Form OPIC-162 Self-Monitoring Questionnaire

SELF-MONITORING QUESTIONNAIRE for Finance, Insurance, Reinsurance, and Investment Funds Projects

Form: OPIC-162

OMB Number: 3420-0019

Expiration Date:

Overseas Private Investment Corporation

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

An Agency of the United States Government

Please read the following information carefully. This form requests information from OPIC clients, which is required annually by OPIC’s governing legislation. The information provided in this questionnaire will allow OPIC to better assess the impact of OPIC-assisted projects on the U.S. economy and employment, as well as the impact on host country economic development and the effects on the environment and workers’ rights 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 confidential commercial information in accordance with OPIC’s Freedom of Information Act (FOIA) regulations (22 CFR part 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 retain benefits. Public reporting burden for this collecting of information is estimated to average four 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 Records Manager, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527; and to the OPIC Desk Office of Information and Regulatory Affairs,, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

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

GETTING STARTED

Welcome to OPIC’s Self-Monitoring Questionnaire (SMQ). As the U.S. Government’s development finance institution, OPIC takes its developmental mission seriously. The SMQ is an integral part of the OPIC monitoring and oversight function as it enables OPIC to collect data on the environmental, social, and long-term development impacts of each OPIC-supported project (or subproject). Additionally, data collected in the SMQ are aggregated and used to satisfy OPIC’s U.S. Congressional reporting requirements.

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

The SMQ must be completed on-line (click button below). To submit the SMQ on-line, you will be asked to enter the project type, contract number, and password. The OPIC contract number is provided annually in reminder e-mails sent to you by OPIC staff, and the password is created by each individual SMQ respondent. If you do not know your contract number, have forgotten your password, or encounter any other difficulties with the SMQ process, please e-mail the SMQ Helpdesk at [email protected].

Please answer all questions as completely as possible. If space is inadequate, please supply additional information on separate sheets of paper and attach them to your electronic submission in Part IV of the process. For all questions, the terms “Project” and “Financial Intermediary” refer to the investment supported by the OPIC insurance or reinsurance contract and/or finance agreement identified by contract number herein.

Some questions and bolded terms found in the SMQ may not be familiar. Should you need it, the document entitled, “Guidelines for completing the OPIC Self-Monitoring Questionnaire” provides detailed instructions and definitions of terms. If you do not have a copy of this document, please e-mail the SMQ Helpdesk at [email protected].

For your reference, a PDF of the entire SMQ can be found here.

To initiate the on-line process, please click on the “Self-Monitoring Questionnaire” button below.

SELF MONITORING QUESTIONNAIRE START BUTTON

The Self-Monitoring Questionnaire (SMQ) is divided into two sections: Section A and Section B. Please note that only one of these sections needs completion. The electronic form will automatically direct you to the relevant section, depending on your response to question 2A in Part I (this question distinguishes the industry of the OPIC-supported project as Financial Services or Non-Financial Services).

Section A is to be completed by all OPIC Finance, Insurance and Reinsurance projects, and by all OPIC Investment Fund portfolio companies and framework agreement/on-lending facility subprojects unless this is a Financial Intermediary transaction (see below).

Section B is to be completed by Financial Intermediary transactions. As such, 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.

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

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 including insurance companies, 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, investment, or insurance from an OPIC-supported Financial Intermediary.

PART I – PROJECT (OR SUBPROJECT) SUMMARY

PROJECT (OR SUBPROJECT) INFORMATION
A	Project (or Subproject) Name:
B	Contract/loan #:
C	What percentage of the Project (or Subproject) ownership is locally-owned (i.e. the percentage of ownership in the Project (or Subproject) held by citizens of the host country)?				____%
	Is any of the local ownership comprised of Small & Medium Enterprises (SME)?			Yes	No
	If “Yes”, please provide what percentage of local ownership is comprised of Small & Medium Enterprises.				____%
	Is any of the local ownership comprised of women-owned and/or managed businesses?			Yes	No
	If “Yes”, please provide what percentage of local ownership is comprised of women-owned and/or managed businesses.				____%
D	Does the Project (or Subproject) involve other Development Finance Institutions (DFIs)?			Yes	No
	If “Yes,” please indicate which DFIs below
	Multilateral (e.g. World Bank, International Finance Corporation)		Regional (e.g. InterAmerican Development Bank, Asian Development Bank, European Bank for Reconstruction and Development)
	Bilateral (e.g. FMO, CDC)		Other (please specify below)

