Form OPIC-248 Office of Investment Questionnaire

OVERSEAS PRIVATE INVESTMENT CORPORATION

OFFICE OF INVESTMENT POLICY QUESTIONNAIRE

Welcome to OPIC’s Office of Investment Policy Questionnaire (“OIPQ”). If you wish to attach supporting documentation, you may do so at any time, but it is not required for an initial submission. Analysts from OPIC’s Office of Investment Policy will review the OIPQ, including any supporting documentation provided.

OPIC’s Office of Investment Policy reviews each potential OPIC-supported project for its: 1) expected development impact in the host country; 2) anticipated impact on the U.S. economy and U.S. employment; 3) environmental, health, and safety elements; and 4) labor-related considerations. For a description of OPIC’s Office of Investment Policy, please click here: http://www.opic.gov/doing-business/investment.

OFFICE OF INVESTMENT POLICY QUESTIONNAIRE

OPIC 248 (new)

OMB Number: _____

Expiration Date: _______

Overseas Private Investment Corporation

1100 New York Avenue, NW Washington, DC 20527-0001

An Agency of the United States Government

This form requests information from potential OPIC clients that is required by OPIC’s governing legislation - the Foreign Assistance Act (FAA) of 1961, Title IV, as amended - to assist OPIC in determining whether a project and its sponsor(s) meet eligibility criteria for OPIC financing, specifically with regard to the soundness of the project, the qualifications of the sponsor(s), creditworthiness, effects, and legislative and regulatory compliance. Complete responses to the questions are required on this form to apply for OPIC support per the FAA.

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. Statements of fact provided to OPIC in this document must be accurate as of the date of execution of this document. In addition to other rights and remedies available to OPIC, misrepresentations or failure to disclose relevant information may result in criminal prosecution pursuant to 22 USC 2197(n), as well as a default or termination if a commitment is issued. Neither submission nor acceptance of this application implies that the project is eligible for financing or that financing will be provided.

Client information contained in this form will be deemed designated as confidential commercial information in accordance with OPIC's Freedom of Information Act (FOIA) regulations (22 CFR 706), and will be treated as confidential commercial information to the extent permitted by applicable law. As a federal agency, OPIC may not collect, or sponsor the collection of, information unless it displays a valid OMB Control Number with an expiration date that has not expired.

Paperwork Reduction Act Notice: This information is required to obtain benefits. The public reporting burden for this collection of information is estimated to average 45 minutes 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 Essie Bryant, Agency Clearance Officer, 1100 New York Ave., NW, Washington, DC, and Wendy Liberante, Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.

I have read and agree to the terms and conditions listed above.

GETTING STARTED

OFFICE OF INVESTMENT POLICY QUESTIONNAIRE

In order to initiate the process, please click on the “Office of Investment Policy Questionnaire” button above. As the U.S. Government’s development finance institution, OPIC takes its developmental mission seriously. An integral part of the OPIC application process, the OIPQ enables OPIC to estimate the potential long-term developmental impacts of each OPIC-supported project (or subproject) and to identify any potential environmental and social considerations. Additionally, data collected in the OIPQ is aggregated and used to satisfy OPIC’s U.S. Congressional reporting requirements.

The terms “Applicant”, “Financial Intermediary”, “Project”, and “Subproject” have their definitions given to them in Appendix D of OPIC’s Environmental and Social Policy Statement, as referenced below:

Applicants – Investors, lenders, insurers or projects sponsors seeking OPIC support.

Project – All facilities owned or controlled within a physical project boundary that constitute a commercially viable business unit eligible for OPIC support.

Financial Intermediary – Investment funds, banks or other financial institutions, or other entities or vehicles that receive financing, guaranties or insurance from OPIC and provide debt or equity investment directly to projects or enterprises (“Subprojects”).

Subproject – A project or enterprise that receives financing or investment from an OPIC-supported Financial Intermediary.

All projects that OPIC supports are subject to OPIC’s Environmental and Social Policy Statement and applicable International Finance Corporation Environmental, Health and Safety Guidelines.

