Form OPIC-168(A-B) Expedited Screening Questionnaire for Downstream Investm

		OPIC 168A AND 168B, OMB#3420-0020, Exp. 09/30/2009
		PRIVILEGED BUSINESS INFORMATION
		OPIC Expedited Screening Questionnaire (ESQ) - Downstream Investments This form requests information from OPIC clients, which is required by OPIC’s governing legislation. The information provided in this questionnaire will allow OPIC to better assess the effects that OPIC-assisted downstream investments have on the U.S. economy and employment, as well as the environment and economic development abroad. Complete responses to the collection of information in this form are mandatory, per the Foreign Assistance Act of 1961, as amended, Section 231(k)(2). 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 by the FOIA. An Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number with an expiration date that has not expired. Overseas Private Investment Corporation (An Agency of the United States Government) 1100 New York Avenue, NW Washington DC 20527 Telephone: (202) 336-8498 Fax: (202) 408-9859 Please send completed form to the attention of: Finance Department or Investment Fund Department
		Notice: Public reporting burden for this collecting of information is estimated to average three 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 aspect of this collection of information, including suggestions for reducing this burden to Agency Forms Officer, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503. Instructions: In the interests of consistency, uniformity and economy, OPIC Form 168 has been expanded to meet the information gathering requirements of the Agency. All parties seeking OPIC consent on a proposed downstream investment must answer the expedited screening questionnaire (OPIC 168A) as completely as possible. The U.S. effects and host country development questionnaire (OPIC 168B) must be completed in accordance with the Schedule delineated on financing agreement or insurance contract. This form is used for downstream investments supported by both OPIC investment fund and finance programs. As such, the term “downstream investment” refers to 1) portfolio companies of OPIC investment fund and 2) borrowing companies of OPIC on-lending and framework agreement facilities. If space is inadequate, please supply additional information on separate sheets of paper and attach them to this form.
		PRIVILEGED BUSINESS INFORMATION

OPIC 168A: Expedited Screening Questionnaire (ESQ) – Downstream Investments

1. Downstream investment Information
Facility/Fund:			     
Downstream Investment Company:			     
Country:			     
OPIC Participation Amount:			$     
Equity Contribution:			$     
Additional Debt:			$     
Total Downstream Investment Amount:			$     
Industry:			     
Registration No:(OPIC Use Only)			   -    -   -  
2. Publicly releasable description of the business activity supported by the downstream investment. Please be sure to include the specific use of the downstream investment/investment proceeds:
		     
3. Describe the environmental implications of the business activity supported by the downstream investment, including the activity or process involved, the siting (i.e., the exact downstream investment location) and potential environmental impacts. OPIC will evaluate the information to determine the level of environmental sensitivity involved and may contact the Investor with additional questions. The following types of information may be useful in OPIC’s evaluation of the downstream investment:
A	Description of Activity or Process: Please include the inputs (such as raw materials and fuel) to the process, the process used to transform inputs into output(s), and the by-products from the process. The description should identify any activity or process that can pose a major threat to human health or/and the environment, including major pollutants (air emissions, effluent discharges, or solid wastes). Major threats such as the risk of fire, explosion, or the release of hazardous substances should be identified
	     
B	Siting: Characterize the site as industrial, commercial, residential, agricultural or other rural and as previously developed or undeveloped. Provide a map to identify the site location and the proximity of nearby protected areas (Parks, Reserves, Monuments, etc) or sensitive ecosystems.
	     
4. Does the transaction involve the use of on-site contractors or subcontractors?				Yes No
	     

5. Sales of Product or Service: Please indicate the product or service to be produced. If more than one product or service will be produced (e.g., circuit boards, memory chips and CDs), please identify each product or service
	A:      			B:      		C:      
	In the table below, please estimate average annual sales by final destination as well as the composition of sales according to product or service over the first five years of operations. Please include only incremental production, i.e., new output expected to result from the investment amount indicated in questions 1a and 1b.
Final Destination Sales			Product/Service A (U.S.$)		Product/Service B (U.S. $)		Product/Service C (U.S.$)
Host Country			$     		$     		$     
United States			$     		$     		$     
Other Countries			$     		$     		$     
1.      			$     		$     		$     
2.      			$     		$     		$     
3.      			$     		$     		$     
Remaining sales			$     		$     		$     
Total			$     		$     		$     
6. Related Supporting Downstream investment Information:
A		Does the downstream investment occupy a monopoly position in any of its markets?						Yes No
B		Does the host government have majority ownership or effective management control of the business receiving the facility downstream investment?						Yes No
C		Is the downstream investment subject to any legal or regulatory requirement to source raw materials locally or to export a minimum level of production?						Yes No
D		Is the downstream investment a subsidiary or affiliate of, or contractor for, a U.S. company?						Yes No
E		If 6D is “yes,” will U.S. operations be reduced or terminated as a result of the facility downstream investment?						Yes No
		IF you checked “yes” in any of the above boxes, please provide a brief explanation
		     

	I hereby represent the information provided in this document is complete and accurate to the best of my knowledge, and that I am an authorized representative of the borrower.
	Signature:      		Date:      	Telephone:      
	Name and title:      	Email address:      

OPIC 168B: U.S. Effects and Developmental Impact Questionnaire Form

Facility/Fund:

     

Downstream Investment Company:

     

Country:

     

OPIC Participation Amount:

$     

Total Downstream Investment Amount:

$     

Registration No:(OPIC Use Only)

   -    -   -  

1. DOWNSTREAM INVESTMENT TRANSACTIONS: SOURCES & USES

A. SOURCES

B. USES

Debt/Equity

Initial Expenditure

Annual Operational Expenditure

Downstream Investment

$     

Host country

$     

$     

Framework/Fund

$     

U.S.

$     

$     

OPIC IG

$     

Other developing countries

$     

$     

Other sources

$     

Other developed countries

$     

$     

Total*

$     

Total*

$     

$     

*1A Total should equal total figure in 1B Column 1 (Initial Expenditure).

2. U.S. SUPPLIERS INFORMATION

Please provide a detailed list of U.S. manufacturers supplying key goods and services for the downstream investment. OPIC considers U.S. procurement to be equipment manufactured by, or services provided by, U.S. workers.

A

Initial Procurement: Please list items procured from the United States for initial downstream investment expenditures from Question 1B, Column 1, above.

Manufacturer

City and State

Product

(N)ew or (U)sed

Amount ($)

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

B

On-going Capital Expenditures (Purchase Price Average Annual Over 5 Years): Please list items procured from the United States for downstream investment operations from Question 1B, Column 2, above.

Manufacturer

City and State

Product

N)ew or (U)sed

Amount ($)

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

     

     

     

 

$     

3. AVERAGE ANNUAL FINANCIAL OUTFLOW FROM THE HOST COUNTRY OVER THE FIRST 5 YEARS OF OPERATION

In each column, estimate the downstream investment’s average annual financial outflow from the host country to the respective destinations.

Remittance to the United States

Remittance to Other Countries

A

Total Downstream investment(s) Principal and Interest:

$     

$     

B

Lease Payment:

$     

$     

C

Dividends or Profits:

$     

$     

D

Return on Equity:

$     

$     

E

Fees:

$     

$     

F

Other:      

$     

$     

4. HUMAN CAPACITY BUILDING

A

Indicate the current number of employees and the estimated incremental number of persons to be employed by the business activity supported by the downstream investment

Management

Professional/Technical

Unskilled Labor

Current

5th Year

Current

5th Year

Current

5th Year

Local:

     

     

     

     

     

     

Expatriate:

     

     

     

     

     

     

Total:

     

     

     

     

     

     

B

For the new jobs identified above, indicate the percentage that will receive formal training in each category:

Management

     %

Professional/Technical

     %

Unskilled Labor

     %

C

Will the business activity supported by the downstream investment provide training outside of the host country? If yes, please indicate countries:     

Yes No

5. PRIVATE SECTOR DEVELOPMENT

A

What is the percentage of local ownership of the downstream investment at the time of application?

     %

B

If there is local ownership, is the local owner a Small & Medium Enterprise (SME)?1

Yes No

C

Will the business activity supported by the downstream investment encourage private ownership, such as through privatization, or creation of opportunities for individual property (including home) ownership? If yes, please explain.      

