OPIC-248 Marked up version of form

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: https://www.opic.gov/who-we-are/our-investment-policies.

http://www.opic.gov/doing-business/investment.

OFFICE OF INVESTMENT POLICY QUESTIONNAIRE

OPIC-248

OMB 3420-0032

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 2.4 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 to Records Manager, Overseas Private Investment Corporation 1100 New York Ave., 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, D.C. 20503. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to Essie BryantRecords Manager, Agency Clearance Officer, 1100 New York Ave., NW, Washington, DC, and to the OPIC Desk Office of Information and Regulatory Affairs 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”, “Project”, “Project Company”, and “Financial Intermediary”, “Project”, and “Subproject” are based on definitions given to them in Appendix D of OPIC’s Environmental and Social Policy Statement, as referenceddefined below:

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

Project – A long-term investment in one or more OPIC eligible countries, including investments made by an OPIC-supported Financial Intermediary. All facilities owned or controlled within a physical project boundary that constitute a commercially viable business unit eligible for OPIC support, including a project or enterprise that receives financing, investment, or insurance from an OPIC-supported Financial Intermediary.

Project Company -- The entity that directly undertakes the Project, which may or may not be the direct beneficiary of OPIC’s support (depending on the proposed structure of the transaction).

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

Subproject – A project or enterprise that receives financing, investment, or insurance 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 Performance Standards and Environmental, Health and Safety Guidelines.

PART I – PROJECT (OR SUBPROJECT) SUMMARY

INVESTMENT

FUNDS

REINSURANCE

INSURANCE

FINANCE

Please click on the appropriate OPIC product line:

PROJECT (OR SUBPROJECT) INFORMATION
A	Applicant (or Financial Intermediary) Name:
B	Project (or Subproject) Name:
C	Target percentage ownership of Applicant (or Financial Intermediary) in the Project (or Subproject).		____%
D	Please provide the estimated percentage of local ownership of the Pproject, if any.		____%
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.		____%
F	Do women-owned businesses account for any local ownership?	Yes	No
	If Yes, please provide the percentage of local ownership that is comprised of women-owned and/or managed businesses.		____%
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 Project?	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 U.S. employees are currently employed by such U.S. company or its subsidiaries or affiliates that produce this product?	________

PROJECT (OR SUBPROJECT) DESCRIPTION
A	Please check appropriate box for the Project:	Financial Services		Non-Financial Services
B	Please check appropriate box for the Project:	New Enterprise (no existing facilities and/or operations)		Existing Enterprise
C	Project (or Subproject) City and Country
D	Describe the use of proceeds of this OPIC-supported investment:
E	Description of the Project (or Subproject) and its operations:
C	Does (or will) the Project (or Subproject) involve construction?				Yes	No
D	Does (or will) the Project (or Subproject) involve seasonal labor?				Yes	No
	If Financial Services, please proceed to Part II (B)

F	If Non-Financial Services, please check the appropriate Project sector classification:
	Agriculture/Agribusiness
	If Agriculture/Agribusiness, please answer the following questions:		Current	Projected by 5th year
	Average agricultural yield (tonne/hectare)		# (tonne per hectare)	# (tonne per hectare)
	Number of farmers that are currently linked to the Project as:
	Employees		#	#
	Suppliers		#	#
	Buyers		#	#
	Contractors		#	#
	Education
	If Education, please answer the following questions:		Current	Projected by 5th year
	Number of students enrolled		#	#
	Number of local students enrolled (excluding children of expatriates)		#	#
	Number of needs-based scholarships for local students (per year)		#	#
	Energy
	If Energy, please answer the following question:		Current	Projected by 5th year
	Energy delivered to offtaker(s) per year (GWh)		#GWh	#GWh
	Health
	If Health, please answer the following question:		Current	Projected by 5th year
	Number of patient consultations provided per year		#	#
	Housing
	If Housing, please answer the following questions:		Current	Projected by 5th year
	Number of new residential dwellings		#	#
	Number of refurbished residential dwellings		#	#

