OPIC 256 marked copy

Investment Funds Department Questionnaire

INVESTMENT FUNDS DEPARTMENT QUESTIONNAIRE

Form: OPIC 256

OMB Number: 3420-0037_____

Expiration Date: 4/30/2018 _______

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 questionnaire implies that the project is eligible for OPIC support or that support 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. 

Paperwork Reduction Act Notice: This information is required to obtain benefits.  As a federal agency, OPIC may not collect nor sponsor the collection of information unless it displays a valid OMB Control Number with an expiration date that has not expired.  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 to the OPIC Desk Officer at the Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

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

Proposal Date	DEFAULT
GP Main Point of Contact (First Name)	TEXT BOX
GP Main Point of Contact (Last Name)	TEXT BOX
GP Main Point of Contact (Email)	TEXT BOX
GP Main Point of Contact (Phone Number)	TEXT BOX
Name of Firm	TEXT BOX
Address of Firm Headquarters	TEXT BOX
City of Firm Headquarters	TEXT BOX
Country of Firm Headquarters	TEXT BOX
Other Firm Locations (cities)	TEXT BOX
Year Firm Established	TEXT BOX
Website of Firm	TEXT BOX

FUND OVERVIEW
Fund Name	TEXT BOX
Fund Target Size in USD (including OPIC amount)	TEXT BOX (numerical)
Max Fund Target Size in USD (including OPIC amount)	TEXT BOX (numerical)
Min Fund Target Size in USD (including OPIC amount)	TEXT BOX (numerical)
Proposed GP Commitment (%)	TEXT BOX (percentage)
Proposed OPIC Commitment	TEXT BOX (numerical)
Percent of GP Carry allocated to Investment Team	TEXT BOX
Fund Strategy	TEXT BOX (drop down menu)
Fund Sectors	TEXT BOX (drop down menu)
If Other Sectors Please Describe	TEXT BOX
Fund Geography (region)	TEXT BOX (drop down menu)
Fund Geography (countries)	TEXT BOX
Projected Fund IRR (gross)	TEXT BOX (percentage)
Fund Strategy – (description of strategy)	TEXT BOX

MANAGEMENT OVERVIEW
Fund Team Formation: Describe how the manager and the team were initially formed, and provide a brief history of how they have evolved to date. You may also refer to appropriate sections in the PPM or marketing presentation.	TEXT BOX
Number of Partners	TEXT BOX (numerical)
Number of Senior Investment Professionals	TEXT BOX (numerical)
Percent of Fund Manager or GP that is U.S. owned (e.g. owned by U.S. citizens or entities)	TEXT BOX (percentage)
How many cumulative years of private equity investing on the current team	TEXT BOX (drop down menu)
How many cumulative years of PE and other relevant experience on the current team	TEXT BOX (drop down menu)
How many cumulative years has each member worked with each other (2 people working together for 1 year = 2 years)	TEXT BOX (drop down menu)
How many cumulative years of experience does the team have in the target geography	TEXT BOX (drop down menu)
Firm’s Assets Under Management	TEXT BOX (numerical)
Number of Funds Previously Managed by this Firm	TEXT BOX (numerical)
SENIOR INVESTMENT TEAM BACKGROUND

Name	Title	Year joined firm	Location (city, country)	Focus (industry, function, if any)	Prior work experience	Education

LP BASE
Total Capital Raised to Date in USD	TEXT BOX (numerical)
Total Capital Raised to Date (% of Target Fund Size)	TEXT BOX (percentage)
Has the Fund achieved a first close	TEXT BOX (drop down menu)
Total anticipated capital from U.S. investors	TEXT BOX (numerical)
Has the Fund retained or does it plan to retain a placement agent to raise U.S. Equity (yes/no)	TEXT BOX (drop down menue)
Name of Placement Agent (if applicable)	TEXT BOX
List institutional investors likely to commit to the Fund/invested in prior funds managed by the GP (and location of each LP)	TEXT BOX
List any Development Finance Institutions (DFIs) with whom the Fund is engaged in discussions or has received (soft) commitments	TEXT BOX
TRACK RECORD
What is the realized Return of the GP	TEXT BOX (drop down menu)
What is the realized and unrealized Return of the GP	TEXT BOX (drop down menu)
What is the blended, un-weighted multiple of cost (MoC) attributable to the Senior Team for their whole careers (MDs, Principals)	TEXT BOX (drop down menu)
Attach a summary of prior fund performance (see Track Record template)	FILE UPLOAD

INVESTMENT POLICY & ESG
Explain how your fund will meet the general objectives of this Call, and if applicable please further describe how the fund’s investment thesis aligns with any special considerations associated with this Call.		TEXT BOX
(i) Explain why you are seeking OPIC funding. (ii) What efforts have been taken to raise capital from private sector investors and what has been the outcome of those efforts? (iii) Is there a lack of available private sector support for the Fund, or for portfolio companies and if so for what reason?		TEXT BOX
Describe the developmental impact you believe the Fund will have in the host country/countries (e.g. job creation, infrastructure improvements, social policies/corporate social responsibility initiatives, technology and knowledge transfer, etc.).		TEXT BOX
(i) Does the Fund require portfolio companies or borrowers to adhere to minimum standards regarding labor, human rights, and social and environmental risks? (ii) Does the Fund have established ESG policies and procedures? If so, please describe the Fund’s supervision of the implementation of these standards by its portfolio companies and/or borrowers. You may also refer to appropriate sections in the PPM or marketing presentation. Please also include references to the Fund’s practices concerning provision of access to accountability and remedy for negative sub-project impacts on individuals and communities.		TEXT BOX
Has the Fund adopted policies and procedures to screen investors and investees for “Know Your Customer” and Reputational/Integrity Risk? (ii) If applicable, please describe how you apply these policies and procedures to investments in the fund and investments by the fund in portfolio companies.		TEXT BOX
OTHER - MISCELLANEOUS
(i) Describe any potential conflicts of interest of which you are aware. (ii) How do you plan to resolve potential conflicts of interest within the Fund, or with other investment vehicles managed by your organization or its affiliates?		TEXT BOX
Are there any substantive litigation, dispute resolutions, or regulatory actions brought against the manager, its principals or any portfolio companies?		TEXT BOX
If yes, please attach an explanation describing any litigation or community dispute or complaint resolution processes that have occurred or are occurring involving the manager, its principals and/or its portfolio companies.		FILE UPLOAD
ATTACHMENTS
Attach the Fund's most recent marketing presentation		FILE UPLOAD
Attach the Fund's investment pipeline		FILE UPLOAD
Attach the Fund's PPM (if available)		FILE UPLOAD
PROPOSAL DOCUMENTS
Document Name	Description		Document Date	File Name