OPIC 162 (blackline copy)

PDF FOR REFERENCE ONLY – THIS FORM IS TO BE COMPLETED ON-LINE –

PAPER SUBMISSIONS WILL NOT BE ACCEPTED

SELF-MONITORING QUESTIONNAIRE for Finance, Insurance, Reinsurance, and Investment Funds Projects

Form: OPIC-162

OMB Number: 3420-0019

Expiration Date: 06/30/2019

Overseas Private Investment Corporation

1100 New York Avenue, NW Washington, DC 20527-0001

An Agency of the United States Government

Please read the following information carefully. This form requests information from OPIC clients, which is required annually by OPIC’s governing legislation. The information provided in this questionnaire will allow OPIC to better assess the impact of OPIC-supported projects on the U.S. economy and employment, as well as the impact on host country economic development and the effects on the environment and workers’ rights abroad.

Complete responses to the collection of information in this form are mandatory, per the Foreign Assistance Act of 1961, as amended, Section 231(k)(2). Client information contained in this questionnaire will be designated as confidential commercial information in accordance with OPIC’s Freedom of Information Act (FOIA) regulations (22 CFR part 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 retain benefits. Public reporting burden for this collecting of information is estimated to average 4.7 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 or any other aspect of this collection of information, including suggestions for reducing this burden to Agency Forms Officer, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527; and to 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.

GETTING STARTED

Welcome to OPIC’s Self-Monitoring Questionnaire (SMQ). As the U.S. Government’s development finance institution, OPIC takes its developmental mission seriously. The SMQ is an integral part of the OPIC monitoring and oversight function as it enables OPIC to collect data on the environmental, social, and long-term development impacts of each OPIC-supported project. Additionally, data collected in the SMQ are aggregated and used to satisfy OPIC’s U.S. Congressional reporting requirements.

OPIC’s Office of Investment Policy reviews each OPIC-supported project for its: 1) environmental, health, and safety risks; 2) labor-related risks; 3) impact on the U.S. economy and U.S. employment; and 4) development impact in the host country. For a description of OPIC’s Office of Investment Policy, please click here: http://www.opic.gov/doing-business-us/OPIC-policies.

The SMQ must be completed on-line (click button below). To submit the SMQ on-line, you will be asked to enter the project type, contract number, and password. The OPIC contract number is provided annually in reminder e-mails sent to you by OPIC staff, and the password is created by each individual SMQ respondent. If you do not know your contract number, have forgotten your password, or encounter any other difficulties with the SMQ process, please e-mail the SMQ Helpdesk at [email protected].

Please answer all questions as completely as possible. If space is inadequate, please supply additional information on separate sheets of paper and attach them to your electronic submission in Part IV of the process. For all questions, the terms “Project” and “Financial Intermediary” refer to the investment supported by the OPIC insurance or reinsurance contract and/or finance agreement identified by contract number herein.

Some questions and bolded terms found in the SMQ may not be familiar. Should you need it, the document entitled, “Guidelines for completing the OPIC Self-Monitoring Questionnaire” provides detailed instructions and definitions of terms. If you do not have a copy of this document, please e-mail the SMQ Helpdesk at [email protected].

For your reference, a PDF of the entire SMQ can be found here.

To initiate the on-line process, please click on the “Self-Monitoring Questionnaire” button below.

SELF MONITORING QUESTIONNAIRE START BUTTON

The Self-Monitoring Questionnaire (SMQ) is divided into two sections: Section A and Section B. Please note that only one of these sections needs to be completed . The electronic form will automatically direct you to the relevant section, depending on your response to question 2A in Part I (this question distinguishes the industry of the OPIC-supported project as Financial Services or Non-Financial Services).

Section A is to be completed by all OPIC Finance, Insurance and Reinsurance projects, and by all OPIC Investment Fund portfolio companies and framework agreement/on-lending facilities unless this is a Financial Intermediary transaction (see below).

Section B is to be completed for Financial Intermediary transactions. As such, the term “Financial Intermediary” refers to, but is not limited to, general-lending banks, specialized-lending institutions, mortgage facilities, microfinance institutions, private equity funds, and other capital market transactions.

The terms “Project” and “Financial Intermediary” are based on definitions given to them in Appendix D of OPIC’s Environmental and Social Policy Statement, as referenced below:

Project – All facilities owned or controlled within a physical project boundary that constitute a commercially viable business unit eligible for OPIC support.

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

– 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 Environmental, Health, and Safety Guidelines.