	Information & Communications Technologies
	If “Information & Communications Technologies”, please answer the following questions:	Current	Projected by 5th year
	Number of mobile subscriptions, including voice and/or data	#	#
	Number of fixed data subscriptions	#	#
	Number of fixed voice (telephone) subscriptions	#	#
	Transportation
	If Transportation” please answer the following questions:	Current	Projected by 5th year
	Units of cargo containers transported through the road/railway/port/airport per year (twenty foot equivalent units)	# TEUs	# TEUs
	Tons of bulk cargo transported through the road/railway/port/airport per year	# tons	# tons
	Passengers using transportation service per year	#	#
	Waste & Sanitation
	If Waste & Sanitation, please answer the following questions:	Current	Projected by 5th year
	Amount of waste disposed per year (tons)	# tons	# tons
	Volume of wastewater treated per year (m³)	# m³	# m³
	Water
	If Water, please answer the following questions:	Current	Projected by 5th year
	Volume of potable water produced per year (m³)	# m³	# m³

	Other
	If Other, please answer the following questions:
	Please describe the Project sector, with appropriate North American Industry Classification code
	What is the Project’s target client or customer?
	Please provide the number of clients or customers currently served by the Project per year	_________#
	Please provide the expected number of clients or customers served by the Project per year as a result of this OPIC-supported investment (by 5th year)	_________#
E	Describe the use of proceeds of this OPIC-supported investment:
F	Description of the Project (or Subproject) and its operations:
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
A	Project (or Subproject) Site Location (please include GPS coordinates and, if available, a map of site location):
B	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
A	Please indicate if the Project (or Subproject) involves any of the following:
	Construction of a dam or weir.	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
	If Yes, please estimate the number of people affected.	___________#
	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

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 Construction Employees Seasonal Employees

Local

Expatriate 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

1.    PROJECT OPERATIONS AND MANAGEMENT EMPLOYMENT

A

Please provide the current and projected number of Project employees for operations & management (not including employment during the construction phase) by the 5th year of operations.

Current Employment (Operations and Management)

Projected Employment (Operations & Management) by the 5th year of operations as a result of this OPIC-Supported Investment

Total Projected Employment (Operations & Management) by the 5th year of operations

Local

Foreign Nationals

Male

Female

Local

Foreign Nationals

Local

Foreign Nationals

Managerial

Professional/

Technical

Unskilled Labor

TOTAL

B

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

Yes

No

For physical construction

For administrative needs

For other operational needs

23. PROJECT (OR SUBPROJECT) CONSTRUCTION LABOR
A	If physical construction is involved, has construction already begun?						Yes	No
	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	Please provide the current and projected number of Project (or Subproject) employees during the construction phase.
		Employment (Construction Phase )
		Local			Foreign nationals
Managerial
Professional/Technical
Unskilled Labor
TOTAL
BC	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
CD	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?

32. JOB QUALITY PROJECT (OR SUBPROJECT) EMPLOYEE TRAINING
A		Does or Wwill the Project (or Project Company) provide training above and beyond standard on-the-job trainingoffer employee development programs, such as tuition reimbursement or formal mentorships to both current and new permanent non-management employees identified above in Question 1A of Part IIIabove?	Yes				No
		If Yes, please describe what type of training opportunities will be provided to the managerial,employee development programs will be available to professional/technical, and/or unskilled personnel.
B	Does or Wwill the Project offer other employee benefits that exceed local legal requirements to both current and new non-management employees identified above in Question 1A above?			Yes		No
	If Yes, please provide a list of employee benefits that exceed local law that are or will be available to non-management personnel:
BC		Please provide what percentage of new permanent employees will receive training. Please provide the average monthly wage (in local currency) that is or will be paid to full-time equivalent unskilled employees identified in Question 1A above.			____local currency/month
CD		Please provide the average monthly wage (in local currency) that is or will be paid to full-time equivalent professional/technical employees identified in Question 1A above.			__ local currency/ month

4. PROJECT (OR SUBPROJECT) ENVIRONMENTAL AND SOCIAL IMPACTS
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?	Yes	No
	If Yes, please explain. (e.g., paperless banking, favorable financing terms for Project (or Subproject) clients engaging in activities which preserve the environment, etc…).

B	Does (or will) the Project contribute money towards activities that benefit local communities (e.g., recreational facilities, schools, medical clinics, scholarship programs, other charitable activities)?	Yes	No
	If Yes, please provide the actual or expected annual budget for these activities and describe these activities.	_____$/year

B	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:      

C	Does the Project (or Subproject) have an Environmental and Social Management System (ESMS)?	Yes	No
	If Yes, please attach a copy of the ESMS (in English).	Yes	No

5. PROJECT (OR SUBPROJECT) HUMAN RESOURCE MANAGEMENT
A	Does (or will) the Project (or Subproject) have written human resources policies?	Yes	No
B	If Yes, 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 union reps, anonymous hotline, etc).	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	Are terms of employment clearly communicated to each worker? Does (or will) the Project (or Subproject) have a Human Resources Department and/or Manager?	Yes	No
	If Yes, please describe how employment terms are (or will be) communicated to each worker and attach verifying documentation, such as a sample employment contract.
	If Yes, please indicate the person who is (or will be) responsible for implementing the Project Company’s human resource policies.
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
	If Yes, please specify.

6. PROJECT (OR SUBPROJECT) LABOR-RELATED ISSUES
Does (or will) the Project (or Subproject) involve the following?
A	Migrant or foreign workers (excludes excluding foreign nationalexpatriate 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
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
CF	Restructuring which results in a major retrenchment (i.e., lays off significant numbers of workers).	Yes	No
	If Yes, please describe.

DG	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
	If Yes, please describe.
E	Is there an onsite trade union?	Yes	No
	If Yes, what percentage of workers are covered by a collective bargaining agreement?	____%
	If Yes, please attach a copy of the collective bargaining agreement, if applicable.
FH	Labor-related lawsuits against the Project (or Subproject).	Yes	No
	If Yes, please describe.
GI	Labor unrest in the last three years in the form of strikes or other general industrial disputes.	Yes	No
	If Yes, please describe.
HJ	Ongoing or unresolved issues/disputes with a Project (or Subproject) trade union.	Yes	No
I	Is there onsite security?	Yes	No
	If Yes, are security guards armed?	Yes	No
	Is security publically or privately contracted?	Publicly Contracted	Privately Contracted

7. TECHNOLOGY AND KNOWLEDGE TRANSFERBUSINESS INNOVATION
Please indicate if the Project (or Subproject) will operationalize a product, process, and/or technology that is new or not widely used in the domestic sector as a result of the OPIC-supported investment. 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.
A	Products and/or services Management practices (if “New” or “Uncommon”, please describe).	New	Uncommon	No
	If New or Uncommon, please describe.
B	Marketing and/or distribution techniquesBusiness Processes (if “New” or “Uncommon”, please describe).	New	Uncommon	No
	If New or Uncommon, please describe.
C	Production and/or processing technologies (if “New” or “Uncommon”, please describe).	New	Uncommon	No
	If New or Uncommon, please describe.
D	Products and/or services (if “New” or “Uncommon”, please describe).	New	Uncommon	No
DE	Will there be any technical assistance provided by the Project (or Subproject)? provide technical assistance (e.g. training of customers, industry counterparts, suppliers, technical expertise from fund manager, etc…)? If “Yes”, please explain.		Yes	No
	If Yes, please explain.

FE	Will (or has) the Project (or Subproject) secure(d) voluntary sustainability certification from an internationally-recognized certifying authority? 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
	If Yes, please identify.

PART IIB – PROJECT (OR SUBPROJECT) COUNTRY EFFECTS

(For Financial Services Projects (or Subprojects))

PROJECT (OR SUBPROJECT) [FINANCIAL INTERMEDIARY] COUNTRY EMPLOYMENT
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

FINANCIAL INTERMEDIARY– CURRENT TOTAL PORTFOLIO
A.	Please provide the following portfolio information on the Financial Intermediary’s current total portfolio.	Current Total Portfolio
	Number of transactions per year	#
	Number of clients	#
	Value of outstanding portfolio ($US)	$
	Average transaction amount per client ($US)	$
	Maximum transaction amount to a single client ($US)	$
	Minimum transaction amount to a single client ($US)	$
	Average tenor (in months)	(months)
	% of the portfolio that are rural clients (based on number of clients) that are rural clients	%
	% of the portfolio (based on number of clients) that are women or women-owned businesses (based on number of clients)	%

PROJECT (OR SUBPROJECT) PORTFOLIO – TRANSACTION TYPE & PORTFOLIO INFORMATION
Please identify the type of Project (or Subproject) transactions supported by the OPIC-supported investment. Check all that apply.
Microfinance loans		Yes	No
If Yes, please provide the following portfolio information and projections on the OPIC-supported Microfinance portfolio:
A	Current portfolio information and projections for OPIC-supported Microfinance portfolio:	Current Portfolio	Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year	# (per year)	# (total over next five years)
	Number of Project (or Subproject) clients	#	# (total over next five years)
	Value of Project (or Subproject) outstanding portfolio ($US)	$	$
	Average transaction amount per client ($US)	$	$
	Maximum transaction amount to a single client ($US)	$	$
	Minimum transaction amount to a single client ($US)	$	$
	Average tenor (in months)	# months	# months
	Purpose of the transactions as a percentage of the outstanding value of the Microfinance portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
B	Start-Up Capital	%	%
	Working Capital	%	%

	Expansion Capital	%	%
	Equipment Purchase	%	%
	Other (please specify):      	%	%
C	Business activities/sectors of clients as a percentage of the outstanding value of the applicable portfolio in 3A above.	Current Portfolio	Projected OPIC-supported portfolio
	Manufacturing	%	%
	Agriculture	%	%
	Construction	%	%
	Transportation	%	%
	Communication	%	%
	Tourism	%	%
	Trade/Retail	%	%
	Energy	%	%
	Services (please specify):	%	%
	Other (please specify):      	%	%
D	Demographic distribution of clients as a percentage of the number of clients in the applicable portfolio in 3A above.	Current Portfolio	Projected OPIC-supported portfolio
	Women (or women-managed businesses)	%	%
	Rural	%	%
	Other (please specify): ________	%	%

SME Loans		Yes	No
	If Yes, please provide the following portfolio information and projections on the OPIC-supported SME portfolio:
A	Current portfolio information and projections for OPIC-supported SME portfolio:	Current Portfolio	Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year	# (per year)	# (total over next five years)
	Number of Project (or Subproject) clients	#	# (total over next five years)
	Value of Project (or Subproject) outstanding portfolio ($US)	$	$
	Average transaction amount per client ($US)	$	$
	Maximum transaction amount to a single client ($US)	$	$
	Minimum transaction amount to a single client ($US)	$	$
	Average tenor (in months)	# months	# months
	Purpose of the transactions as a percentage of the outstanding value of the SME portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
B	Start-Up Capital	%	%
	Working Capital	%	%
	Expansion Capital	%	%

	Equipment Purchase	%	%
	Other (please specify):      	%	%
C	Business activities/sectors of clients as a percentage of the outstanding value of the SME portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Manufacturing	%	%
	Agriculture	%	%
	Construction	%	%
	Transportation	%	%
	Communication	%	%
	Tourism	%	%
	Trade/Retail	%	%
	Energy	%	%
	Services (please specify):	%	%
	Other (please specify):      	%	%
D	Demographic distribution of clients as a percentage of the number of clients in the SME portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Women (or women-managed businesses)	%	%
	Rural	%	%
	Other (please specify): ________	%	%

Consumer Loans			Yes	No
If Yes, please provide the following portfolio information and projections on the OPIC-supported Consumer lending portfolio:
A	Current portfolio information and projections for OPIC-supported Consumer loan portfolio:		Current Portfolio	Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year		# (per year)	# (total over next five years)
	Number of Project (or Subproject) clients		#	# (total over next five years)
	Value of Project (or Subproject) outstanding portfolio ($US)		$	$
	Average transaction amount per client ($US)		$	$
	Maximum transaction amount to a single client ($US)		$	$
	Minimum transaction amount to a single client ($US)		$	$
	Average tenor (in months)		# months	# months
B		Demographic distribution of clients as a percentage of the number of clients in the Consumer Lending portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
		Women (or women-managed businesses)	%	%
		Rural	%	%
		Other (please specify): ________	%	%

Mortgages				Yes		No
If Yes, please provide the following portfolio information and projections on the OPIC-supported Mortgage portfolio:
A	Current portfolio information and projections for OPIC-supported Mortgage portfolio:		Current Portfolio		Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year		# (per year)		# (total over next five years)
	Number of Project (or Subproject) clients		#		# (total over next five years)
	Value of Project (or Subproject) outstanding portfolio ($US)		$		$
	Average transaction amount per client ($US)		$		$
	Maximum transaction amount to a single client ($US)		$		$
	Minimum transaction amount to a single client ($US)		$		$
	Average tenor (in months)		# months		# months
B	Please provide the purpose of the mortgages as a percentage of the outstanding value of the Mortgage portfolio in A above.		Current Portfolio		Projected OPIC-supported portfolio
	Mortgages for new homeowners		%		%
	Home Improvement loans		%		%
	Productive loan (e.g. home equity loan or /line of credit)		%		%
	Other (please specify):      		%		%

C	Please provide the target market of mortgages as a percentage of the outstanding value of the Mortgage portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Low-income homes	%	%
	Middle-income homes	%	%
	High-income homes	%	%
	Residential rental properties	%	%
	Commercial properties	%	%
	Other (please specify):      	%	%
D	Please provide the demographic distribution of clients as a percentage of the number of clients in the Mortgage portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Women (or women-managed businesses).	%	%
	Rural	%	%
	Other (please specify)	%	%

