Form OPIC-115 Application for Financing

Application for Financing (Form 115)

OMB No. 3420-0015

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, 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. Information in Form SF-LLL will be reported to Congress and available for public inspection.

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 Agency Clearance Officer, Records Management, Overseas Private Investment Corporation, 1100 New York Ave., NW, Washington, DC, 20527 and Wendy Liberante, Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503.

QUESTION 1: IDENTIFY THE PROJECT COMPANY/BORROWER

OPIC provides direct loans and loan guaranties that are used to undertake long-term investment projects (each a “Project”) in OPIC eligible countries (each a “Project Country”) [link to country list]. The entity that directly undertakes the Project in the Project Country (the “Project Company”) may also be the entity that has the direct borrowing relationship with OPIC or is the direct beneficiary of an OPIC-guaranteed loan (the “Borrower”), but sometimes they are different entities, depending upon the proposed structure of the transaction. Please list the location and contact information for the Project Company and Borrower.

	 Same as Project Company
Project Company	Borrower
Name:	Name:
Address (incl. city and country):	Address (incl. city and country):
Office Phone Number:	Office Phone Number:
Fax Number:	Fax Number:
E-mail:	E-mail:
Is the address of the Project Company the location of the Project? (Yes/No)
If “No,” please list the specific location of the Project (city, country):

QUESTION 2: IDENTIFY THE Authorized Representative

Please provide contact information for the individual who will be signing the completed application; i.e. shareholder in or executive of the Project Company or Borrower, etc.

Name and Title of Representative:

Relationship to the Project Company or Borrower: (Change this to a drop-down box)

Name of Representative’s Company (if different from the Project Company/Borrower)

Address:

Phone Number:

Fax Number:

E-mails:

QUESTION 3: IDENTIFY tHE OWNERS of the PROJECT COMPANY/Borrower

Please list ultimate beneficial owners of the Project Company. For example, if the Project Company is wholly owned by another company, and that other company is owned 50-50 by two individuals, that other company is the intermediate owner of the Project Company (with 100% direct ownership), and the two individuals are the ultimate beneficial owners of the Project Company (each having 50% indirect beneficial ownership). The table below allows you to list each direct owner, and if applicable, to list each indirect owner under the relevant direct owner. You need not list any party that owns (directly or indirectly) less than 5% of the Project Company. For owners with less than 5%, state “Multiple, less than 5%” and list the sum of their ownership shares so that you may account for 100% of the Project Company ownership. Click here for an example: (insert link).

If there is more than one layer of ownership (i.e. some of the ownership is indirect) please attach a diagram showing the ownership structure [link to upload function].

Please note that to be eligible for OPIC Financing, the Project Company/Borrower must be at least 50.1% (i.e. majority) owned by private entities (i.e. a government or parastatal entity is not the majority owner) and must have the meaningful involvement of the U.S. private sector (see Question 4).

Direct Owner Name	Country of Citizenship (for Individuals) or Incorporation (for Entities)	Email Address	Percent Direct Ownership of Project Company/Borrower	Ownership of this Entity includes Entities that Indirectly Own 5% or more of the Project Company/Borrower
				Y/N
				Y/N
				Y/N
			100%	Y/N

QUESTION 4: IDENTIFY THE U.S. CONNECTIONS.

For a Project to qualify for OPIC Financing, there must be meaningful involvement of the U.S. private sector (the “Qualifying Sponsor(s)”) with the Project.

How does OPIC define U.S.? (any one of the following)

• Any for-profit entity organized in the United States with at least 25% of its equity/share capital U.S. owned.

• Any for-profit entity organized outside the United States with more than 50% of its equity/share capital U.S. owned

• U.S. citizens or lawful permanent residents (i.e. Green Card holders).

• Any non-profit entity that is organized in the United States.

How does OPIC measure meaningful U.S. involvement?

• OPIC generally requires U.S. involvement in the Project Company/Borrower in an amount that is equivalent to at least 25% of the equity/share capital of the Project Company/Borrower.

• The 25% benchmark may be met with equity investment (ownership/contribution), long-term debt investment in the Project or other U.S. contracts (e.g. construction contracts) or by combining these types of involvement in the Project among one or more Qualifying Sponsors.

