OPIC -254 edits

Personal Financial Statement Form -- Version showing Edits.docx

Personal Financial Statement

OPIC -254 edits

OMB: 3420-0035

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OVERSEAS PRIVATE INVESTMENT CORPORATION


PERSONAL FINANCIAL STATEMENT


OPIC Form 254

OMB 3420-0035

Expiration: [ ]


Disclosures and Notices Please retain a copy for your records.


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


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


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

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


Responses to questions which call for estimates or projections should take the form of good faith statements made to the best of the subject individual’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. Anyone who knowingly makes a false statement or omission with the intent to influence OPIC’s insurance, reinsurance, guarantees, loans, or other investments may be criminally prosecuted pursuant to 22 U.S.C. § 2197(n). Such acts are also grounds for OPIC to terminate a commitment and declare a contract default. These rights are in addition to any other rights or remedies available to OPIC. Neither submission nor acceptance of this questionnaire implies that the project is eligible for OPIC support or that support will be provided.


Paperwork Reduction Act Notice: This is a voluntary information collection, however, failure to complete this form may result in OPIC’s inability to complete review of the associated project’s application. OPIC may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB number. The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Agency Clearance Officer, Records Management, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527 and to the OPIC Desk Officer, Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

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

Individual Identification and Contact Information


Full Legal Name (required)


Social Security Number:


Residence Address (required):




Business Phone:


Residence Phone:


Mobile Phone:


Email Address (required):



Assets and Liabilities Summary as of [ ]


Assets


Asset Description

USD Equivalent Value

Owned Jointly?1 (Y/N)

  1. Cash on hand and in Banks (liquid accounts)



  1. IRA(s) or Other Retirement Account(s)



  1. Stocks and Bonds (Publicly Traded)



  1. Equity Ownership Interests (Private Companies)



  1. Accounts and Notes Receivable



  1. Life Insurance – Cash Surrender Value Only



  1. Real Estate (current market value)



  1. Vehicles and other Personal Property



  1. Other Assets



Total Assets




Liabilities and Net Worth

Liability Description

USD Equivalent Value

Joint Obligation? (Y/N)

  1. Accounts Payable



  1. Notes Payable to Banks and Others



  1. Mortgages Loans on Real Estate



  1. Taxes Payable



  1. Other Liabilities



Total Liabilities



  1. Net Worth



Total Liabilities and Net Worth




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


  1. Cash In Banks

Name and Location of Bank

Approx. Balance











Total



  1. IRA(s) and Other Retirement Account(s)

Account Fiduciary Institution

Approx. Balance











Total


  1. Stocks and Bonds (Publicly Traded)

Name of Security

Fiduciary Institution

Approx. Balance








































Total









  1. Equity Ownership Interests (Private Companies)

Name of Company

Portion of Equity Owned (%)

Are the shares/ interests freely transferable2? (Y/N)

Approx. Value

























Total




  1. Accounts and Notes Receivable

Name of Debtor

Approx. Balance









Total



  1. Life Insurance – Cash Surrender Value Only

Name of Issuing Firm

Approx. Value





Total



  1. Real Estate

Address

Description

Approx. Value






















Total







  1. Vehicles and Other Personal Property

Description

Current Location

Value net of liens
















Total



  1. Other Assets

Description

Approx. Value









Total



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


  1. Accounts Payable

Name of Creditor

Approx. Balance







Total



  1. Notes Payable to Banks and Others

Name of Creditor

Approx. Balance









Total






  1. Mortgages on Real Estate

Address of Property

Name of Creditor

Approx. Balance




























Total



  1. Taxes Payable

Taxing Authority

Approx. Balance







Total



  1. Other Liabilities

Description

Approx. Balance







Total



Contingent Liabilities


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


Contingent Liabilities

Description

Est. Potential Obligation











Total



Source(s) of Income


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


Source(s) of Income


20__

20__

20__

Salary




Net Investment Income




Real Estate Income




Other (description:______________________)




Total








Signature Page


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


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



Printed Name of Individual


Signature of Individual


Date





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

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

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