PART I – PROJECT (OR SUBPROJECT) SUMMARY

FINANCE

INSURANCEE

INVESTMENT FUNDS

Please click on the appropriate OPIC product line:

	PROJECT (OR SUBPROJECT) INFORMATION
P	A	Applicant (or Financial Intermediary) Name:
P	B	Project (or Subproject) Name:
P	C	Target percentage ownership of Applicant (or Financial Intermediary) in the Project (or Subproject).		____%
DM/S/L/P	D	Please provide the estimated percentage of local ownership of the project, if any.		____%
P	E	Is any of the local ownership comprised of Small & Medium Enterprises (SME)?	Yes	No
		If “Yes”, please provide what percentage of local ownership is accounted for by Small & Medium Enterprises. If none, please skip this question.		____%
P	F	Do women-owned businesses account for any local ownership?	Yes	No
		If “Yes”, please provide what percentage of local ownership is comprised women-owned and/or managed businesses.		____%
S	G	Do any of the U.S. investors in the Project (or one of its subsidiaries or affiliates) currently produce the same product(s) as the one to be produced by this investment?	Yes	No
		If “Yes”, will the number of employees engaged in the U.S. production of this product be reduced as a result of this OPIC-supported investment?	Yes	No
		How many employees are currently employed by such U.S. company or its subsidiaries or affiliates that produce this product?	________

	PROJECT (OR SUBPROJECT) DESCRIPTION
S/P	A	Project (or Subproject) Industry		Financial Services		Non-Financial Services
P	B	Project (or Subproject) Classification		New Enterprise (no existing facilities and/or operations)		Existing Enterprise
P	C	Does (or will) the Project (or Subproject) involve construction?					Yes	No
DM/P	D	Does (or will) the Project (or Subproject) involve seasonal labor?					Yes	No
P	E	Describe the use of proceeds of this OPIC-supported investment:
P	F	Description of the Project (or Subproject) and its operations:
DM	G	What is the Project’s (or Subproject’s) target client or customer?
		Please provide the number of clients or customers currently served by the Project (or Subproject).					_____
		Please provide the expected number of clients served by the Project (or Subproject) as a result of this OPIC-supported investment.					_____

	PROJECT (OR SUBPROJECT) SITING
S/P	A	Project (or Subproject) City and Country:
S/P	B	Project (or Subproject) Site Location (please include GPS coordinates and, if available, a map of site location):
P	C	Please indicate whether the Project (or Subproject) will be located in or near any of the following:
		Natural forest areas, including primary forests, old growth forests, forests that serve as critical carbon sinks or forests with high levels of biodiversity.	Yes	No
		Areas on the United Nations List of Natural Parks, World Heritage Areas, or other internationally recognized protected areas (such as wilderness areas, national monuments, or nature preserves.	Yes	No
		Sensitive locations of national or regional importance including wetlands, floodplains, coral reefs, mangrove swamps or areas prone to erosion, desertification or seismic activity.	Yes	No

	PROJECT (OR SUBPROJECT) ENVIRONMENTAL AND SOCIAL CHARACTERISTICS
P	A	Please indicate if the Project (or Subproject) involves any of the following:
		Construction of a dam.	Yes	No
		Production or trade in any product or activity deemed illegal under host country laws or regulations or international conventions and agreement or subject to international phase-outs or bans.	Yes	No
		Resettlement of people or disruption of businesses.	Yes	No
		Use of previously contaminated sites.	Yes	No
		Production or trade in radioactive materials.	Yes	No
		Production or trade in or use of unbounded asbestos fibers.	Yes	No
		Marine or coastal fishing practices harmful to vulnerable and protected species or damaging to biodiversity or habitats.	Yes	No

PART IIA – PROJECT (OR SUBPROJECT) COUNTRY EFFECTS

(For Non-Financial Services Projects (or Subproject))

PROJECT (OR SUBPROJECT) EMPLOYMENT

DM/L

A

Please provide the current number of Project (or Subproject) employees and how many employees will be hired by the Project (or Subproject) as a result of the OPIC-supported investment.

Current Number of Permanent Employees

Number of Permanent Employees Directly Hired by the Project (or Subproject) by Year Five of Operations as a result of this OPIC-Supported Investment

Temporary Employees

Local

Expatriate

Construction Employees

Seasonal Employees

Male

Female

Male

Female

Local

Expatriate

Local

Expatriate

Local

Expatriate

Managerial

Professional/ Technical

Unskilled Labor

TOTAL

B

Will the Project (or Subproject) utilize workers employed by third parties (i.e., through contractors/subcontractors) once the Project (or Subproject) is operational?

For physical construction

For administrative needs

For other operational needs

	PROJECT (OR SUBPROJECT) EMPLOYEE TRAINING
DM/L	A	Will the Project (or Project Company) provide training above and beyond standard on-the-job training to both current and new permanent employees identified above in Question 1A of Part III?	Yes	No
		If “Yes”, please describe what type of training opportunities will be provided to the managerial, professional/technical, and/or unskilled personnel.
DM/L	B	Please provide what percentage of new permanent employees will receive training.			____%

	PROJECT (OR SUBPROJECT) CONSTRUCTION LABOR
	A	If physical construction is involved, has construction already begun?							Yes	No
		If “Yes”, how approximately how much has been completed (estimate in % completed terms)?
		Estimated start-up/construction period (if applicable): MM/YYYY – MM/YYYY				Estimated operational start date (if applicable): MM/YYYY
	B	Will the Project (or Subproject) utilize workers employed by third parties (i.e., through contractors/subcontractors) during Project (or Subproject) start-up or construction phase?							Yes	No
			For physical construction		For administrative needs			For other operational needs
	C	Will the Project (or Subproject) require the establishment of temporary worker housing facilities?							Yes	No
		If “Yes”, how many workers are expected to be housed at these facilities?

	PROJECT (OR SUBPROJECT) SOCIAL IMPACTS
DM/L		Does (or will) the Project (or Subproject) provide ancillary services or benefits to the local community (i.e. philanthropic and/or charitable initiatives not directly related to the business operations of the Project Company)? If “Yes”, please select the benefits that apply and describe the specifics of each program.				Yes	No
			Recreational facilities		Scholarship programs
			Schools		Charitable donations/activities
			Medical clinics		Other:      

	PROJECT (OR SUBPROJECT) HUMAN RESOURCE MANAGEMENT
P	A	Does (or will) the Project (or Subproject) have written human resources policies?	Yes	No
P	B	If “Yes”, please indicate the areas covered by the human resources policies:
DM/L		Benefits (e.g. healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare, etc).	Yes	No
		If “Yes”, please list which Project (or Subproject) benefits are above and beyond what is required by Project (or Subproject) Country law:
P		Mechanism(s) for workers’ to express grievances (e.g., direct access to supervisors and/or the human resources department, workers’ committees, and/or trade union reps, anonymous hotline, etc).	Yes	No
P		General conditions of work that, in the minimum, comply with local applicable labor laws (e.g., limits on hours of work, wages (including premium or overtime pay), sick leave, collective bargaining agreements, etc).	Yes	No
P		Disciplinary procedures.	Yes	No
P	C	Does (or will) the Project (or Subproject) have a Human Resources Department and/or Manager?	Yes	No
P	D	Does (or will) the Project (or Subproject) have management experience in applying international labor standards, such as those in the IFC Performance Standards or as part of certifications (e.g., Fair Trade Certified, SA8000, or Rainforest Alliance)?	Yes	No

	PROJECT (OR SUBPROJECT) LABOR-RELATED ISSUES
	Does (or will) the Project (or Subproject) involve the following?
P	A	Migrant or foreign workers (excludes expatriate management or highly-skilled non-manual workers).	Yes	No
P	B	Workers under the age of 18 (directly or indirectly employed by the Project (or Subproject).	Yes	No
P	C	Known use of harmful child labor at the Project (or Subproject) or (if applicable) in the Project’s (or Subproject’s) primary supply chain.	Yes	No
P	D	Known use of forced labor at the Project (or Subproject) or (if applicable) in the Project’s (or Subproject’s) primary supply chain.	Yes	No
P	E	Retention of foreign workers’ (directly or indirectly employed) passports	Yes	No
P	F	Restructuring which results in a major retrenchment (lays off significant numbers of workers).	Yes	No
P	G	Known non-compliance with local laws or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits).	Yes	No
P	H	Labor-related lawsuits against the Project (or Subproject).	Yes	No
P	I	Labor unrest in the last three years in the form of strikes or other general industrial disputes.	Yes	No
P	J	Ongoing or unresolved issues/disputes with a Project (or Subproject) trade union.	Yes	No