PART I – PROJECT SUMMARY

PROJECT INFORMATION
A	Project Name:
B	Contract/loan #:
C	Please provide the percentage of local ownership of the project, if any.		____%
D	Is any of the local ownership comprised of Small & Medium Enterprises (SME)?	Yes	No
	If “Yes”, please provide the percentage of local ownership comprised of Small & Medium Enterprises.		____%
E	Is there any female ownership of the Project?	Yes	No
	If Yes, please provide the percentage of local ownership that is or will be female-owned.		____%
F	Please provide the current number of members of the Project’s Board of Directors or other governing body, if applicable.	________# male	________# female
G	Please provide the current number of women in executive management positions.		________#
H	Does the project involve other Development Finance Institutions (DFIs)?	Yes	No
	If “Yes,” please indicate which DFIs below (please check all that apply) African Development Bank (AfDB) Asian Development Bank (AsDB) Belgium Investment Company for Developing Countries (BIO) Banque Ouest Africaine de Developpement (BOAD) Black Sea Trade and Development Bank (BSTDB) Commonwealth Development Corporation (CDC Group) Compañía Española de Financiación del Desarollo (COFIDES) European Bank for Reconstruction and Development (EBRD) European Investment Bank (EIB) Finish Fund for Industrial Cooperation (FINNFUND) German Development Finance Company (DEG) International Finance Corporation (IFC) Investment Fund for Developing Countries (IFU) Inter-American Development Bank (IDB) Islamic Corporation for the Development of the Private Sector (ICD) Multilateral Investment Guarantee Agency (MIGA) Netherlands Development Finance Company (FMO) Norwegian Investment Fund for Developing Countries (NORFUND) Oesterreichische Entwicklungsbank (OeEB) The Private Infrastructure Development Group Trust (PIDG) Swedfund International AB (SWEDFUND) Swiss Investment Fund for Emerging Markets (SIFEM) Société de Promotion et de Participation pour la Coopération Economique (PROPARCO) Other (please specify):

I	Do any of the U.S. investors in the project (or one of its subsidiaries or affiliates) currently produce the same product(s) as that produced by this project?	Yes	No
	If “Yes,” has the number of U.S. employees engaged in the U.S. production of this product been 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 DESCRIPTION

A

Project Type

Financial Services

Non-Financial Services

B

Describe the use of proceeds of this OPIC-supported investment.

C

Has the project description changed since it was originally approved by OPIC?

Yes

No

If “Yes”, please indicate the changes below:

New business lines

Exited markets

New products or services

Exited product lines or services

New international markets

Other:

D

Project Site Region(s): (select all that apply) Asia & Pacific Europe & Eurasia Latin America & Caribbean Middle East & North Africa Sub-Saharan Africa Global

E

Project City and Country:

Project Site Location (please include GPS coordinates):

F

Has the project become fully operational?

Yes

No

If “Yes,” please provide the date the project became fully operational.

______/____ Month / Year

If “No,” please specify the use(s) of the project funds during the reporting period: (select all that apply)

Engineering

Consulting

Construction (non-production)

Marketing

Other (please specify):

G

Please provide the number of direct competitors currently operating in the project market.

_______

H

Please specify the project’s most recently completed fiscal year and use data from this year to complete the rest of this form.

Starting Date MM/YYYY

Ending Date MM/YYYY

I

What is the total value of remittances (dividends, profits, loans/interest, royalties, etc.) from the project during the reporting period?

To the United States

$     

To other countries, excluding the U.S. and the project country

$     

J

What was the value of the project’s revenues over the reporting period: (If multiple product lines, please provide information on each product on a separate sheet.)

N/A

The project country

The U.S.

Other countries (in descending order of value):

$     

$     

$     

K

If the project is Financial Services, (as indicated in Question 2A) please proceed to Part II B.

If the project is Non-Financial Services (as indicated in in Question 2A), please check the appropriate project sector Classification.