E	Do any of the U.S. investors in the Project (or one of its subsidiaries or affiliates) currently produce the same product(s) as that produced by this Project?		Yes	No
	If “Yes”, has the number of U.S. employees engaged in the U.S. production of this product been 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?		________
F	What is the total value of remittances (dividends, profits, loans/interest, royalties, etc.) from the project?
	To the United States	$     
	To other countries, excluding the U.S. and the Host Country?	$     
G	What was the value of the Project’s final destination sales to the following: (If multiple product lines, please provide information on each product on a separate sheet.)		N/A
	The Host Country	$     
	The U.S.	$     
	Other countries in descending order of value):
		$     
		$     
		$     

PROJECT (OR SUBPROJECT) DESCRIPTION
A	Project (or Subproject) Industry		Financial Services					Non-Financial Services
B	Description of the Project (or Subproject) and its operations:
C	Has the Project (or Subproject) description changed since it was originally approved by OPIC?								Yes	No
	If “Yes”, please indicate the changes below:
	New business lines				Exited markets
	New products or services				Exited product lines or services
	New international markets				Other:
D	Has the Project (or Subproject) become operational?								Yes	No
	If “Yes,” please provide the date the Project (or Subproject) became operational.								_____/______/____ Day / Month / Year
E	Please specify the Project’s (or Subproject’s) most recently completed fiscal year and use data from this year to complete the rest of this form.					Starting Date MM/YYYY			Ending Date MM/YYYY
F	What is the Project’s (or Subproject’s) target client or customer? Please specify.
	Please provide the number of clients or customers currently served by the Project (or Subproject).								_______

PROJECT (OR SUBPROJECT) SITING
A	Project (or Subproject) City and Country:
B	Project (or Subproject) Site Location (please include GPS coordinates):

PART II A – PROJECT (OR SUBPROJECT) COUNTRY EFFECTS

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

PROJECT (OR SUBPROJECT) EMPLOYMENT

A

Please provide the current number of Project (or Subproject) employees.

Current Number of Permanent Employees

Temporary Employees

Local

Expatriate

Construction Employees

Seasonal Employees

Male

Female

Male

Female

Local

Expatriate

Local

Expatriate

Managerial

Professional/ Technical

Unskilled Labor

TOTAL

B

Has the Project (or Subproject) utilized workers employed by third parties (i.e., through contractors/subcontractors) since the Project (or Subproject) became operational?

For physical construction

For administrative needs

For other operational needs

PROJECT (OR SUBPROJECT) EMPLOYEE TRAINING
A	Has the Project (or Project Company) provided 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 have been provided to the managerial, professional/technical, and/or unskilled personnel.
B	How many permanent employees received training described in item 2A above this reporting year?			______

PROJECT (OR SUBPROJECT) CONSTRUCTION LABOR
A	If physical construction is involved, has construction already begun?		Yes		No		Not Applicable
	If “Yes”, 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	Has the Project (or Subproject) required the establishment of temporary worker housing facilities?			Yes		No
	If “Yes”, how many workers are housed at these facilities?					______

ENVIRONMENTAL AND SOCIAL BENEFITS
A	As a result of this OPIC-supported investment, has the Project (or Subproject) implemented initiatives (either corporate or project-related) that are directed at restoring and/or preserving the environment?				Yes	No
	If “Yes”, please describe.
B	Does 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)?				Yes		No
	If “Yes”, please select the benefits that apply:
		Recreational facilities		Scholarship programs
		Schools		Charitable donations/activities
		Medical clinics		Other:      
	Describe the specifics of each program indicated above.

HUMAN RESOURCE MANAGEMENT
A	Does the Project (or Subproject) have written human resources policies?		Yes	No
B	Please indicate the areas covered by the human resources policies:
	Benefits (e.g. healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare, etc).		Yes	No
		If “Yes”, please list which of these benefits, if any, are above and beyond what is required by Project (or Subproject) Country law:
	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
	General conditions of work that, at 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
	Disciplinary procedures.		Yes	No
C	Does the Project (or Subproject) have a Human Resources Department and/or Manager?		Yes	No
D	Does 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