	TECHNOLOGY AND KNOWLEDGE TRANSFER
	Please indicate if the Project (or Subproject) will include any of the following technology and knowledge transfer factors in the Project (or Subproject) Country. Where applicable, please indicate whether any of these factors are new or uncommon in the Project (or Subproject) Country and provide details.
DM/L	A	Management practices (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM/L	B	Marketing and/or distribution techniques (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM	C	Production and/or processing technologies (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM/L	D	Products and/or services (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM	E	Will the Project (or Subproject) provide technical assistance (e.g. training of customers, industry counterparts, suppliers, etc…)? If “Yes”, please explain.		Yes	No
DM	F	Will the Project (or Subproject) seek any industry standards (e.g. ISO 140000, 18001, 22000, EMAS, SA 8000, HACCP, OHSAS 18001) and/or voluntary certifications (e.g. Fairtrade International, U.N. Global Compact)? If “Yes”, please identify and explain.		Yes	No

PART IIB – PROJECT (OR SUBPROJECT) COUNTRY EFFECTS

(For Financial Services Projects (or Subprojects))

	PROJECT (OR SUBPROJECT) COUNTRY EMPLOYMENT
DM/L	A	Please provide the current number of Project (or Subproject) employees, and how many employees will be hired as a result of the OPIC-supported investment.
			Current Number of Permanent Employees				Number of Permanent Employees Hired by the Project (or Subproject) by Year Five of Operation as a Result of this OPIC-Supported Investment
			Local		Expatriate
			Male	Female	Male	Female	Local	Expatriate
	Managerial
	Professional/ Technical
	Unskilled Labor
	TOTAL

	PROJECT (OR SUBPROJECT) SOCIAL IMPACTS
DM	A	As a result of this OPIC-supported investment, will the Project (or Subproject) implement initiatives (either corporate or transactional) which are directed at restoring and/or preserving the environment? If “Yes”, please explain (e.g. paperless banking, favorable financing terms for Project (or Subproject) clients engaging in activities which preserve the environment, etc…).				Yes	No
DM/L	B	Does (or will) the Project (or Subproject) provide ancillary benefits or services to the local community (i.e. philanthropic and/or charitable initiatives not directly related to the business operations of the Project Company)? If “Yes”, please select the benefits that apply and describe the specifics of each program.				Yes	No
			Recreational facilities		Scholarship programs
			Schools		Charitable donations/activities
			Medical clinics		Other (please specify):      

	PROJECT (OR SUBPROJECT) HUMAN RESOURCE MANAGEMENT
P	A	Does (or will) the Project (or Subproject) have written human resources policies?	Yes	No
P	B	If “Yes”, please indicate the areas covered by the human resources policies:
DM/L		Benefits (e.g. healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare, etc…).	Yes	No
		If “Yes”, please list which Project (or Subproject) benefits are above and beyond what is required by Project (or Subproject) Country law:
P		Mechanism(s) for workers’ to express grievances (e.g., direct access to supervisors and/or the human resources department, workers’ committees, and/or trade unions reps, or an anonymous hotline).	Yes	No
P		General conditions of work that, in the minimum, comply with local applicable labor laws ((e.g., limits on hours of work, wages (including premium or overtime pay), sick leave, collective bargaining agreements, etc…)).	Yes	No
P		Disciplinary procedures.	Yes	No
P	C	Does (or will) the Project (or Subproject) have a Human Resources Department and/or Manager?	Yes	No
P	D	Does (or will) the Project (or Subproject) have management experience in applying international labor standards, such as those in the IFC Performance Standards or as part of certifications (e.g., Fair Trade Certified, SA8000, or Rainforest Alliance)?	Yes	No