Agriculture/Agribusiness

If “Agriculture/Agribusiness”, please answer the following:

Average agricultural yield (tonne/hectare)

______

Number of farmers that are linked to the project as:

Employees

______

Suppliers

______

Buyers

______

Contractors

______

Education

If “Education” please answer the following

Number of students enrolled

______

Number of female students enrolled

Number of local students enrolled (excluding children of foreign nationals)

______

Number of needs-based scholarships for local students (per year)

______

Energy

If “Energy”, please answer the following questions:

Please identify the type(s) of energy generated (check all that apply): Wind Solar Geothermal Biofuels Thermal (coal) Thermal (natural gas) Thermal (oil) Hydro Other (please specify):

Energy delivered to offtaker(s) in gigawatt hours (GWh)

_____(GWh)

Energy Access

If “Energy Access” please answer the following:

Number of new on-grid connections

#

Number of new micro-grid connections

#

Number of new household power systems installed

#

Number of new modern lighting devices sold

#

Health

If “Health” please answer the following

Number of patient consultations during the reporting period

_________

Number of patient consultations provided to women during the reporting period

Housing

If “Housing” please answer the following

Number of new residential dwellings

_________

Number of refurbished residential dwellings

_________

Information & Communications Technologies

If “Information & Communications Technologies”, please answer the following

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

Units of cargo containers transported through the road/railway/port/airport per year in twenty foot equivalent units (TEUs)

____#TEUs

Tonnes of bulk cargo transported through the road/railway/port/airport per year

___#tonnes

Number of Passengers using transportation services per year

____#

Waste & Sanitation

If “Waste & Sanitation”, please answer the following

Amount of waste disposed per year (in tonnes)

_____#tonnes

Volume of wastewater treated per year (in m3)

____#m3

Water

If “Water”, please answer the following

Volume of potable water produced per year

____#m3

Other

If “Other”, please answer the following

Please describe the project sector, with appropriate North American Industry Classification code.

K

What is the project target client or customer?

Please provide the total number of clients or customers served by the project during the reporting period

____#

Please provide the total number of female clients or customers served by the project during the reporting period.

____#

PART II A – PROJECT COUNTRY EFFECTS

(For Non-Financial Services Projects)

INITIAL SOURCES OF PROJECT PROCEEDS (NON-FINANCIAL PROJECTS ONLY)
		DEBT	EQUITY	OTHER	TOTAL
A	OPIC	$	N/A	$	$
B	Project	$	$	$	$
	What amount, if any, was from an offshore non-U.S. source?	$	$	$	$
C	U.S. sources other than sponsor. (Please specify source and amounts per source)	$	$	$	$
	What amount, if any is from a U.S. public source (please specify source, examples: USAID, Export-Import Bank, U.S. Trade and Development Agency)	$	$	$	$
D	Project Country sources (please specify sources, countries, and amounts per country)	$	$	$	$
E	Non-U.S. and non-project country sources (please specify, sources)	$	$	$	$
F	Development Finance Institutions (International Finance Corporation, Inter-American Development Bank, etc) (please specify)	$	$	$	$
G	Other sources (please specify)	$	$	$	$
H	INITIAL PROJECT PROCEEDS TOTAL:	$	$	$	$

INITIAL USES OF PROJECT PROCEEDS (NON-FINANCIAL PROJECTS ONLY)
Refers to expenditures financed by the Project Proceeds Total included in 3H above.
A	Purchased or spent in the Project 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 Country or the U.S. (please specify countries and amounts per country)	$
D		Miscellaneous Project costs, including costs 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 PROCEEDS USES:	$

PROJECT EMPLOYMENT

A

Please provide the total current number of project direct employees for operations & management and during the construction phase (if applicable).

Total Current Direct Employment (Operations & Management)

Local

Foreign nationals

Male

Female

Male

Female

Managerial

Professional/ Technical

Unskilled Labor

TOTAL

B

Has the project utilized workers employed by third parties (i.e., through contractors/subcontractors) over the reporting period?

For physical construction

For administrative needs

For other operational needs

PROJECT CONSTRUCTION AND TEMPORARY EMPLOYMENT (if applicable)

A

If your project has a construction phase and utilizes or utilized temporary construction workers, please provide the following below. Please also provide the same information for seasonal employees as listed.

Temporary Employees

Construction Employees

Seasonal Employees

Male

Female

Male

Female

Local

Foreign National

Total

JOB QUALITY
A	Does the project (or project company) offer employee development programs such as tuition reimbursement or formal mentorships to current non-management direct employees identified above in Question 1A of Part II?	Yes		No
	If “Yes,” please describe what type of employee development programs are available to professional/technical and/or unskilled personnel.
B	How many employees have been promoted during the reporting period		_____#
	Please indicate the number of employees promoted from unskilled positions to professional or technical positions		____#
	Please indicate the number of employees promoted from professional or technical positions to managerial positions		_____#
C	Please provide the average monthly wage (in local currency) that is paid to full-time equivalent unskilled employees identified in Question 1A above.		____local currency/month
D	Please provide the average monthly wage (in local currency) that is paid to full-time equivalent professional/technical employees identified in Question 1A above.		____local currency/month

PROJECT HUMAN RESOURCE MANAGEMENT
A	Does the project have written human resources policies?	Yes			No
	Have there been any significant changes to the human resources policies during the reporting period?	Yes			No
	If “Yes,” please describe.
B	Please indicate the areas covered by the human resources policies:
	(Examples of Benefits: healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare, etc.)
	Is/are mechanism(s) in place for workers to express grievances (e.g., direct access to supervisors and/or the human resources department, workers’ committees, and/or trade unions reps, or an anonymous hotline)?	Yes			No
	Do general conditions of work 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
	Are disciplinary procedures in place?	Yes			No
C	Are terms of employment clearly communicated to each worker?	Yes			No
	If “Yes,” please describe how employment terms are communicated to each worker and attach verifying documentation, such as a sample employment contract.
D	Does the project management have experience in applying international labor standards, such as those in the IFC Performance Standards?		Yes	No
	If “Yes,” please specify.

PROJECT LABOR-RELATED ISSUES
A	Has there been a significant change since the beginning of the reporting period in the number of employees, composition of employees, demographics (gender, skill level, nationality/place of origin, etc.) of the workforce?	Yes	No
	If “Yes,” please describe.
Did the project involve the following during the reporting period?
B	Migrant or foreign workers (excludes foreign national management or highly-skilled non-manual workers)	Yes	No
	If yes, please provide the following information regarding the migrant or foreign workers: Number, National Origin, Skill Level, and Position and if they are living onsite at the project (foreign national management or highly skilled non-manual workers are exempt).
C	Workers under the age of 18 directly or indirectly employed by the project	Yes	No
	If “Yes,” please briefly describe the general duties of these workers and include the age of the youngest worker.
D	Restructuring that resulted in a major retrenchment (i.e. layoffs of significant numbers of workers)	Yes	No
	If “Yes,” please describe the positions, skill levels, gender, and the national origins of the workers who were dismissed.
	If “Yes,” did the project organization develop and implement a retrenchment plan?
	If “Yes,” please describe and/or attach this plan.
	Is there any foreseen possibility of a major retrenchment in the next reporting year?	Yes	No
E	Known non-compliance with local laws, OPIC labor-related requirements, or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits)	Yes	No
	If “Yes,” please describe.
F	Is there an onsite trade union?	Yes	No
	If “Yes,” what percentage of workers are covered by a collective bargaining agreement?	_____%
G	Labor-related lawsuits against the project	Yes	No
	If “Yes,” please describe.
H	Labor unrest during the reporting period in the form of strikes or other general industrial disputes	Yes	No
	If “Yes,” please describe.
I	Ongoing or unresolved issues/disputes with a project trade union	Yes	No
J	Is there onsite security?	Yes	No
	If “Yes,” are security guards armed?	Yes	No
	Is security publicly or privately contracted?	Publicly Contracted	Privately Contracted
K	Was the project or project organization required to submit to OPIC any reports on employment or labor practices or systems during the reporting period?	Yes	No
	If “Yes,” please list reports and dates of transmission of the reports. If a required report has not yet been submitted, please leave the date field blank and specify in the comments section why it has not been submitted and when it is expected to be submitted.
		_____/______/____ Day / Month / Year
		_____/______/____ Day / Month / Year
		_____/______/____ Day / Month / Year
		_____/______/____ Day / Month / Year

BUSINESS INNOVATION
Please indicate if the project has operationalized a product, process, and/or technology that is new or not widely used in the domestic sector during the reporting period as a result of the OPIC-supported investment. Where applicable, please indicate whether any of these factors were new or uncommon in the project country and provide details.
A	Products and/or Services	New	Uncommon		No
	If “New” or “Uncommon”, please describe.
B	Business Processes	New	Uncommon		No
	If “New” or “Uncommon”, please describe.
C	Production and/or processing technologies	New	Uncommon		No
	If “New” or “Uncommon”, please describe.
D	Has the project provided technical assistance (e.g. training of customers, industry counterparts, suppliers, technical expertise from fund manager) during the reporting period?		Yes	No
	If “Yes”, please explain:
E	Has the project secured voluntary sustainability certification from an internationally recognized certifying authority during the reporting period?		Yes	No
	If “Yes”, please identify.

BENEFITS TO WOMEN, ENVIRONMENT, AND COMMUNITY
A	Does the Project (1) have any direct or ancillary benefits for women, (2) consider gender issues in the project design and/or implementation, or (3) include specific actions to address gender-related vulnerabilities?	Yes	No
	If Yes, please describe.
B	As a result of the OPIC-supported investment, has the project implemented new initiatives (either corporate or project-related) that are directed at restoring and/or preserving the environment during the reporting period?	Yes	No
	If “Yes” please explain (e.g. paperless banking, favorable financing terms for project clients engaging in activities which preserve the environment.
C	Did the project contribute money towards activities that benefit local communities (e.g. recreational facilities, schools, medical clinics, scholarship programs, other charitable activities) during the reporting period?	Yes		No
	If “Yes” please provide the value of these expenditures during the reporting period and describe these activities.	_____________$/year
D	Does the project have an Environment and Social Management System (ESMS)?	Yes			No
	If “Yes” please explain or attach a copy of the ESMS (in English)

ENVIRONMENTAL IMPACT
A	Is the project currently in compliance with all conditions in the OPIC contract or consent with respect to environment, health and safety?	Yes		No
	If “No”, please describe the areas of non-compliance.
B	Has the project been cited or fined for any violation of local or host country environmental, health or safety laws during the reporting period?	Yes		No
	If “Yes”, please explain briefly below.
C	Has the project submitted all OPIC-required reports on environment, health and safety during the reporting period?	Yes		No
	If “Yes”, please list reports and dates of transmission of the reports. If a required report has not yet been submitted, please leave the date field blank and specify in the comments section why it has not been submitted and when it is expected to be submitted
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
D	Have there been any changes in the design or capacity of the project that result in increased hazards to workers, area residents, or the environment during the reporting period?	Yes		No
	If yes, please describe briefly below.
E	Have any accidents occurred that resulted in loss of human life or material impacts on the environment during the reporting period?	Yes		No
	If so, describe briefly below.

PROJECT COUNTRY REGULATORY ENVIRONMENT
A		Has the project resulted from or caused any project country reforms, new legislation, or new regulations during the reporting period?					Yes	No
		If “Yes”, please explain.
	B	Has the project partnered with or received support from a public entity (i.e. – a local development bank/federal or local government/NGO) during the reporting period?					Yes	No
		If “Yes,” please indicate the type of party involved and describe their involvement.
			Project country government entity:      			International non-governmental organization:      
			Local non-governmental organization:      			U.S. entity:      
				Other:      

PROJECT OPERATIONAL PROCUREMENT
A	Has the project procured goods and services from project country sources during the reporting period?	Yes	No
	If “Yes,” please provide the average annual amount of operational procurement (excluding utilities, rent, tax payments, and labor) from project country sources during the reporting period.	$
	Please also briefly describe the goods and/or services that have been procured by OPIC support.

13. PROJECT PAYMENTS TO HOST GOVERNMENT
A	Please provide all taxes or transfers to the host government made by the project during the reporting period.	$______________
B	If the project is eligible for a tax holiday, indicate the duration of the tax holiday.	___ year(s)
C	If duties and/or tax payments to project country government have been reduced as a result of the project, please estimate the amount lost during the reporting period.	$____

PART II B – PROJECT COUNTRY EFFECTS

(For Financial Services Projects)

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

PORTFOLIO-TRANSACTION TYPE

Please identify the type of project transactions supported by the OPIC-supported investment. Check all that apply.

A

MICROFINANCE LOANS ONLY

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

SME LOANS ONLY

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

B

MICROFINANCE OR SME LOAN PORTFOLIO INFORMATION

If the OPIC investment supports Microfinance or SME loans, please provide the following total portfolio information for the reporting period:

Total Portfolio

OPIC-supported portfolio

Number of project transactions

#

#

Number of project clients

#

#

Value of project outstanding portfolio

$

$

Average transaction amount per client

$

$

Maximum transaction amount to a single client

$

$

Minimum transaction amount to a single client

$

$

Average tenor (in months)

# in months

# in months

Purpose of the transactions as a percentage of the outstanding value of portfolio A above.

Total Portfolio

OPIC-supported portfolio

Start-up Capital

%

%

Working Capital

%

%

Expansion Capital

%

%

Equipment Purchase

%

%

Other (please specify):

%

%s

Business activities/sectors of clients as a percentage of the outstanding value of portfolio 1 A above.

Total Portfolio

OPIC-supported portfolio

Manufacturing

%

%

Agriculture

%

%

Construction

%

%

Transportation

%

%

Communication

%

%

Tourism

%

%

Trade/Retail

%

%

Energy

%

%

Services (please specify):

%

%

Other (please specify):

%

%

Demographic distribution of clients as a percentage of the outstanding value of portfolio A above.