LABOR-RELATED ISSUES
Does the Project (or Subproject) currently involve the following?
A	Migrant or foreign workers (excludes expatriate management or highly-skilled non-manual workers).	Yes	No
B	Workers under the age of 18 (directly or indirectly employed by the Project (or Subproject).	Yes	No
	If “Yes,” please briefly describe the general duties of these workers and include the age of the youngest worker.
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
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
E	Retention of foreign workers’ (directly or indirectly employed) passports.	Yes	No
F	A major retrenchment (i.e., lay-offs of significant numbers of workers).	Yes	No
G	Known non-compliance with local laws, OPIC labor-related requirements, or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits).	Yes	No
H	Labor-related lawsuits against the Project (or Subproject).	Yes	No
I	Labor unrest in the last year in the form of strikes or other general industrial disputes.	Yes	No
	If “Yes,” please briefly describe the nature of the strike and list the start and end dates of the strike.
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) has included any of the following technology and/or knowledge transfer factors in the Project (or Subproject) Country. Where applicable, please indicate whether any of these factors were new or uncommon in the Project (or Subproject) Country and provide details.
A	Management practices	New	Uncommon		No
	If “New” or “Uncommon”, please describe.
B	Marketing and/or distribution techniques	New	Uncommon		No
	If “New” or “Uncommon”, please describe.
C	Production and/or processing technologies	New	Uncommon		No
	If “New” or “Uncommon”, please describe.
D	Products and/or services	New	Uncommon		No
	If “New” or “Uncommon”, please describe.
E	Has the Project (or Subproject) provided technical assistance (e.g. training of customers, industry counterparts, suppliers, etc…)?		Yes	No
	If “Yes”, please describe:
F	Has the Project (or Subproject) received any industry standard certifications (e.g. ISO 140000, 18001, 22000, EMAS, SA 8000, HACCP, OHSAS 18001) and/or voluntary certifications (e.g. Fairtrade International, U.N. Global Compact)?		Yes	No
	If “Yes”, please identify and describe:

ENVIRONMENTAL IMPACT
A	Is the Project currently in compliance with all conditions in the OPIC contract or consent with respect to environment, health and safety?	Yes			No
	If “No”, please describe the areas of non-compliance.
B	Has the Project been cited or fined for any violation of local or host country environmental, health or safety laws?	Yes			No
	If “Yes”, please explain briefly below.
C	Has the Project submitted all OPIC-required reports on environment, health and safety?	Yes		No		Not Applicable
	If “Yes”, please list reports and dates of transmission of the reports.
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
D	Have there been any changes in the design or capacity of the Project that result in increased hazards to workers, area residents, or the environment?	Yes			No
	If yes, please describe briefly below.
E	Have any accidents occurred that resulted in loss of human life or material impacts on the environment?	Yes			No
	If so, describe briefly below.

PROJECT (OR SUBPROJECT) COUNTRY REGULATORY ENVIRONMENT
A		Has the Project (or Subproject) resulted from or caused any Project Country reforms, new legislation, or new regulations?				Yes	No
		If “Yes”, please explain.
	B	Does the Project (or Subproject) involve a public-private partnership? If “Yes”, please indicate below the type of party involved, the name of each party, and describe how each party indicated is involved in the Project (or Subproject).				Yes	No
			Project Country government entity:      		International non-governmental organization:      
			Local non-governmental organization:      		Other:      

OPERATIONAL PROJECT (OR SUBPROJECT) FUNDING
A	Has the Project (or Subproject) procured goods and services from Project country sources on an on-going basis since the Project (or Subproject) became fully operational?	Yes	No
	If “Yes”, please provide the average annual amount of operational procurement from Project country sources as a result of this OPIC-supported investment.	$
	Please also briefly describe the goods and/or services that have been procured by these funds.

PROJECT (OR SUBPROJECT) PAYMENTS
A	How much did the Project (or Subproject) pay to the host country government in duties, taxes, and other payments in the last fiscal year?	$______________
B	If the Project (or Subproject) is eligible for a tax holiday, indicate the duration of the tax holiday.	___ year(s)
C	If duties and/or tax payments to Project country government have been reduced as a result of the Project (or Subproject), please estimate the amount lost.	$____

PART II B – PROJECT (OR SUBPROJECT) COUNTRY EFFECTS

(For Financial Services Projects (or Subprojects))