	PROJECT (OR SUBPROJECT) LABOR-RELATED ISSUES
	Does (or will) the Project (or Subproject) involve the following?
P	A	Migrant or foreign workers (excludes expatriate management or highly-skilled non-manual workers).	Yes	No
P	B	Workers under the age of 18 ((directly or indirectly employed by the Project (or Subproject)).	Yes	No
P	C	Known use of harmful child labor at the Project (or Subproject) or (if applicable) in the Project’s (or Subproject’s) primary supply chain.	Yes	No
P	D	Known use of forced labor at the Project (or Subproject) or (if applicable) in the Project’s (or Subproject’s) primary supply chain.	Yes	No
P	E	Retention of foreign workers’ (directly or indirectly employed) passports	Yes	No
P	F	Restructuring which results in a major retrenchment (lays off significant numbers of workers).	Yes	No
P	G	Known non-compliance with local laws or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits).	Yes	No
P	H	Labor-related lawsuits against the Project (or Subproject).	Yes	No
P	I	Labor unrest in the last three years in the form of strikes or other general industrial disputes.	Yes	No
P	J	Ongoing or unresolved issues/disputes with a Project (or Subproject) trade union.	Yes	No

	PROJECT (OR SUBPROJECT) TECHNOLOGY AND KNOWLEDGE TRANSFER
	Please indicate if the Project (or Subproject) will include any of the following technology and knowledge transfer factors in the Project (or Subproject) Country. Where applicable, please indicate whether any of these factors are new or uncommon in the Project (or Subproject) Country and provide details.
DM/L	A	Management practices (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM/L	B	Marketing and distribution techniques (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM	C	Production or processing technologies (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM/L	D	Financial product and/or services (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DM	E	Will the Project (or Subproject) provide technical assistance (e.g. training of customers, industry counterparts, suppliers, etc…)? If “Yes”, please explain.		Yes	No
DM	F	Will the Project (or Subproject) seek any industry standards and/or voluntary certifications (e.g. Equator Principles, U.N. Global Compact)? If “Yes”, please identify and explain.		Yes	No

	PROJECT (OR SUBPROJECT) PORTFOLIO – TRANSACTION TYPE AND AMOUNTS
DM	A	Please identify the type of Project (or Subproject) transactions supported by the OPIC-supported investment.
		     %	Loans (non-mortgages)	     %	Leasing contracts
		     %	Mortgages	     %	Equity investments
		     %	Insurance contracts	     %	Other (please specify):      
DM	B	Please provide the following portfolio information and projections.				Current Portfolio	Projected OPIC-supported portfolio
		Number of Project (or Subproject) transactions per year
		Value of Project (or Subproject) outstanding portfolio				$	$
		Average transaction size per client over the last year				$	$
		Maximum transaction size to a single client over the last year				$	$
		Minimum transaction size to a single client over the last year				$	$
		Median transaction size to a single client over the last year				$	$

	PROJECT (OR SUBPROJECT) PORTFOLIO – CLIENT PROFILE
	Please respond the following questions with figures that represent the Project’s (or Subproject’s) portfolio supported by this OPIC-supported investment.
DM	A	Economic segments of clients as a percentage of the portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		Consumers (not including mortgages)	%	%
		Microenterprises	%	%
		Small & Medium Enterprises	%	%
		Large Corporations	%	%
		Other (please specify):      	%	%
DM	B	Purpose of the transactions as a percentage of the portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		Start-Up Capital	%	%
		Working Capital	%	%
		Expansion Capital	%	%
		Equipment Purchase	%	%
		Other (please specify):      	%	%
DM	C	Business activities/sectors of clients as a percentage of the portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		Manufacturing	%	%
		Agriculture	%	%
		Construction	%	%
		Transportation and Communication	%	%
		Consumer	%	%
		Tourism	%	%
		Trade/Retail	%	%
		Energy	%	%
		Services (please specify):	%	%
		Other (please specify):      	%	%
DM/L	D	Duration of transactions as a percentage of the portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		< 6 months	%	%
		7 – 12 months	%	%
		13 – 24 months	%	%
		25 – 36 months	%	%
		36 – 60 months	%	%
		> 60 months	%	%
DM/L	E	Demographic distribution of clients as a percentage of the portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		Percentage of clients that are women (or women-managed businesses).	%	%
		Rural	%	%
		Urban	%	%
		Other (please specify):	%	%