Equity Investments			Yes		No
If Yes, please provide the following portfolio information and projections on the OPIC-supported Equity portfolio:
A	Current portfolio information and projections for OPIC-supported Equity portfolio:	Current Portfolio		Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year	# (per year)		# (total over next five years)
	Number of Project (or Subproject) clients	#		# (total over next five years)
	Value of Project (or Subproject) outstanding portfolio ($US)	$		$
	Average transaction amount per client ($US)	$		$
	Maximum transaction amount to a single client ($US)	$		$
	Minimum transaction amount to a single client ($US)	$		$
	Average tenor (in months)	# months		# months
B	Economic segments of clients as a percentage of the outstanding value of the Equity portfolio in A above.	Current Portfolio		Projected OPIC-supported portfolio
	Microenterprises	%		%
	Small & Medium Enterprises	%		%
	Large Corporations	%		%
	Other (please specify):      	%		%

C	Purpose of the transactions as a percentage of the outstanding value of the Equity portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Start-Up Capital	%	%
	Working Capital	%	%
	Expansion Capital	%	%
	Equipment Purchase	%	%
	Other (please specify):      	%	%
D	Business activities/sectors of clients as a percentage of the outstanding value of the Equity portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Manufacturing	%	%
	Agriculture	%	%
	Construction	%	%
	Transportation	%	%
	Communication	%	%
	Tourism	%	%
	Trade/Retail	%	%
	Energy	%	%
	Services (please specify):	%	%
	Other (please specify):      	%	%
E	Demographic distribution of clients as a percentage of the number of clients in the Equity portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Women (or women-managed businesses).	%	%
	Rural	%	%
	Other (please specify):	%	%

Leasing contracts		Yes	No
If Yes, please provide the following portfolio information and projections on the OPIC-supported Leasing portfolio:
A	Current portfolio information and projections for the OPIC-supported Leasing portfolio:	Current Portfolio	Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year	# (per year)	# (total over the next five years)
	Number of Project (or Subproject) clients	#	# (total over next five years)
	Value of Project (or Subproject) outstanding portfolio ($US)	$	$
	Average transaction amount per client ($US)	$	$
	Maximum transaction amount to a single client ($US)	$	$
	Minimum transaction amount to a single client ($US)	$	$
	Average tenor (in months)	# months	# months
B	Please provide the economic segments of clients as a percentage of the outstanding value of the Leasing portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Microenterprises	%	%
	Small & Medium Enterprises	%	%
	Large Corporations	%	%
	Other (please specify):      	%	%

C	Please provide the business activities/sectors of clients as a percentage of the outstanding value of the Leasing portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Manufacturing	%	%
	Agriculture	%	%
	Construction	%	%
	Transportation	%	%
	Communication	%	%
	Tourism	%	%
	Trade/Retail	%	%
	Energy	%	%
	Services (please specify):	%	%

	Other (please specify):      	%	%
D	Please provide the demographic distribution of clients as a percentage of the number of clients in the Leasing portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Women (or women-managed businesses).	%	%
	Rural	%	%
	Other (please specify):	%	%

Insurance contracts		Yes	No
If Yes, please provide the following portfolio information and projections on the OPIC-supported Insurance portfolio:
A	Current portfolio information and projections for the OPIC-supported Insurance portfolio:	Current Portfolio	Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year	# (per year)	# (total over next five years)
	Number of Project (or Subproject) clients	#	# (total over next five years)
	Value of Project (or Subproject) outstanding portfolio ($US)	$	$
	Average transaction amount per client ($US)	$	$
	Maximum transaction amount to a single client ($US)	$	$
	Minimum transaction amount to a single client ($US)	$	$
	Average tenor (in months)	# months	# months

B	Please provide the economic segments of clients as a percentage of the outstanding value of the Insurance portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Microenterprises	%	%
	Small & Medium Enterprises	%	%
	Large Corporations	%	%
	Other (please specify):      	%	%

C	Please provide the business activities/sectors of clients as a percentage of the outstanding value of the Insurance portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Manufacturing	%	%
	Agriculture	%	%
	Construction	%	%
	Transportation	%	%

	Communication	%	%
	Tourism	%	%
	Trade/Retail	%	%
	Energy	%	%
	Services (please specify):	%	%
	Other (please specify):      	%	%
D	Please provide the demographic distribution of clients as a percentage of the number of clients in the Insurance portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Women (or women-managed businesses).	%	%
	Rural	%	%
	Other (please specify):	%	%

Other (please specify):      		Yes	No
If Yes, please provide the following portfolio information and projections on the OPIC-supported portfolio:
A	Current portfolio information and projections for OPIC-supported portfolio:	Current Portfolio	Projected OPIC-supported portfolio
	Number of Project (or Subproject) transactions per year	# (per year)	# (total over first five years)
	Number of Project (or Subproject) clients	#	# (total over first five years)
	Value of Project (or Subproject) outstanding portfolio ($US)	$	$
	Average transaction amount per client ($US)	$	$
	Maximum transaction amount to a single client ($US)	$	$
	Minimum transaction amount to a single client ($US)	$	$
	Average tenor (in months)	# months	# months
B	Economic segments of clients as a percentage of the outstanding value of the portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Microenterprises	%	%
	Small & Medium Enterprises	%	%
	Large Corporations	%	%
	Other (please specify):      	%	%

C	Purpose of the transactions as a percentage of the outstanding value of the portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Start-Up Capital	%	%
	Working Capital	%	%
	Expansion Capital	%	%
	Equipment Purchase	%	%
	Other (please specify):      	%	%
D	Business activities/sectors of clients as a percentage of the outstanding value of the portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Manufacturing	%	%
	Agriculture	%	%
	Construction	%	%
	Transportation	%	%
	Communication	%	%
	Tourism	%	%
	Trade/Retail	%	%
	Energy	%	%
	Services (please specify):	%	%
	Other (please specify):      	%	%
E	Demographic distribution of clients as a percentage of the number of clients in the portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	Women (or women-managed businesses).	%	%
	Rural	%	%
	Other (please specify):	%	%

3.    PROJECT (OR SUBPROJECT) FINANCIAL INTERMEDIARY COUNTRY EMPLOYMENT

A

Please provide the current and projected number of Project (or Subproject) employees for operations & management of the Financial Intermediary. and how many employees will be hired as a result of the OPIC-supported investment.

Current Number of Permanent Employees Employment (Operations and Management)

Number of Permanent Employees Hired by the Project (or Subproject) Projected Employment (Operations & Management) by the 5th year of operations as a result of this OPIC-Supported Investment

Total Projected Employment (Operations & Management) by the 5th year of operations

Local

Expatriate Foreign Nationals

Male

Female

Local

Expatriate Foreign Nationals

Local

Expatriate Foreign Nationals

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

4. JOB QUALITY PROJECT (OR SUBPROJECT) EMPLOYEE TRAINING
A		Will the Project (or Project Company)Financial Intermediary provide training above and beyond standard on-the-job trainingoffer employee development programs, such as tuition reimbursement or formal mentorships to both current and new permanent non-management direct employees identified above in Question 1A of Part IIIabove?	Yes				No
		If Yes, please describe what type of training opportunities will be provided to the managerial,employee development programs will be available to professional/technical, and/or unskilled personnel.
B	Will the Financial Intermediary offer other employee benefits that exceed local legal requirements to both current and new non-management employees identified above in Question 1A above?			Yes		No
	If Yes, please provide a list of employee benefits that exceed local law that are or will be available to non-management personnel:
BC		Please provide what percentage of new permanent employees will receive training. Please provide the average monthly wage (in local currency) that is or will be paid to full-time equivalent unskilled employees identified in Question 1A above.			____local currency/month
CD		Please provide the average monthly wage (in local currency) that is or will be paid to full-time equivalent professional/technical employees identified in Question 1A above.			__ local currency/ month

5. PROJECT (OR SUBPROJECT) ENVIRONMENTAL AND SOCIAL IMPACTS
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?	Yes	No
	If “Yes”, please explain (e.g. paperless banking, favorable financing terms for Project (or Subproject) clients engaging in activities which preserve the environment, etc.).

B	Does (or will) the Project (or Subproject) contribute money towards activities that benefit local communities (e.g., recreational facilities, schools, medical clinics, scholarship programs, other charitable activities)?	Yes		No
	If “Yes”, please provide the actual or expected annual budget for these activities and describe these activities.	_________$/year
C	Does the Project (or Subproject) have an Environmental and Social Management System (ESMS)?	Yes	No
	If Yes, please attached a copy of the ESMS (in English).

