Personal Financial Statement

Forms and Documents

Document Name	Status
Form OPIC-254 Personal Financial Statement Form	New
OPIC 254 - Supporting Statement [FINAL 150108].doc Supporting Statement A	2015-01-09

IC Document Collections

IC ID	Document Title	Status
213862	Personal Financial Statement Form	New

ICR Details

OMB Control No: 3420-0035	ICR Reference No: 201411-3420-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: OPIC	Agency Tracking No: OPIC-254
Title: Personal Financial Statement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/09/2015
	Date Received in OIRA: 11/13/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved
Responses	75	0	0
Time Burden (Hours)	75	0	0
Cost Burden (Dollars)	5,625	0	0

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Abstract: Individual sponsors of OPIC-supported projects would use this form to provide a detailed breakdown of their current personal balance sheet (assets, liabilities and net worth), any contingent liabilities and their income stream. OPIC personnel would utilize this information to evaluate the individual sponsor's ability to meet their financial obligations (such as guaranty of completion) with regard to the OPIC-supported project.

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Authorizing Statute(s): US Code: 22 USC 234(d) Name of Law: Foreign Assitance Act of 1961
  

Citations for New Statutory Requirements: US Code: 22 USC Section 234 (d) Name of Law: Foreign Assistance Act if 1961

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 51377	08/28/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 67208	11/12/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Personal Financial Statement	OPIC-254	Personal Financial Statement

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	75	0	0	75	0	0
Annual Time Burden (Hours)	75	0	0	75	0	0
Annual Cost Burden (Dollars)	5,625	0	0	5,625	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The personal financial statement is considered supporting documentation to the OPIC application for financing, but it is only requested if a sponsor of the project being financed is an individual (rather than a corporate entity) and that individual is providing equity investment in or other credit support to the project. OPIC officers generally do not request that individual project sponsors provide personal financial statement information until the officers have already reviewed the application for financing and determined that the application has a high probability of advancing to the underwriting phase. So, though OPIC currently receives approximately 200 applications for financing on an annual basis, approximately 120 of them will make it to the underwriting phase, and half of those applications will not involve any individual sponsors. Therefore, assuming that 60 active applications have individual sponsors and that some will have more than one individual sponsor from whom the OPIC officer requires personal financial information in order to complete the underwriting, OPIC can conservatively estimate that it may elicit up to 75 personal financial statement forms per year.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/13/2014

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