Form OPIC-254 Personal Financial Statement

OVERSEAS PRIVATE INVESTMENT CORPORATION

PERSONAL FINANCIAL STATEMENT

OPIC Form 254

OMB [ ]

Expiration: _______

Disclosures and Notices Please retain a copy for your records.

This form is used to assist OPIC in determining whether a project and its sponsor(s) meet eligibility criteria for OPIC loans or guaranties. The Foreign Assistance Act of 1961, Title IV, as amended (“FAA”) (codified at 22 U.S.C. § 2191 et seq.) requires OPIC to evaluate the project and its sponsors’ creditworthiness, qualifications, and legislative & regulatory compliance before extending support. Complete and accurate responses to the questions are necessary for OPIC to properly evaluate your application for support.

The information provided is used by OPIC to determine the strength of the underlying credit support for the associated project. OPIC may share the information in this form as permitted by law, including the Freedom of Information Act (FOIA). Financial information in this form will be deemed designated as “confidential commercial information” in accordance with OPIC’s FOIA regulations, 22 C.F.R. Part 706, and will be treated as confidential commercial information to the extent permitted by law. Personal information belonging to an individual will not be released under the FOIA unless the information is already public or if the public interest is greater than the private interest under 5 U.S.C. § 552(b)(6).

You are not required to provide your social security number. If you choose not to provide your social security number, OPIC may be unable to fully evaluate your finances and, therefore, your project’s financial soundness. As part of determining whether a project is economically and financially sound, OPIC looks to the financial status of those providing equity or collateral support. Providing your social security number will assist OPIC in verifying your financial status by running a credit check, and to distinguish you from other individuals with the same or similar name or other personal identifiers.

This is notice of OPIC’s right to access financial records held by financial institutions that are or have been doing business with you or your business under the Right to Financial Privacy Act of 1978. The law provides that OPIC shall have a right of access to your financial records in connection with its consideration or administration of assistance to you in the form of a loan or loan guaranty to your project. OPIC is required to provide a certificate of its compliance with the Act to a financial institution in connection with its first request for access to your financial records, however no further certification is required for subsequent access. OPIC’s access rights continue for the term of any approved loan or guaranty agreement. No further notice to you of OPIC’s access rights is required during the term of any such agreement. The law also authorizes OPIC to transfer to another Government authority any financial records included in an application for a loan, or concerning an approved loan or guarantee, as necessary to process, service, or foreclose on a loan guaranty or collect on a defaulted loan guaranty.

Information 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, a misrepresentation or a failure to disclose relevant information may result in criminal prosecution under 22 U.S.C. §2197(n), a statute providing for penalties of up to $1,000,000 and 30 years in prison in cases of fraud against OPIC. Misrepresentations or omissions will also result in a default or termination if a commitment is issued.

START

Paperwork Reduction Act Notice: This is a voluntary information collection, however, failure to complete this form may result in OPIC’s inability to complete review of the associated project’s application. OPIC may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB number. The public reporting burden for this collection of information is estimated to average 1 hour 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 to the Records Manager, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527; and to the OPIC Desk Office at the Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

□ I acknowledge that I have read the disclosure and notices above.

Individual Identification and Contact Information

Full Legal Name (required)
Social Security Number:
Residence Address (required):
Business Phone:
Residence Phone:
Mobile Phone:
Email Address (required):

Assets and Liabilities Summary as of [date]

Assets

Asset Description	USD Equivalent Value	Owned Jointly?1 (Y/N)
Cash on hand and in Banks (liquid accounts)
IRA(s) or Other Retirement Account(s)
Stocks and Bonds (Publicly Traded)
Equity Ownership Interests (Private Companies)
Accounts and Notes Receivable
Life Insurance – Cash Surrender Value Only
Real Estate (current market value)
Vehicles and other Personal Property
Other Assets
Total Assets

Liabilities and Net Worth

Liability Description	USD Equivalent Value	Joint Obligation? (Y/N)
Accounts Payable
Notes Payable to Banks and Others
Mortgages Loans on Real Estate
Taxes Payable
Other Liabilities
Total Liabilities
Net Worth
Total Liabilities and Net Worth

Assets Detail: Please provide detail for each asset class listed in the summary.

Cash In Banks
Name and Location of Bank	Approx. Balance
Total

IRA(s) and Other Retirement Account(s)
Account Fiduciary Institution	Approx. Balance
Total

Stocks and Bonds (Publicly Traded)
Name of Security	Fiduciary Institution	Approx. Balance
Total

Equity Ownership Interests (Private Companies)
Name of Company	Portion of Equity Owned (%)	Are the shares/ interests freely transferable2? (Y/N)	Approx. Value
Total

Accounts and Notes Receivable
Name of Debtor	Approx. Balance
Total

Life Insurance – Cash Surrender Value Only
Name of Issuing Firm	Approx. Value
Total

Real Estate
Address	Description	Approx. Value
Total

Vehicles and Other Personal Property
Description	Current Location	Value net of liens
Total

Other Assets
Description	Approx. Value
Total

Liabilities Detail: Please provide detail for each liability class in the summary.

Accounts Payable
Name of Creditor	Approx. Balance
Total

Notes Payable to Banks and Others
Name of Creditor	Approx. Balance
Total

Mortgages on Real Estate
Address of Property	Name of Creditor	Approx. Balance
Total

Taxes Payable
Taxing Authority	Approx. Balance
Total

Other Liabilities
Description	Approx. Balance
Total

Contingent Liabilities

A contingent liability is a potential obligation that may be incurred depending upon the outcome of a future event. For instance, if an individual has co-signed/guaranteed a loan or is the defendant of litigation, they have a contingent liability. Please list all contingent liabilities and the estimated amount of the potential obligation. If there are no contingent liabilities, list “None.”

Contingent Liabilities
Description	Est. Potential Obligation
Total

Source(s) of Income

Please provide information regarding your income for the most recent three (3) calendar years.

Source(s) of Income
	20__	20__	20__
Salary
Net Investment Income
Real Estate Income
Other (description:______________________)
Total

Signature Page

[ ] I consent to OPIC and its agents running a report of my credit record and using the information from that report in determining whether to provide government support for __(project name)__.

I certify that the above information, submitted to obtain OPIC support for a project application, gives a correct representation of my financial condition as of this date. I further certify that the above representations and all supporting documentation are true, accurate, and complete. This Personal Financial Statement has been made for the purpose of applying for OPIC support of a project application and may be relied upon by OPIC as a true statement of the facts contained herein. If I become aware that any of the information in this Personal Financial Statement was incorrect at the time of submission, I agree to provide the updated information in writing to OPIC immediately.

Printed Name of Individual

Signature of Individual

Date

PRINT COMPLETED FORM

1 If any assets are co-owned with another party or any liabilities are joint liabilities, please attach a separate sheet listing the joint assets/liabilities and the names of the co-owners/co-obligors.

2If shares/ownership interests are “freely transferable,” that means that the owner may sell or transfer them without getting permission from other parties. Some private companies have restrictions on sales or transfers, which limits the liquidity of the asset.