Total Portfolio

OPIC-supported portfolio

Rural Not Applicable We Do Not Track

%

%

Other (please specify): Not Applicable We Do Not Track

%

%

Project’s impact on female microfinance clients or women-owned or -led SMEs

Total Portfolio

OPIC-Supported Portfolio

Number of female clients and/or women-owned or -led SMEs Not Applicable We Do Not Track

#

#

Value of portfolio to female clients and/or women-owned or -led SMEs Not Applicable We Do Not Track

$

$

Please describe current initiatives that have increased the Financial Intermediary’s outreach and/or service to female borrowers and/or women-owned or women-led SMEs (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).

C

EQUITY INVESTMENTS

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

SME loans and Microfinance combined

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

EQUITY INVESTMENT OR OTHER PORTFOLIO INFORMATION

If the OPIC investment supports Equity Investments and/or Other Investments, please provide the following portfolio information for the reporting period.

Total Portfolio

OPIC-Supported portfolio

Number of project transactions

#

#

Number of project clients

#

#

Value of project outstanding portfolio

$

$

Average transaction amount per client

$

$

Maximum transaction amount to a single client

$

$

Minimum transaction amount to a single client

$

$

Average tenor (in months)

$

$

$

$

$

Economic segments of clients as a percentage of the outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Microenterprises

%

%

Small & Medium Enterprises

%

%

Large Corporations

%

%

Other (please specify):

%

%

Purpose of the transactions as a percentage of the outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Start-Up Capital

%

%

Working Capital

%

%

Expansion Capital

%

%

Equipment Purchase

%

%

Other (please specify):

%

%

Business activities/sectors of clients as a percentage of the outstanding value of portfolio 1 A above

Total Portfolio

OPIC-Supported Portfolio

Manufacturing

%

%

Agriculture

%

%

Construction

%

%

Transportation

%

%

Communication

%

%

Tourism

%

%

Trade/Retail

%

%

Energy

%

%

Services (please specify):

%

%

Other (please specify):

%

%

Demographic distribution of clients as a percentage of the outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Rural Not Applicable We Do Not Track

%

%

Other (please specify): Not Applicable We Do Not Track

%

%

Project’s impact on women-owned or led enterprises

Total Portfolio

OPIC-Supported Portfolio

Number of female clients, or women-owned and/or led enterprises Not Applicable We Do Not Track

#

#

Value of portfolio to female clients, or women-owned or -led enterprises Not Applicable We Do Not Track

$

$

Please describe current initiatives that have increased the Financial Intermediary’s outreach and/or service to female borrowers, or women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).

D

LEASING CONTRACTS

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

LEASING PORTFOLIO INFORMATION

If the OPIC investment will support Leasing, please provide the following total portfolio information and projections for the reporting period.

Total Portfolio

OPIC-Supported Portfolio

Number of project transactions

#

#

Number of project clients

#

#

Value of project outstanding portfolio

$

$

Average transaction amount per client

$

$

Maximum transaction amount to a single client

$

$

Minimum transaction amount to a single client

$

$

Average tenor (in months)

# in months

# in months

Please provide the economic segments of clients as a percentage of the outstanding total value of portfolio A above

Total Portfolio

OPIC-supported portfolio

Microenterprises

%

%

Small & Medium Enterprises

%

%

Large Corporations

%

%

Other (please specify):

%

%

Please provide the business activities/sectors of clients as a percentage of the total outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Manufacturing

%

%

Agriculture

%

%

Construction

%

%

Transportation

%

%

Communication

%

%

Tourism

%

%

Trade/Retail

%

%

Energy

%

%

Services (please specify):

%

%

Other (please specify):

%

%

Demographic distribution of clients as a percentage of the total outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Rural Not Applicable We Do Not Track

%

%

Other (please specify): Not Applicable We Do Not Track

%

%

Project’s impact on women-owned or led enterprises

Total Portfolio

OPIC-Supported Portfolio

Number of women-owned and/or led enterprises served Not Applicable We Do Not Track

#

#

Value of portfolio to women-owned or -led enterprises Not Applicable We Do Not Track

$

$

Please describe current initiatives that have increased the Financial Intermediary’s outreach and/or service women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).