PROJECT (OR SUBPROJECT) COUNTRY EMPLOYMENT
A	Please provide the current number of Financial Intermediary employees.
		Current Number of Permanent Employees
		Local				Expatriate
		Male			Female	Male			Female
Managerial
Professional/ Technical
Unskilled Labor
TOTAL
B	Has the Financial Intermediary utilized workers employed by third parties (i.e., through contractors/subcontractors) since the Project (or Subproject) became operational?
	For physical construction			For administrative needs				For other operational needs

ENVIRONMENTAL AND SOCIAL BENEFITS
A	As a result of this OPIC-supported investment, has the Financial Intermediary implemented initiatives (either corporate or transactional) which are directed at restoring and/or preserving the environment?				Yes	No
	If “Yes”, please describe (e.g. paperless banking, favorable financing terms for Project (or Subproject) clients engaging in activities which preserve the environment, etc).
B	Does the Financial Intermediary 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)?				Yes	No
	If “Yes”, please select the benefits that apply:
		Recreational facilities		Scholarship programs
		Schools		Charitable donations/activities
		Medical clinics		Other (please specify):      
	Describe the specifics of each program indicated above.

HUMAN RESOURCE MANAGEMENT
A	Does the Financial Intermediary have written human resources policies?		Yes	No
B	Please indicate the areas covered by the human resources policies:
	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:
	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
	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
	Disciplinary procedures.		Yes	No
C	Does the Financial Intermediary have a Human Resources Department and/or Manager?		Yes	No
D	Does the Financial Intermediary 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

LABOR-RELATED ISSUES
Does the work of the Financial Intermediary currently involve the following?
A	Migrant or foreign workers (excludes expatriate management or highly-skilled non-manual workers).	Yes	No
B	Workers under the age of 18 ((directly or indirectly employed by the Project (or Subproject)).	Yes	No
	If “Yes,” please briefly describe the general duties of these workers and include the age of the youngest worker.
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
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
E	Retention of foreign workers’ (directly or indirectly employed) passports.	Yes	No
F	A major retrenchment (i.e., lay-offs of significant numbers of workers).	Yes	No
G	Known non-compliance with local laws, OPIC labor requirements, or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits).	Yes	No
H	Labor-related lawsuits against the Financial Intermediary.	Yes	No
I	Labor unrest in the last year in the form of strikes or other general industrial disputes.	Yes	No
	If “Yes,” please briefly describe the nature of the strike and list the start and end dates of the strike.
J	Ongoing or unresolved issues/disputes with a Financial Intermediary trade union.	Yes	No

TECHNOLOGY AND KNOWLEDGE TRANSFER
Please indicate if the Financial Intermediary has incorporated 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.
A	Management practices	New	Uncommon	No
	If “New” or “Uncommon”, please describe.
B	Marketing and distribution techniques	New	Uncommon	No
	If “New” or “Uncommon”, please describe.
C	Production or processing technologies	New	Uncommon	No
	If “New” or “Uncommon”, please describe.
D	Financial product and/or services	New	Uncommon	No
	If “New” or “Uncommon”, please describe.
E	Has the Financial Intermediary provided technical assistance (e.g. training of customers, industry counterparts, suppliers, etc…)?		Yes	No
	If “Yes”, please describe.
F	Has the Financial Intermediary received any industry standard certifications and/or voluntary certifications (e.g. Equator Principles, U.N. Global Compact, SMART Campaign Client Protection Principles)?		Yes	No
	If “Yes”, please identify and describe.

ENVIRONMENTAL IMPACT
A	Is the Financial Intermediary currently in compliance with all conditions in the OPIC contract or consent with respect to environment, health and safety?	Yes		No
	If “No”, please describe the areas of non-compliance.
B	Has the Financial Intermediary been cited or fined for any violation of local or host country environmental, health or safety laws?	Yes		No
	If “Yes”, please explain briefly below.
C	Has the Financial Intermediary submitted all OPIC-required reports on environment, health and safety?	Yes		No
	If “Yes”, please list reports and dates of transmission of the reports.
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
D	Have there been any changes in the design or capacity of the Financial Intermediary that result in increased hazards to workers, area residents, or the environment?	Yes		No
	If yes, please describe briefly below.
E	Have any accidents occurred that resulted in loss of human life or material impacts on the environment?	Yes		No
	If so, describe briefly below.