Yes No

6. LEVERAGING IMPACTS

A

Does the business activity supported by the downstream investment involve other federal/regional/multilateral organizations (such as AID, TDA, IFC, MIGA, etc.)? If Yes, please list organizations:      

Yes No

B

Does the business activity supported by the downstream investment involve a public-private partnership (e.g. thru local development bank/ministry/NGO)? If yes, please explain.      

Yes No

7. SOCIAL EFFECTS

A

Does the downstream investment company have (or will it adopt) a written equal employment policy that adheres to the labor standards defined in the International Labor Organization's Convention 1112? If yes, please provide a written copy of this policy (or a draft copy) and describe how the policy is (or will be) communicated to employees. If no, please describe any equal employment policy that will apply to the proposed investment.      

Yes No

B

Will there be any benefits or policies in place that specifically address the needs of women at the workplace? (Examples are childcare, maternity leave, non-harassment policies)? If Yes, please explain.      

Yes No

C

Will the business activity supported by the downstream investment benefit a poor (e.g., rural) region of the host country? If Yes, please explain.      

Yes No

D

Will the downstream investment extend company benefits to its employees? If Yes, please explain. (e.g., health coverage, daily meals, transportation, or housing assistance)      

Yes No

E

Will the downstream investment provide benefits to the local community? If Yes, please explain. (e.g., recreational facilities, community center, schools, or medical clinics)      

Yes No

F

Does the business activity supported by the downstream investment 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

8. DEVELOPMENTAL INFRASTRUCTURE IMPROVEMENTS
A	Will the business activity supported by the downstream investment strengthen the physical infrastructure of the host country? (e.g., communications, power, transportation)	Yes No
B	Will the business activity supported by the downstream investment strengthen the financial infrastructure of the host country? If Yes, please explain.(e.g., micro finance, on-lending, mortgage lending, or financial market development)	Yes No
C	Will the business activity supported by the downstream investment strengthen the social infrastructure of the host country? (e.g., nutrition, shelter, water & sanitation, health, or education)	Yes No
	If you answered Yes to any of the above questions, please indicate the economic status of the user population.      
7. MACROECONOMIC & INSTITUTIONAL EFFECTS
A	Estimate the average annual revenues (duties, taxes or other payments) of the host government resulting from the business activity supported by the downstream investment’s first five years of operations.
B	Duties, taxes, and other payments:	$     
C	Duties and taxes lost as a result of the investment (e.g. because of import substitution):	$     
D	Duration of tax holiday, if any:	     
E	Is the investment being implemented in the context of a government regulatory, judicial or other institutional reform program? If Yes, please describe the reform program.      	Yes No
F	As a result or condition of this investment, will the government implement regulatory, judicial or other institutional reforms? If Yes, please describe the reforms.      	Yes No
9. TECHNOLOGY & KNOWLEDGE TRANSFER
A	Will the business activity supported by the downstream investment introduce innovative management practices? If Yes, please explain.      	Yes No
B	Will the business activity supported by the downstream investment bring new marketing and distribution strategies to the host country? If Yes, please explain.      	Yes No
C	Will the business activity supported by the downstream investment apply new production technology for the first time? If Yes, please explain.      	Yes No
D	Will the business activity supported by the downstream investment market products available for the first time? If Yes, please explain.      	Yes No
E	Will the business activity supported by the downstream investment lower local prices? If Yes, please explain.      	Yes No
F	Will the business activity supported by the downstream investment contribute to the economic diversification of the host country? If Yes, please explain.      	Yes No

	I hereby represent the information provided in this document is complete and accurate to the best of my knowledge, and that I am an authorized representative of the borrower.
	Signature:      	Date:      	Telephone:      
	Name and title:      	Email address:      

1 Small- and Medium Enterprise (SME): Up to 300 employees, total assets of up to $15 million, and total annual sales of up to $15 million. (IFC)

2 International Labor Organization (ILO) Convention (No. 111) defines discrimination with respect to employment and occupation as: “Any distinction, exclusion or preference made on the basis of race, color, sex, religion, political opinion, national extraction or social origin, which has the effect of nullifying or impairing equality of opportunity or treatment in employment or occupation.” The scope of the Convention covers access to vocational training, access to employment and to particular occupations, and terms and conditions of employment.