B	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:      

6. PROJECT (OR SUBPROJECT) HUMAN RESOURCE MANAGEMENT
A	Does (or will) the Project (or Subproject) have written human resources policies?	Yes	No
	If Yes, please attach a copy of the Project Company’s human resource policies (in English).
B	If Yes, please indicate the areas covered by the human resources policies:
	Benefits (e.g. healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare).	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 union reps, 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).	Yes	No
	Disciplinary procedures.	Yes	No
C	Are terms of employment clearly communicated to each worker? Does (or will) the Project (or Subproject have a Human Resources Department and/or Manager	Yes	No
	If Yes, please describe how employment terms are (or will be) communicated to each worker and attach verifying documentation, such as a sample employment contract.
	If Yes, please indicate the person who is (or will be) responsible for implementing the Project Company’s human resource policies.
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
	If Yes, please specify.

5. PROJECT (OR SUBPROJECT) HUMAN RESOURCE MANAGEMENT
A	Does (or will) the Project (or Subproject) have written human resources policies?	Yes	No
	If Yes, please attach a copy of the Project Company’s human resource policies (in English).
B	If Yes, 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 union reps, anonymous hotline, etc).	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	Are terms of employment clearly communicated to each worker?	Yes	No
	If “Yes”, please describe how employment terms are (or will be) communicated to each worker and attach verifying documentation, such as a sample employment contract.
	If “Yes”, please indicate the person who is (or will be) responsible for implementing the Project Company’s human resource policies.

76. PROJECT (OR SUBPROJECT) LABOR-RELATED ISSUES
Does (or will) the Project (or Subproject) involve the following?
A	Migrant or foreign workers (excludes expatriate management or highly-skilled non-manual workers).	Yes	No
AB	Workers under the age of 18 ((directly or indirectly employed by the Project (or Subproject)).	Yes	No
	If “Yes”, please describe.
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
BF	Restructuring which results in a major retrenchment (i.e., lays off significant numbers of workers).	Yes	No
	If “Yes”, please describe.
CG	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
	If “Yes”, please describe.
DH	Labor-related lawsuits against the Project (or Subproject).	Yes	No
	If “Yes”, please describe.
EI	Labor unrest in the last three years in the form of strikes or other general industrial disputes.	Yes	No
	If “Yes”, please describe.
FJ	Ongoing or unresolved issues/disputes with a Project (or Subproject) trade union.	Yes	No
	If “Yes”, please explain.

8. BUSINESS INNOVATION PROJECT (OR SUBPROJECT) TECHNOLOGY AND KNOWLEDGE TRANSFER
Please indicate if the Project (or Subproject) will operationalize a product, process, and/or technology that is new or not widely used in the domestic sector as a result of the OPIC-supported investment. 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.
A	New Financial Products and/or services Management Practices (if “New” or “Uncommon”, please describe.	New	Uncommon	No
	If New or Uncommon, please describe.
B	Business Processes Marketing and distribution techniques (if “New” or “Uncommon”, please describe.	New	Uncommon	No
	If New or Uncommon, please describe.
C	Innovative Financing Structures Production or processing technologies (if “New” or “Uncommon”, please describe.	New	Uncommon	No
	If New or Uncommon, please describe.
D	Financial product and/or services (if “New” or “Uncommon” , please describe.
D	Will the Project (or Subproject) providethere be any technical assistance provided by the Project (or Subproject) (e.g., training of customers, industry counterparts, suppliers, etc…? If “Yes” please explain.		Yes	No
	If Yes, please describe.
E	Will (or has) the Project (or Subproject) secure(d) voluntary sustainability certification from an internationally-recognized certifying authority? seek any industry standards and/or voluntary certifications (e.g., Equator Principles, U.N. Global Compact)? If “Yes”, please identify and explain.		Yes	No
	If Yes, please identify.

PROJECT (OR SUBPROJECT) PORTFOLIO – TRANSACTION TYPE AND AMOUNTS
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):      
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 amount per client				$	$
	Maximum transaction amount to a single client				$	$
	Minimum transaction amount to a single client				$	$
	Median transaction amount to a single client				$	$