E

CONSUMER LOANS

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

CONSUMER LOAN PORTFOLIO INFORMATION

If the OPIC investment supports Consumer Loans, please provide the following portfolio information for the reporting period:

Total Portfolio

OPIC-supported portfolio

Number of project transactions

#

#

Number of project clients

#

#

Value of project outstanding portfolio

$

$

Average transaction amount per client

$

$

Maximum transaction amount to a single client

$

$

Minimum transaction amount to a single client

$

$

Average tenor (in months)

# in months

# in months

Demographic distribution of clients as a percentage of the outstanding value of portfolio A above.

Total Portfolio

OPIC-supported portfolio

Rural Not Applicable We Do Not Track

%

%

Other (please specify): Not Applicable We Do Not Track

%

%

Project’s impact on female borrowers

Total Portfolio

OPIC-Supported Portfolio

Number of female clients served Not Applicable We Do Not Track

#

#

Value of portfolio to female clients Not Applicable We Do Not Track

$

$

Please describe current initiatives that have increased the Financial Intermediary’s outreach and/or service to female borrowers, or women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).

F

INSURANCE CONTRACTS

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

INSURANCE CONTRACTS PORTFOLIO INFORMATION

If the OPIC investment supports Insurance Contracts, please provide the following total portfolio information and projections for the reporting period.

Total Portfolio

OPIC-Supported Portfolio

Number of project transactions

#

#

Number of project clients

#

#

Value of project outstanding portfolio

$

$

Average transaction amount per client

$

$

Maximum transaction amount to a single client

$

$

Minimum transaction amount to a single client

$

$

Average tenor (in months)

# in months

# in months

Please provide the economic segments of clients as a percentage of the outstanding total value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Microenterprises

%

%

Small & Medium Enterprises

%

%

Large Corporations

%

%

Other (Please specify)

%

%

Please provide the business activities/sectors of clients as a percentage of the total outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Manufacturing

%

%

Agriculture

%

%

Construction

%

%

Transportation

%

%

Communication

%

%

Tourism

%

%

Trade/Retail

%

%

Energy

%

%

Services (please specify)

%

%

Other (please specify)

%

%

Demographic distribution of clients as a percentage of the total outstanding value of portfolio A above

Total Portfolio

OPIC-Supported

Rural Not Applicable We Do Not Track

%

%

Other (please specify): Not Applicable We Do Not Track

%

%

Project’s impact on women-owned or led enterprises

Total Portfolio

OPIC-Supported Portfolio

Number of female clients, or women-owned and/or led enterprises served Not Applicable We Do Not Track

#

#

Value of portfolio to female clients, or women-owned or -led enterprises Not Applicable We Do Not Track

$

$

Please describe current initiatives that have increased the Financial Intermediary’s outreach and/or service to female borrowers, or women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).

G

MORTGAGES

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

Other (please specify)

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

Total Portfolio

OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

MORTGAGE PORTFOLIO INFORMATION

If the OPIC investment supports Mortgages, please provide the following portfolio information and projections for the reporting period.

Total Portfolio

OPIC-Supported Portfolio

Number of projects transactions

#

#

Number of projects clients

#

#

Value of project outstanding portfolio

$

$

Average transaction amount per client

$

$

Maximum transaction amount to a single client

$

$

Minimum transaction amount to a single client

$

$

Average tenor (in months)

# in months

# in months

How much capital has been invested in the project as of the end of the reporting period?

$

$

Has the project received additional financing (public and/or private) during the reporting period?

Yes

No

If “Yes,” how much additional financing did the project receive during the reporting period?

$

Please provide the purpose of the mortgages as a percentage of the outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Mortgages for new homeowners

%

%

Home improvement loans

%

%

Productive loan (e.g. home equity, loan/line of credit)

%

%

Other (please specify):

%

%

Please provide the target market of mortgages as a percentage of the outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Low-income homes

%

%

Middle-income homes

%

%

High-income homes

%

%

Residential rental properties

%

%

Commercial properties

%

%

Other (please specify):

%

%

Please provide the demographic distribution of clients as a percentage of the outstanding value of portfolio A above

Total Portfolio

OPIC-Supported Portfolio

Rural Not Applicable We Do Not Track

%

%

Other (please specify): Not Applicable We Do Not Track

%

%

Project’s impact on Female Homeowners

Total Portfolio

OPIC-Supported Portfolio

Number of female homeowners served Not Applicable We Do Not Track

#

#

Value of portfolio to female homeowners Not Applicable We Do Not Track

$

$

Please describe current initiatives that have increased the Financial Intermediary’s outreach and/or service to female homeowners (i.e., tailored financial products/services, trainings, seminars, outreach to women associations).

