	$	$	$
(g)	Other (specify)	$	$	$
(h)	FUNDING TOTAL: $	$	$	$
*e.g. technical assistance or management service agreements, leases, consigned equipment, etc.
6. OFFSHORE FUNDS
Of the Project funding listed in #5(b) and #5(c) 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 Project Country, but rather from another country, for example, a foreign bank account owned by a U.S. entity)?				$

7. USES OF PROJECT FUNDS
Start-up/construction Project Expenditures refers to the total sources of Project funding included in Question #5(h) above, including land, buildings, raw materials, equipment, labor, services, working capital and other costs. Also indicate 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 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 (months)		---------------------------------
(a)	Purchased or spent in the Project Country	$	$
(b)	Purchased from the U.S.*	$	$
(c)	Purchased from developing countries other than the Project Country (specify)	$	$
(d)	Purchased from industrialized countries other than the U.S. (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 #7(c) or (d) above. **(Note: Column 1 total should equal total figure (equity+debt+other) given for #5(h) 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 U.S. 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		Product	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
	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		Product	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
	TOTAL

9. DESTINATION OF PROJECT SALES AND PRODUCTION
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 Project Country:	$
Exported to the U.S.:	$
Exported to other countries (list countries and amounts below):
Country:	$
Country:	$
Country:	$
Country:	$
TOTAL	$

10. IMPORT SUBSTITUTION
(a)		Will the Project Company’s production that is sold in the Project 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 Project Country 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 Project 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 U.S.			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 Payments:		$			$
(d)		Dividends or Profits:		$			$
(e)		Return on Initial Capital Investment:		$			$
(f)		Fees (other than OPIC fees):		$			$
(g)		Other:		$			$
13. U.S. EXPORT SUBSTITUTION
(a)		Will any of the Project Company’s production sold within the Project 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 Project 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 Project Company that might affect Project imports, exports, or employment (e.g., local content or export requirements, trade balancing or local hiring requirements, etc.).

PART 2A – Project Country Developmental Effects

(For All Projects Except Financial Services/Intermediaries)

The term “financial intermediary” 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.

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		5th Year	Construction		5th Year	Construction		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 Company provide training outside the Project Country? If yes, please indicate countries and type of training provided.								Yes	No
3. 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 a 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
		Project Country government entity:      		International Non Governmental Organization:      
		Local Non Governmental Organization:      		Other:      
6. Will the Project Company have (or will it adopt) a written equal employment policy? If yes, please indicate below what is 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 Project Country? If yes, please indicate where below:						Yes		No
	Rural region of Project Country			Poor urban area in Project 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 Project 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 Project 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 Project Country’s economy? If Yes, please explain.							Yes			No
14. Project Country government fiscal impact:
14(a) Estimate the average annual revenues (duties, taxes or other payments) paid to the Project Country government as a result of the Project’s first five years of operations:							$
14(b) If the Project Company is eligible for a tax holiday, indicate the duration of the tax holiday:
14(c) If duties and/or tax payments to the Project Country 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 Project 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 Project Country. If new or uncommon in Project Country, please provide details.
17(a) Innovative management practices:				New	Uncommon				No
17(b) Marketing and distribution expertise:				New	Uncommon				No
17(c) Production or processing technologies:				New	Uncommon				No
18. Will the Project Company market products available for the first time in the Project Country? If yes, please explain.						Yes		No
19. Will the Project lower local prices? If yes, please explain.						Yes		No

Part 2B: Project Country Developmental Questions

(Only for Financial Services/Intermediaries Projects. Applicant should only complete Part 2B if directed by OPIC staff to do so.)

Where available, for the questions below, please provide information only for OPIC-supported activities – not for the institution as a whole.

	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:      
	How long has the FI been in operation?												      Years
	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			     					     					     
	What percentage of these employees will receive training?
	Managerial				Professional/Technical							Unskilled Labor
	     %				     %							     %
	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:      
	Will the Project Company 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:      
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:      

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
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:      
Will the FI be involved in any public-private partnerships? If yes, please indicate below:							Yes		No
		Local government ministry:      		International Non Governmental Organization:      
		Local Non Governmental Organization:      		Other:      
Is there any innovative product or service that helps the FI gain a competitive edge in the market? If yes, please describe.								Yes		No
Please indicate whether the following technology and knowledge transfer factors are evident in the FI’s activities in the Project Country. If new or uncommon in Project Country, please provide details.
12a. Innovative management practices:					New	Uncommon				No
12b. Marketing and distribution expertise:					New	Uncommon				No
12c. Production or processing technologies:					New	Uncommon				No
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:      			U.S. 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:

Projected average annual revenue				$     
Projected number of loans				     
Projected number of borrowers				     
Projected average annual taxes, duties, and fees paid to the Project Country government over the first 5 years				$     
Projected average outstanding loan size per borrower				$     
Projected maximum loan size to a single borrower				$     
Projected minimum loan size to a single borrower				$     
Projected median loan size to a single borrower				$     
Projected percentage of borrowers that will be women (or women-managed businesses)				     %
Projected type of clients as a percentage of the portfolio
     %	Microenterprises (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 as a firm with a 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:      
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
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:      

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:      
Projected geographic distribution of borrowers as a percentage of portfolio
     %		Urban
     %		Rural
     %		Other:
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.
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:      
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)

Will the Project involve any physical modification of the Project site or construction? If yes, please explain:	 Yes  No
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
Will the Project involve the storage, use, transport, handling or production of potentially hazardous materials, including fuel? If yes, please explain:	 Yes  No
Will the Project produce solid wastes during construction or operation? If yes, how will the solid wastes be handled?	 Yes  No
Will the Project release pollutants including any toxic or noxious substances to the air? If yes, how will the pollutants be handled?	 Yes  No
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
Does the Project pose a risk of accidents during construction or operation that could pose a risk to human health or the environment? If yes, please explain:	 Yes  No
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
Is the Project located in or near areas vulnerable to natural hazards (earthquake, landslides, flooding)? If yes, please describe further:	 Yes  No
Does the Project have an environmental, health or safety management system in place? If yes, please describe the system in detail:	 Yes  No
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)

Does the Project involve investing in, lending to, or acquiring an existing enterprise? If no, proceed skip to Question #3. If yes, please answer the following: (a) Are any parts of the workforce organized in a legally recognized trade union? (b) If yes to (a), is the trade union recognized by management? If no, briefly explain.		Yes Yes Yes	No No No
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
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
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
Will all workers at the Project site be directly employed by the Project Company, 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 (“EPC”) contractors will be used during the construction phase” or “operations and maintenance (“O&M”) 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
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 zone?		Yes Yes	No No

This is a voluntary information collection.  The estimated burden for completing this form is 3 hours and 10 minutes. You are not required to respond to any collection of information unless it displays a currently valid OMB approval number.  Comments on the burden should be sent to: Essie Bryant, Agency Clearance Officer, 1100 New York Ave., NW, Washington, DC, and David Rostker, Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.   

PART 5 – DUNS Number

               

D-U-N-S Number for Project Company or Borrower

1

2

3

4

5

6

7

8

9

-

1

2

3

4

A D&B^® D-U-N-S^® Number is a unique nine-digit sequence, with an optional 4 digit extension for some locations. A D-U-N-S number is recognized as the universal standard for identifying and keeping track of over 100 million businesses worldwide. Dun & Bradstreet (D&B) provides a D-U-N-S Number, a unique nine digit identification number, for each physical location of a business. OPIC uses the D-U-N-S Number to facilitate public reporting requirements applicable to OPIC’s programs.

Please provide the Project Company’s D-U-N-S Number; or, the Borrower’s D-U-N-S Number if the Project Company will not be the Borrower under the proposed OPIC financing.

If a D-U-N-S^® Number is not available when this application is submitted to OPIC, a D-U-N-S Number may be obtained after the date of this application; provided that, such D-U-N-S Number is obtained and reported to OPIC prior to the issuance of an OPIC financing commitment. D-U-N-S Number assignment is FREE for all businesses. A D-U-N-S number may be obtained by accessing the following website:

http://fedgov.dnb.com/webform

SECTION III: SIGNATURE

Authorized Representative
“Under penalty of law, I certify that the statements and information provided herein are true to and correct to the best of my knowledge and belief.”
Signature:
Print name and title:	Date:

PRIVILEGED BUSINESS INFORMATION

Page 14