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.
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):      	%	%
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):      	%	%
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):      	%	%
D	Duration of transactions as a percentage of the portfolio.	Current Portfolio	Projected OPIC-supported portfolio
	< 6 months	%	%
	6 – 12 months	%	%
	13 – 24 months	%	%
	25 – 36 months	%	%
	37 – 60 months	%	%
	> 60 months	%	%
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:
A	Mortgage maturity period as a percentage of the mortgage portfolio.	Current Portfolio	Projected OPIC-supported portfolio
	< 5 years	%	%
	5-10 years	%	%
	11 - 15 years	%	%
	16 – 20 years	%	%
	> 20 years	%	%
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):      	%	%
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):      	%	%
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
A	Does (or will) the Project (or Subproject) occupy a monopoly position in any of its markets?	Yes	No
	If “Yes”, please explain.
	If No, please estimate how many firms currently provide the same or similar products and/or services in the local market?	_____#
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.
C	Are there any Project (or Subproject) Country performance requirements (e.g., local content requirements or incentives, 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.
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
A	OPIC:	$	$ N/A	$	$
B	Applicant (or Financial Intermediary):	$	$	$	$
	What amount, if any, is from an offshore non-U.S. source?	$	$	$
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?	$	$	$
	What amount, if any, is from a U.S. public source (i.e., USAID grants, Export-Import Bank financing, U.S. Trade and Development Agency grants) (please specify):	$	$	$
D	Project (or Subproject) Country sources (please specify source and amounts per source)	$	$	$	$
E	Non-U.S. and non-Project (or Subproject) Country sources (please specify sources, countries, and amounts per country):	$	$	$	$
F	Development Finance Institutions (e.g. International Finance Corporation, Inter-American Development Bank, etc.). Please specify.	$	$	$	$
G	Other sources (please specify):	$	$	$	$
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 2GH above.
A	Purchased or spent in the Project (or Subproject) Country	$
	Of the amount in 3A above, how much will be spent on the procurement of goods and services from domestic suppliers?	$
B	Purchased from the U.S.	$
C	Purchased from countries other than the Project (or Subproject) Country or the U.S. (please specify countries and amounts per country)	$
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).	$
E	TOTAL INITIAL PROJECT (OR SUBPROJECT) FUNDING USES:	$

INITIAL PROJECT (OR SUBPROJECT) U.S. PROCUREMENT
Please list items to be procured from the U.S. from Question 3B, above. Also, please ensure that the total below is equal to the total in Question 3B above.
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
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
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 sourcesvalue of the Project’s (or Subproject’s) purchases of goods and services (excluding internal labor and utility costs) from domestic suppliers 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
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 or INTEREST/FEE REVENUE (FOR FINANCIAL INTERMEDIARIES)
A	Please provide current annual total sales figures (or interest and fee revenue, if a financial intermediary) and projected increases in annual as well as additional sales figures (or interest and fee revenue) expected or projected as a result of this OPIC-supported investment by the 5th year of operations.
Product		Current Annual Production Capacity		Projected Increase in Annual Production Capacity as a result of this OPIC-Supported Investment		Total Expected Projected Annual Production Capacity
		Current Annual Gross Sales Value/Revenue ($US)	Current Annual Volume (Units)	Incremental Increase in Gross Annual Sales Value/ Revenue ($US)	Incremental Volume (Units)	Total Annual Gross Sales Value/ Revenue ($US)	Total Annual Volume (Units)
TOTAL

B	Does you the Project currently export or plan to export any of your its production?								Yes		No
C	Please provide current annual exports sales to export markets and the projected increase in annual exports expected as a result of this OPIC-supported investment by the 5th year of full operations:
Exported Product		Export Country	% of Exports	Current Annual Exports Sales		Projected Increase in Annual Exports Sales as a result of this OPIC-Supported Investment		Total Expected Projected Annual Exports by the 5th year of operations
				Current Gross Sales/ Revenue Value ($US)	Current Volume (Units)	Incremental Sales Value/Revenue ($US)	Incremental Volume (Units)	Total Gross Sales Value/ Revenue ($US)		Total Volume (Units)
TOTAL
D Will the Project (or Subproject) reduce dependency on imports? Yes No
If Yes, please describe.

8. PROJECT (OR SUBPROJECT) PAYMENTS TO HOST GOVERNMENT
A	Please provide total Project (or Subproject) Country tax, royalty, and fee payments.all transfers to the host government made by the Project (or Subproject).
Country		Current Annual Payment Figure ($US)	Projected Increase in Annual Payment Figure as a Result of this OPIC-Supported Investment ($US)	Total Expected Annual Payments ($US)
Project (or Subproject) Country
TOTAL
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 (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
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 ($US)	$	$
B	Other Loan Principal and Interest (from U.S. or other lenders) ($US)	$	$
C	Lease Payments ($US)	$	$
D	Return on Initial Capital Investment ($US)	$	$
E	Annual Fees (other than OPIC fees, please specify) ($US)	$	$

PART IV – Investor / Representative Certification

Investor/Representative Certification

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

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Author	OPIC
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File Created	2021-01-24