• Other forms of involvement (e.g. franchise or long-term management contracts) may be considered – please discuss with an OPIC staff member, if applicable.

How does OPIC measure the duration of U.S. involvement?

• For an on-going project, Qualifying Sponsor(s) must retain a 25% interest in the Project through final disbursement of the OPIC supported loan.

• In the case of a start-up (or “Greenfield”) project Qualifying Sponsors must retain a 25% interest through physical completion of the Project.

Please list the Qualifying Sponsor(s) information (including a U.S. state of residence or incorporation and zip code) and the nature of each entity’s involvement with the Project.

Name	State	Zip Code	Telephone	Email	Nature of Contribution (Ownership %, other – describe)	Interested in OPIC PRI?1
						(checkbox)

QUESTION 5: CATEGORIZATION OF U.S. PARTIES INVOLVED WITH THE PROJECT

OPIC Finance’s support for a Project Company/Borrower can take the form of a direct loan or a loan guaranty. By law, only those Projects that significantly involve a U.S. small business are eligible for the direct loan product. The loan guaranty product is open to all eligible Project Companies/Borrowers.

How does OPIC define U.S. Small Business?

• A small business is an enterprise with annual revenues during the last fiscal year of less than $400 million, or for those entities/individuals without revenues, a net worth less than or equal to $100 million OR

• An enterprise with 500 or fewer employees.

In making the determination of whether an entity is a small business, please take into consideration the revenues, worth and employees of all majority-owned affiliates. Also, if the enterprise is majority-owned by another business (but not funds or individuals), include the consolidated revenues, worth and employees, as applicable.

Please list all Qualifying Sponsors that fall into any of these categories.

Sponsor Name	Small Business	Minority-Owned	Women-Owned
	Yes/No	Yes/No	Yes/No

QUESTION 6: Project Description

Please provide a brief description of the Project, making sure to address the following items:

• Does the Project involve the start-up of a new business or is it the expansion of an existing operation? Does it involve the privatization of an operation previously owned/managed by a government entity? If it is an expansion of an existing operation or a privatization, please provide basic operational and financial information (number of years of operation, most recent level of annual sales, size of asset base, number of employees).

• What product(s) or services(s) will the Project produce/sell and what are the target markets? (local, export – list specific countries, as applicable.)

• Why do the Project’s investors/managers believe that this will be a commercially successful endeavor? What positive social/developmental impact(s) do they expect from the Project?

QUESTION 7: Project Costs

Please list the types and estimated amounts of all Project costs. Please be as specific as possible and remember to include estimates of any applicable project development/transaction costs (e.g. engineering or other consulting services, market studies, legal fees, financing fees, etc.) For expansions of existing operations, include only the costs associated with the expansion.

	US$	%
	$	%
	$	%
	$	%
	$	%
	$	%
Total Project Costs	$	100%

QUESTION 8: Project Funding

Please indicate sufficient sources of funding to cover 100% of the Project costs indicated in Question 7. The types listed below are sample categories for your reference. You may edit the categories as necessary to match the types of funding specific to your Project.

	US$	%
Debt:	$	%
OPIC loan (indicate proposed term)	$	%
Other term debt (indicate proposed term and collateral)	$	%
Supplier financing	$	%
Subordinated Debt:
Shareholder subordinated loans	$	%
Third party subordinated debt	$	%
Equity:	$	%
Cash	$	%
In-kind contribution2
Other (please describe)	$	%
Total Project Funding	$	100%

QUESTION 9: WHAT Collateral and/OR Credit Enhancements ARE AVAILABLE

OPIC requires a collateral/credit enhancement package (the “Security Package”) tailored to the specific risks of each Project. The purpose of this Security Package is to provide a secondary source of repayment if the Project’s cash flow is insufficient to service the debt as scheduled. Following are indicative categories of collateral/credit enhancement that OPIC may require. Please indicate below those categories that may be available (check all that apply):

____ Pledge of shares of the Project Company/Borrower

____ Liens/Mortgages on Project Company/Borrower assets (Specify types/locations: ___________)

____ Liens/Mortgages on U.S. assets (Specify types/locations: _____________)

____ Guaranties from creditworthy individuals or companies (Specify name(s) of guarantor(s): ____)

____ Irrevocable standby letter(s) of credit

____ Debt Service Reserve Account

____ “Key Man” Life Insurance

____ Other (describe:____________________________)

QUESTION 10: Management Experience and Track Record

Briefly describe relevant experience that the investors/shareholders and/or key Project managers have in the Project sector and Project Country. For each individual listed below please specify that person’s relationship to the Project (i.e. shareholder, CEO, etc.)