PROJECT (OR SUBPROJECT) COUNTRY REGULATORY ENVIRONMENT
A		Has the Project resulted from or caused any Project Country reforms, new legislation, or new regulations?				Yes	No
		If “Yes”, please explain.
	B	Does the Project involve a public-private partnership? If “Yes”, please indicate below the type of party involved, the name of each party, and describe how each party indicated is involved in the Project.				Yes	No
			Project Country government entity:      		International non-governmental organization:      
			Local non-governmental organization:      		Other:      

PROJECT PAYMENTS
A	How much did the Project pay to the host country government in duties, taxes, and other payments in the last fiscal year?	$______________
B	If the Project is eligible for a tax holiday, indicate the duration of the tax holiday.	___ year(s)
C	If duties and/or tax payments to Project country government have been reduced as a result of the Project, please estimate the amount lost.	$____

TOTAL LOAN PORTFOLIO – TRANSACTION TYPE AND AMOUNTS

A

Please identify the type of transactions supported by the Financial Institution

     %

Loans (non-mortgages)

     %

Leasing contracts

     %

Mortgages

     %

Equity investments

     %

Insurance contracts

     %

Other (please specify):      

B

Please provide the following information on your total loan portfolio.

Total Loan Portfolio

Number of Project (or Subproject) transactions per year

Value of Project (or Subproject) outstanding portfolio

$

Average transaction amount per client.

$

Maximum transaction amount to a single client.

$

Minimum transaction amount to a single client.

$

Median transaction amount to a single client.

$

TOTAL PORTFOLIO – CLIENT PROFILE

A

Economic segments of clients as a percentage of the total loan portfolio.

B

Purpose of the transactions as a percentage of the total loan portfolio.

     %

Consumers (not including mortgages)

     %

Start-Up Capital

     %

Microenterprises

     %

Working Capital

     %

Small & Medium Enterprises

     %

Expansion Capital

     %

Large Corporations

     %

Equipment Purchase

     %

Other (please specify):      

     %

Other (please specify):      

B

Business activities/sectors of clients as a percentage of the total loan portfolio.

     %

Manufacturing

     %

Tourism

     %

Agriculture

     %

Trade/Retail

     %

Construction

     %

Energy

     %

Transportation and Communication

     %

Services (please specify):

     %

Consumer

     %

Other (please specify):      

Duration of transactions as a percentage of the total loan portfolio.

     %

< 6 months

     %

25 – 36 months

     %

6 – 12 months

     %

37 – 60 months

     %

13 – 24 months

     %

> 60 months

C

Demographic distribution of clients as a percentage of the total loan portfolio.

     %

Percentage of clients that are women (or women-managed businesses).

     %

Urban

     %

Rural

     %

Other (please specify):

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

SUSTAINABILITY
A	For your latest fiscal year, please provide one or more of the following repayment performance measures that are applicable to the Financial Intermediary:
	     %	Portfolio At Risk (PAR) Ratio
	     %	Write-off Ratio
	     %	Other:      
B	For your latest fiscal year, please provide one of the following profitability measures that is applicable to the Financial Intermediary:
	     %	Return on Investment
	     %	Operational Self-Sufficiency Ratio
	     %	Other:      

PART III – U.S. Supplier and Procurement Information

As indicated on the cover page, the client data you provide is privileged business information that OPIC treats as confidential to the extent permitted by law. However, it is important for OPIC to be able to demonstrate some of the effects of your project. The historical supplier and procurement information is useful for OPIC to illustrate the specific benefits of your project for the U.S. economy. Unless you provide an attached sheet with a compelling reason why this information should not be made public, OPIC intends to use the information in public statements and releases.

Please check all that apply below

Name of U.S. Supplier

City

State

Zip Code

Minority-owned business

Woman- owned business

U.S. small business

Type of Good or Service Please indicate if used (refurbished)

Amount Procured Most Recent Fiscal Year

Acme, Inc.

Any town

NY

12345

Widgets

$ 100,000

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

Remaining Procurement

$     

Totals

$     

PART IV – Investor / Representative Certification

Section A - Investor/Representative Certification (for Non-financial Services Projects or Subprojects)

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 Project (or Subproject).
Signature:	Date:	Telephone:      
Name and Title:      		Email address:      

Section B - Investor/Representative Certification (for Financial Services Projects or Subprojects)

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 Financial Intermediary.
Signature:	Date:	Telephone:      
Name and title:      		Email address: