OPIC-255 Redline Changes

Aligned Capital Investee Opt-In

Form: OPIC-255

OMB Number: 3420-0033

Expiration Date: [ ]

Instructions

The information in this form is used by companies that are interested in connecting with potential investors through OPIC’s Aligned Capital Program. The Aligned Capital Program is designed to align development finance with other capital, including philanthropic, socially responsible and impact investment, to enable effective deployment of that capital towards projects in the countries and sectors in which OPIC works. This program is independent of OPIC’s other programs. Participation or non-participation will have no bearing on existing or pending applications with OPIC.

Information provided on this form will be automatically shared with any potential investors that have completed an Aligned Capital Investor Screener indicating that their interests are a match with your proposed project. These potential investors may choose to contact you, but are not obliged to do so.

To begin, click the “Start” button below.

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Part A—Identifying Information

1. INVESTEE COMPANY

Name:

Address (including city and country):

Phone Number(s):

2. AUTHORIZED REPRESENTATIVE

Name of Representative:

Relationship to the Company:

Address (including city and country):

Phone Number(s):

E-mails(s):

3. DESCRIPTION OF THE PROJECT

• Write a brief description of the Company’s operations or the project for which the Company is seeking an investment. Include any details of particular interest, such as development goals or targeted populations.

• If you are already working with OPIC to arrange financing for this project, you may include relevant information about the status of your discussions and update this information as often as warranted.

• If you would like to attach a presentation or other materials, please click the “Supporting Documentation” hyperlink at the bottom of the screen.

• Do not include any confidential commercial information as this will be shared directly with potential investors.

Part B—Matching Questions

The information requested in this section will be used to identify potential investors that may be interested in the Company.

Please select one or more applicable responses for each question:

1. Asset Classes/Types of Investments and Sizes of Investment (Select each type of investment and the size per type of investment the Company would be interested in discussing with potential investors.)

(a) ____ Equity

[Drop down with dollar ranges]

(b) ____ Convertible Debt

[Drop down with dollar ranges]

(c) ____ Subordinated/Mezzanine Debt

[Drop down with dollar ranges]

(d) ____ Senior Debt

[Drop down with dollar ranges]

(e) ____ Grants/Technical Assistance

[Drop down with dollar ranges]

2. Total Project Size (Select the total target size of investment/project, including debt. If size has not been finalized, select the current best estimate.)

[Drop down with dollar ranges]

3. Type of Investment Vehicle (Select the most accurate description of the Company.)

____ The Company is the entity that is building/operating a project—Operating Company/Project Company/Special Purpose Vehicle

____ The Company is an entity that invests (usually via equity) in other companies—Investment Vehicle/Fund/Holding Company

____ The Company is an entity that invests (usually via debt) in other companies—Financial Intermediary/Bank/Non-Bank Financial Institution

____     The Company is an entity that invests in other companies in one or more ways—Hybrid Vehicles

4. Sector (Identify the relevant sector for the business of the Company or the proposed project.)

[Drop down list of OPIC Sectors]

5. Regions and Countries (Identify the countries or geographic region where the Company operates or the proposed project will be conducted.)

[Drop down list of OPIC Regions and Countries]

6. Does the Company have, or intend to have, a performance metric or other system for measuring social impact and/or environmental impact?

____ Yes ____ No

Part C —Disclaimers and Certifications

The person completing this form represents and warrants that you are authorized to register on behalf of the Company described in this Aligned Capital Investee Opt-In and that all information provided is accurate and truthful.

OPIC does not control, is not responsible for, has not reviewed and does not endorse any investor that is participating in the Aligned Capital Program. In order for investors to participate in the Aligned Capital Program, they must certify that they are an “accredited investor” within the meaning of Rule 501 of Regulation D under the U.S. Securities Act of 1933, as amended, but OPIC has not verified the accuracy of their statements. OPIC does not warrant the accuracy, completeness or usefulness of the information provided by third parties. OPIC’s creation of this program does not constitute investment advice. Users need to consult with their own investment, accounting, legal and tax advisers to evaluate independently the risks, consequences and suitability of their participation in this program.

This form shall be used only for the Aligned Capital Program, as described herein and on OPIC’s website. OPIC may remove any profile that may, in OPIC’s sole discretion, be offensive, illegal or include inappropriate content.

OPIC may terminate the program at any time, with or without notice.

Paperwork Reduction Act Notice: This is a voluntary information collection, however a company may not participate in the Aligned Capital Program unless this form is completed. Public reporting burden for this collecting of information is estimated to average thirty 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 aspect of this collection of information, including suggestions for reducing this burden to the Records Manager, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527; and to the OPIC Desk Office at the Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

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