Question 11: Private Sector Sources of Financing

OPIC does not compete with private sector providers of project financing. Therefore, OPIC requires that Project developers: (a) evaluate the possibility of obtaining project financing from private sources and (b) decide to pursue OPIC financing because private financing is not available on terms sufficient to make the investment viable or because of specific benefits OPIC participation will bring to the investment.

Have you evaluated the possibility of obtaining financing for the Project from private sector sources?	Yes	No
Have you determined that private sector financing is not a viable option for the Project?	Yes	No
If Yes, please list the reasons why private sector financing is not a viable option for the Project (check all that apply): ____ Private Sector financing is not available at all in the Project Country. ____ Private Sector financing is available, but not on terms (tenor, pricing) that would be viable for the Project. ____ Other (describe):

QUESTION 12: HOW DID YOU LEARN ABOUT OPIC?

OPIC is interested in knowing what types of communications about its programs are most effective. Please select the source of your initial information about OPIC:

____ OPIC’s website or other social media (Twitter, Facebook, etc.)

____ OPIC-sponsored workshop or event (Name of event________________)

____ OPIC speaker at an industry event (Name of event_________________)

____ Other US Government Agency (e.g. State/Embassy, Commerce, Treasury, TDA, DOD, USEXIM, etc.) (insert a dropdown box with choices)

____ Referred by financial or legal advisor (Name of advisor ______________)

____ Referred by portfolio facility manager (Name of facility manager___________________)

____ Past or present OPIC client. (Name of client _______________________)

____ Other (describe: ______)

SUBMISSION Page

Select OPIC Loan Origination Officer

Please select a recipient to receive your application materials. If you are already working with an OPIC loan origination officer, please select their name from the menu below. If not, please select “Officer not assigned” and your application will be forwarded to the OPIC officer who reviews all incoming applications.

Officer Name: (drop-down list)

Note: At the bottom of every page of the electronic form, there is a link that will allow the applicant to attach supporting documentation. A list of the essential supporting documentation requested by OPIC is as follows:

SUPPORTING DOCUMENTATION

Please submit the following documents in support of your application:

1. Financial Statements of each of the primary shareholders contributing equity or debt to the Project Company and/or for the Project Company itself if it is already operating. Financial statements should include a balance sheet, income statement, and cash flow statement (preferably prepared in accordance with U.S. Generally Accepted Accounting Principles (“U.S. GAAP”) or International Financial Reporting Standards (“IFRS”). Financial Statements must be prepared in English or accompanied by a certified English translation. Listed below are the types of financial statements that should be submitted for each type of entity:

For an existing Project Company: - Annual Financial Statements (audited, if available; most recent 3 years)

- Quarterly Financial Statement (most recent quarter)

For a public corporation: - 10K (most recent 3 years)

- 10Q (most recent quarter)

For a private corporation: - Annual Financial Statements (audited, if available; most recent 3 years)

- Quarterly Financial Statement (most recent quarter)

- Tax Returns (most recent 3 years)

For a partnership: - Annual Financial Statements (audited, if available; most recent 3 years)

- General Partner information, including (i) current signed Statement of Net Worth (assets, liabilities, net worth) and (ii) ownership

For an individual: - Current Signed Personal Financial Statement (assets, liabilities, net worth)

- Tax Returns (most recent 3 years)

2. Bank and Trade References (For each private corporation, partnership or individual, please provide three bank references and three trade references.)

3. Complete Business Plan/Preliminary Information Memorandum

The following checklist details the items to include in the business plan. Please provide as complete a business plan as possible.

Project Summary

• Project Description/Status (Describe the purpose for which the OPIC loan is to be used and the Project development activities completed to date -- the Project Company’s date of incorporation, investment made to date, market or feasibility studies performed, status of documentation/permits/government consents/land acquisition, etc.)

• Financial Plan and Credit Support (Describe the proposed OPIC and other lender debt -- loan amount, tenor, grace period -- and source, timing and amount of equity contributions; describe proposed collateral and other credit support)

Project Ownership and Management

• Ownership of the Project Company (provide complete Project Company ownership, including all holding companies or intermediary operating companies, and electronically attach an ownership chart, if available)

• Project Developers (list primary shareholders developing the Project and the professional expertise of such individuals, including experience in the Project country)

• Project Management (describe Project Company management structure and professional expertise of individuals in key management positions)

• Consultants/Advisors (list consultants or advisors to the Project Company, detailing the addresses, contact and role of such consultants or advisors and work or reports completed to date)

Project Sector/Target Market/Economics

• Sector/Industry (describe history, sector reform, recent market trends, competition, supply and demand, pricing, market position of Project Company (at time of market entry and long-term), etc.)

• Product/Services (describe the products or services the Project will produce, in what quantity, and whether for the local market or for export (and if for export, to which countries)

• Project Economic/Technical Specifications (describe Project economics, technical parameters, construction plans/schedule, equipment/land to be procured, off-take arrangements, etc.)

• Agreements (list all key operating agreements necessary to undertake the Project such as concession agreement(s), construction contract(s), offtake agreement(s), environmental impact studies, feasibility studies, marketing studies, technical assistance agreement(s), management services agreement(s), lease(s), etc. (and attach electronically if possible)

Legal, Economic, Political Environment and Government Participation

• Licenses/Permits (list all licenses, permits, consents, approvals, environmental requirements etc. required by the Project Country government and the status of such documentation)

• Legal Regime (list Project country laws, regulations or pending reforms that will impact the Project or the sector)

• Economic/Political Climate (describe the economic and political climate of the Project Country and the specific region in which the Project is located)

• Government/Multilateral Participation (describe any government or multilateral involvement in the Project or the sector and any government incentives such as tax holidays)

• Current or Pending Litigation (describe all current or pending disputes or litigation involving the Project or the Project Company, or shareholders)

Project Strengths/Risks and Risk Mitigation

• Strengths (describe those factors that strengthen the Project economics and contribute to the long-term viability of the Project)

• Risks (describe Project risks such as credit risks, sector/market risks and competition, operational and management risks, political/economic risks, legal/regulatory risks and what steps the Project Company will take to mitigate such risks)

4. Financial Model (Please electronically attach a detailed model of financial projections of the Project over the requested term of the OPIC loan. Describe the primary financial model assumptions and justification for such assumptions. If the Project is an expansion please ensure that the model includes that last two fiscal years of operations as the basis for the projections.)

The model should include detailed assumptions as to the Project’s budget, revenue, expenses, financing terms, timing of equity contributions, loan disbursement schedule, etc. The model must include an income statement, balance sheet and cash flow statement projecting the financial performance of the Project over the life of the OPIC loan. The model must also include the calculation of the following ratios Cash Flow to Debt Service, Current Assets to Current Liabilities, Total Indebtedness to Tangible Net Worth, Return on Assets, and Internal Rate of Return.

OPIC FORM 115 Certifications and Signature Page

TRANSPORTATION INSURANCE CERTIFICATION

OPIC seeks to ensure that American insurance companies have an opportunity to compete for transportation insurance business associated with the export of goods to projects supported by OPIC programs. To encourage fair and open competition for this business, OPIC requires certain certifications from investors receiving its support. Please complete section A, B, or C below, whichever is applicable.

A. No such certification is required from an Applicant that does not have a controlling interest in fact in the Project Company.³ If the Applicant does not have a controlling interest in fact in the Project Company, please check the box below.

□The Applicant does not have a controlling interest in fact in the Project Company.

B. In those instances where the Applicant does have or will have a controlling interest in fact in the Project Company, OPIC requires that the Applicant certify that each contract for the export of goods from the United States in connection with the establishment of the Project contain a clause requiring that United States insurance companies have a fair and open competitive opportunity to provide insurance against risk of loss for such export of goods. If the Applicant is able to so certify, please check the box below.

□ The undersigned certifies that each contract for the export of goods from the United States in connection with the establishment of the Project does have or will have a clause requiring that U.S. insurance companies have a fair and open competitive bid opportunity to provide insurance against risk of loss for such exports.