	8. PROJECT (OR SUBPROJECT) MORTGAGE PORTFOLIO – CLIENT PROFILE
	Please provide the following figures:
DM	A	Mortgage maturity period as a percentage of the mortgage portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		< 5 years	%	%
		6-10 years	%	%
		11 - 15 years	%	%
		16 – 20 years	%	%
		> 20 years	%	%
DM	B	Purpose of the mortgages as a percentage of the mortgage portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		Mortgages for new homeowners	%	%
		Productive loan (e.g. home equity loan/line of credit)	%	%
		Other (please specify):      	%	%
DM	C	Target market of mortgages as a percentage of the mortgage portfolio.	Current Portfolio	Projected OPIC-supported portfolio
		Low-income homes	%	%
		Middle-income homes	%	%
		High-income homes	%	%
		Residential rental properties	%	%
		Commercial properties	%	%
		Other (please specify):      	%	%
DM/L	D	Demographic distribution of clients as a percentage of the mortgage portfolio.
		Percentage of clients that are women (or women-managed businesses).	Current Portfolio	Projected OPIC-supported portfolio
		Urban	%	%
		Rural	%	%

PART III – EFFECTS OF PROJECT (OR SUBPROJECT) ON THE U.S. ECONOMY

	PROJECT (OR SUBPROJECT) COUNTRY REGULATORY ENVIRONMENT
S	A	Does (or will) the Project (or Subproject) occupy a monopoly position in any of its markets?	Yes	No
		If “Yes”, please explain.
S/P	B	Does (or will) the Project (or Subproject) Country government have majority ownership or effective management control of the Project (or Subproject)?	Yes	No
		If “Yes”, please explain.
S	C	Are there any Project (or Subproject) Country performance requirements (e.g., local content requirements, minimum export requirements, maximum import requirements, or local hiring requirements) that might affect Project (or Subproject) imports, exports, or employment?	Yes	No
		If “Yes”, please explain.
DM	D	Does (or will) the Project (or Subproject) result from or cause any Project (or Subproject) Country reforms, new legislation, or new regulations?	Yes	No
		If “Yes”, please explain.

	INITIAL SOURCES OF PROJECT (OR SUBPROJECT) FUNDING
			Debt	Equity	Other	TOTAL
L	A	OPIC:	$	$ N/A	$	$
L	B	Applicant (or Financial Intermediary):	$	$	$	$
		What amount, if any, is from an offshore non-U.S. source?	$	$	$
L	C	U.S. sources other than Applicant (or Financial Intermediary) (please specify source and amounts per source):	$	$	$	$
		What amount, if any, is from an offshore non-U.S. source?	$	$	$
L	D	Project (or Subproject) Country sources (please specify source and amounts per source)	$	$	$	$
L	E	Non-U.S. and non-Project (or Subproject) Country sources (please specify sources, countries, and amounts per country):	$	$	$	$
L	F	Development Finance Institutions (e.g. International Finance Corporation, Inter-American Development Bank, etc.)	$	$	$	$
L	G	Other sources (please specify):	$	$	$	$
L	H	INITIAL PROJECT (OR SUBPROJECT) FUNDING TOTAL :	$	$	$	$

	INITIAL USES OF PROJECT (OR SUBPROJECT) FUNDING
	Refers to expenditures financed by the Project (or Subproject) Funding Total included in Question 2G above.
DM/L	A	Purchased or spent in the Project (or Subproject) Country	$
S/L	B	Purchased from the U.S.	$
L	C	Purchased from countries other than the Project (or Subproject) Country or the U.S. (please specify countries and amounts per country)	$
L	D	Miscellaneous Project (or Subproject) costs included not related to the procurement of assets/services (please specify what these costs represent, the countries in which these costs are incurred, and amount per country).	$
L	E	TOTAL INITIAL PROJECT (OR SUBPROJECT) FUNDING USES:	$

	INITIAL PROJECT (OR SUBPROJECT) U.S. PROCUREMENT
S/L	Please list items to be procured from the U.S. from Question 3B, above. Also ensure that the total in Question 3B, equals the total, below.
	Supplier	City, State	ZIP Code	Enterprise Characteristics		Product	Product Description	Procurement Amount ($)
				Small Enterprise? Minority Owned? Women Owned?	Yes No Don’t Know Yes No Don’t Know Yes No Don’t Know	New Used Don’t Know
	TOTAL

	OPERATIONAL PROJECT (OR SUBPROJECT) FUNDING
L	A	Will the Project (or Subproject) procure goods and services from the U.S on an on-going basis after the Project (or Subproject) is fully operational?	Yes	No
DM/L	B	Will the Project (or Subproject) procure goods and services from Project (or Subproject) Country sources on an on-going basis after the Project (or Subproject) is fully operational?	Yes	No
		If “Yes”, please provide the average annual amount of operational procurement from Project (or Subproject) Country sources as a result of this OPIC-supported investment.	$
		Please also briefly describe the goods and/or services that will be procured by these funds.

	OPERATIONAL PROJECT (OR SUBPROJECT) U.S. PROCUREMENT
S/L	Please list items to be procured from the U.S. once the Project (or Subproject) is fully operational. Figures provided below should be annual averages over a five year time horizon after the Project (or Subproject) becomes fully operational.
	Supplier	City, State	ZIP Code	Enterprise Characteristics		Product	Product Description	Procurement Amount ($)
				Small Enterprise? Minority Owned? Women Owned?	Yes No Don’t Know Yes No Don’t Know Yes No Don’t Know	New Used
	TOTAL

	7. PROJECT (OR SUBPROJECT) SALES AND PRODUCTION
S/L	A	Please provide current total sales figures as well as additional sales figures expected or projected as a result of this OPIC-supported investment.
	Product		Current Production Capacity				Increase in Production Capacity as a result of this OPIC-Supported Investment			Total Expected Production Capacity
			Current Sales Value ($)		Current Volume (Units)		Incremental Sales Value ($)		Incremental Volume (Units)	Total Sales Value ($)	Total Volume (Units)
	TOTAL
	B	Do you currently export or plan to export any of your production?								Yes	No
S/L	C	Please provide sales to export markets expected as a result of this OPIC-supported investment:
	Product		Country	% of Exports	Current Exports		Increase in Exports as a result of this OPIC-Supported Investment			Total Expected Exports
					Current Sales Value ($)	Current Volume (Units)	Incremental Sales Value ($)	Incremental Volume (Units)		Total Sales Value ($)	Total Volume (Units)
	TOTAL

	8. PROJECT (OR SUBPROJECT) PAYMENTS
DM/L	A	Please provide total Project (or Subproject) Country tax, royalty, and fee payments.
	Country		Current Annual Payment Figure	Projected Increase in Annual Payment Figure as a Result of this OPIC-Supported Investment	Total Expected Annual Payments
	Project (or Subproject) Country
	TOTAL
DM/L	B	If the Project (or Subproject) is eligible for a tax holiday, indicate the duration of the tax holiday.			___ year(s)
DM/L	C	If duties and/or tax payments to Project (or Subproject) Country government will be reduced as a result of the Project (or Subproject), please estimate the amount lost.			$____

	9. FINANCIAL OUTFLOW FROM PROJECT (OR SUBPROJECT) COUNTRY
S/L	In each column, estimate the Project (or Subproject) average annual financial outflow from the Project (or Subproject) Country over a five year time horizon. Please only report those outflows related to this OPIC-supported investment.		Remittance to the U.S.	Remittance to Other Countries (please specify countries)
	A	OPIC Payments	$	$
	B	Other Loan Principal and Interest (from U.S. or other lenders)	$	$
	C	Lease Payments	$	$
	D	Return on Initial Capital Investment	$	$
	E	Annual Fees (other than OPIC fees, please specify)	$	$

24