C. In those instances where the Applicant does have or will have a controlling interest in fact in the Project Company, but is unable to provide the certification requested immediately above, please check one of the boxes below and provide details, explaining why you cannot do so at this time. In providing an explanation, please make specific references, as applicable, to project country, legal or other impediments.

□ Laws of the project country prohibit use of American insurance services for transportation insurance.

□ There are no U.S. exports associated with the establishment of this Project.

□ All transportation insurance associated with the export of U.S. goods to the Project is or will be arranged through the Applicant’s worldwide insurance program. It is not practicable to alter these arrangements for U.S. exports to the Project.

□ All transaction insurance associated with the export of U.S. goods to the Project is or will be arranged by a Project participant who is other than the Applicant under such Project participant’s insurance provider(s). It is not practicable to alter these arrangements for U.S. exports to the Project.

□ Other (Please explain):

DUN & BRADSTREET D-U-N-S NUMBER

A Dun and Bradstreet D-U-N-S^® Number is a unique nine-digit sequence for each physical location of a business, with an optional 4 digit extension for some locations. OPIC uses the D-U-N-S Number to facilitate public reporting requirements applicable to OPIC’s programs, so all applicants must provide one to OPIC prior to the issuance of an OPIC financing commitment. D-U-N-S Number assignment is FREE. A D-U-N-S number may be obtained by accessing the following website: http://fedgov.dnb.com/webform

Please provide the Dun & Bradstreet D-U-N-S Number for the entity that will be the Borrower under the proposed OPIC financing:

REQUIRED

OPTIONAL

ANTI-LOBBYING CERTIFICATION⁴

FOR THOSE APPLYING FOR OPIC DIRECT LOANS

All government agencies, including OPIC, are required by law to obtain from applicants for direct loans in excess of $150,000 a certification that no federal funds have been or will be paid to any Person for influencing or attempting to influence a Member of Congress, Congressional staff, or employee of the Executive Branch in connection with their loan applications. Federal law prohibits federal funds, including OPIC loan proceeds, from being used to pay outside lobbyists or the salaries of applicant’s regular employees who are engaged in lobbying activities with respect to the applicant’s loan application. Payments to consultants, lawyers, accountants, or other Persons, including the applicant’s regular employees, for professional or technical services regarding the loan application are not prohibited. Applicants for federal loans in excess of $150,000 must also agree that if they use other than federal funds to hire an outside lobbyist to seek to influence approval of their application, they will file with the lending agency a disclosure form, Standard Form LLL - Disclosure of Lobbying Activities, which identifies the lobbyist who has been retained. On the following pages are the following documents: Certification Regarding Lobbying for Applicants for OPIC Direct Loans, described above (which must be signed and returned to OPIC) which contains a commitment that, if the undersigned has been or will be paying a lobbyist to attempt to influence OPIC's decision on its application, the undersigned company will file Standard Form LLL - Disclosure of Lobbying Activities. The Person who signs the certification on behalf of the undersigned company may be the Person who will sign the loan agreement with OPIC or anyone else with authority to make such a certification on behalf of the undersigned. Standard Form LLL - Disclosure of Lobbying Activities, which must be completed and filed with OPIC only if a lobbyist has been or will be paid to attempt to influence OPIC’s action on the undersigned’s application.

CERTIFICATE REGARDING LOBBYING FOR APPLICATIONS FOR OPIC DIRECT LOANS

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any Person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any of any cooperative agreement, or the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan or cooperative agreement.

2. If any funds have been paid or will be paid, to any Person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to guarantee or insure a loan, the undersigned shall complete and submit Standard Form LLL - Disclosure of Lobbying Activities, in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

Submission of this statement is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. §1352. Any Person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Company Name/Name of Individual (as applicable)

­­­­­­­­­­     

Signature of Certifying Official (as applicable)

Title of Certifying Official (as applicable)

     

FOR THOSE APPLYING FOR OPIC LOAN GUARANTIES

All government agencies, including OPIC, are required by law to obtain from applicants for loan guaranties in excess of $150,000 a statement regarding whether they have used or intend to use a lobbyist to attempt to influence approval of their applications. A lobbyist is someone other than the applicant’s regular employee who is retained not to provide technical or professional services regarding the application but to attempt to use influence through written or oral communications with Members of Congress, Congressional staff, or employees in the Executive Branch. If an applicant for a loan guaranty has used or intends to use a lobbyist to attempt to influence action on its application, the applicant is also required to file with the agency a Standard Form LLL - Disclosure of Lobbying Activities, which identifies the lobbyist who has been retained. On the following pages are the following documents: Statement Regarding Lobbying Activities for Applicants for OPIC Loan Guaranties (which must be signed and returned to OPIC) which contains a commitment that, if the undersigned has been or will be paying a lobbyist to attempt to influence OPIC's decision on its application, the undersigned company will file Standard Form LLL - Disclosure of Lobbying Activities. The Person who signs the Statement on behalf of your company may be the Person who will sign the finance agreement, or anyone else with authority to make such a statement on behalf of the undersigned. (ii) Standard Form LLL - Disclosure of Lobbying Activities, which must be completed and filed with OPIC only if a lobbyist has been or will be paid to attempt to influence OPIC’s action on the undersigned’s application.

CERTIFICATION REGARDING LOBBYING FOR APPLICANTS FOR OPIC LOAN GUARANTIES

If any funds have been paid or will be paid, to any Person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to guarantee or insure a loan, the undersigned shall complete and submit Standard Form LLL – Disclosure of Lobbying Activities, in accordance with its instructions.

Submission of this statement is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. §1352. Any Person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Company Name/Name of Individual (as applicable)

­­­­­­­­­­     

Signature of Certifying Official (as applicable)

Title of Certifying Official (as applicable)

     

STANDARD FORM-LLL
SELF-DISCLOSURE OF LOBBYING ACTIVITIES
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. §1352.
1	Type of Federal Action: Contract Grant Cooperative Agreement Loan Loan Guarantee Loan Insurance
2	Status of Federal Action: Bid/Offer/Application Post-Award
3	Report Type: Initial Filing Material Change -- Year, quarter or date of last report:
4	Reporting Entity: Prime Subawardee -- Tier, if known:      
	Name:      
	Address:      
	City:      	State:      	Zip:      
	Congressional District, if known :      
5	Reporting Entity in No. 4 is a Subawardee, enter the Name and Address of the Prime.
	Name:      
	Address:      
	City:      	State:      	Zip:      
	Congressional District, if known :      
6	Federal Department/Agency :      
7	Federal Program Name/Description :
	CFDA Number, if applicable:      
8	Federal Action Number, if known :      	9	Award Amount, if known :      

10	A	Name of lobbying entity (if an individual, last name, first name, MI):      
		Address:      
		City:      	State:      	Zip:      
	B	Name of individual performing services (including address if different from 10A) (last name, first name, MI):
		Address:      
		City:      	State:      	Zip:      
Signature:
Print Name:      
Title:      
Tel. No.:      
Information requested through this form SF-LLL is authorized by title 31 U.S.C §1352. This disclosure of lobbying activities is a material representation of fact upon which reliance was placed by the tier above when the transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. §1352. This information will be reported to the Congress semi-annually and will be available for public inspection. Any Person who fails to file the required disclosure shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
FEDERAL USE ONLY:

OPIC FORM 115 – APPLICATION FOR FINANCING

SIGNATURE PAGE

I certify that the statements and information provided herein are true to and correct to the best of my knowledge and belief

Name of Authorized Representative:
Signature:	Date:
Title of Authorized Representative:

1 Tooltip Text: OPIC offers Political Risk Insurance that covers a variety of political risks, including political violence, expropriation and currency inconvertibility.  Please check each box to indicate which Sponsors listed would like to learn more about OPIC’s political risk insurance program and availability of coverage for this project.

2 An in-kind contribution could be a hard asset such as a building or equipment. In order for OPIC to credit it as an equity contribution, it must be titled to the Project Company/Borrower, and OPIC must receive reasonable documentation of its market value (e.g. a recent appraisal, sales invoice, etc.)

3 Having a “controlling interest” means having possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of an entity, whether through the ownership of partnership interests or voting security, by contract or otherwise.

4 Applicants will receive either the direct loan or the loan guaranty language, whichever is relevant to their transaction.