3. PROJECT EMPLOYMENT
A	Please provide the current total number of project direct employees for operations & management
			Total Current Direct Employment (Operations and Management)
			Local					Foreign Nationals
			Male			Female
Managerial
Professional/Technical
Unskilled Labor
TOTAL
B		Has the project utilized workers employed by third parties (i.e., through contractors/subcontractors) during the reporting period?
		For physical construction			For administration needs				For other operational needs

4.PROJECT HUMAN RESOURCE MANAGEMENT
	Does the project have written human resources policies?	Yes			No
	Have there been any significant changes to the human resources policies during the reporting period?	Yes			No
	If “Yes,” please describe.
B	Please indicate the areas covered by the human resources policies:
	(Examples of Benefits: healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare, etc.)
	Is/are mechanism(s) in place for workers to express grievances(e.g., direct access to supervisors and/or the human resources department, workers’ committees, and/or trade unions reps, or an anonymous hotline)?	Yes			No
	Do general conditions of work 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
	Are disciplinary procedures in place?	Yes			No
C	Are terms of employment clearly communicated to each worker?	Yes			No
	If “Yes,” please describe how employment terms are communicated to each worker and attach verifying documentation, such as a sample employment contract.
D	Does the project management have experience in applying international labor standards, such as those in the IFC Performance Standards?		Yes	No
	If “Yes,” please specify.

	5. PROJECT LABOR-RELATED ISSUES
	A		Has there been a significant change since the beginning of the reporting period in the number of employees, composition of employees, demographics (gender, skill level, nationality/place of origin, etc.) of the workforce?				Yes			No
			If “Yes,” please describe.
	Did the project involve the following during the reporting period?
	B			Workers under the age of 18 (directly or indirectly employed by the project).				Yes			No
				If “Yes,” please briefly describe the general duties of these workers and include the age of the youngest worker.
	C			Restructuring which results in a major retrenchment (i.e. lays off significant numbers of workers)				Yes			No
				If “Yes,” please describe the positions, skill level, gender, and the national origin of the workers who were dismissed.
				If “Yes,” did the project organization develop and implement a retrenchment plan?
				If “Yes,” please describe and/or attach this plan.
				Is there any foreseen possibility of a major retrenchment in the next reporting year?				Yes			No
	D			Known non-compliance with local laws, OPIC labor-related requirements, or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits)				Yes			No
				If “Yes,” please describe.
	E			Labor-related lawsuits against the project				Yes			No
				If “Yes,” please describe.
	F			Labor unrest during the reporting period in the form of strikes or other general industrial disputes				Yes			No
				If “Yes,” please describe.
	G			Ongoing or unresolved issues/disputes with a project trade union				Yes			No
				If “Yes,” please explain.
H		Was the project or project organization required to submit to OPIC any reports on employment or labor practices or systems during the reporting period?			Yes				No
		If “Yes,” please list reports and dates of transmission of the reports. If a required report has not yet been submitted, please leave the date field blank and specify in the comments section why it has not been submitted and when it is expected to be submitted.
						_____/______/____ Day / Month / Year
						_____/______/____ Day / Month / Year
						_____/______/____ Day / Month / Year
						_____/______/____ Day / Month / Year

6. BUSINESS INNOVATION
Please indicate if the project operationalized a product, process, and/or technology that is new or not widely used in the domestic sector during the reporting period as a result of the OPIC-supported investment. Where applicable, please indicate whether any of these factors are new or uncommon in the project country and provide details.
A	New Financial Products and/or Services	New	Uncommon	No
	If “New” or “Uncommon”, please describe.
B	Business Processes	New	Uncommon	No
	If “New” or “Uncommon”, please describe.
C	Innovative Financing Structures	New	Uncommon	No
	If “New” or “Uncommon”, please describe.
D	Has the project provided technical assistance (e.g., training of customers, industry counterparts, suppliers, technical expertise from fund manager) during the reporting period?		Yes	No
	If “Yes”, please describe.
E	Has the project secured voluntary sustainability certification from an internationally-recognized certifying authority during the reporting period?		Yes	No
	If “Yes”, please identify.

7. BENEFITS TO WOMEN, ENVIRONMENT, AND COMMUNITY
A	Does (or will) the Project (1) have any direct or ancillary benefits for women, (2) consider gender issues in the project design and/or implementation, or (3) include specific actions to address gender-related vulnerabilities?		Yes		No
	If Yes, please describe.
B	As a result of the OPIC-supported investment, has the project implemented new initiatives (either corporate or transactional) which are directed at restoring and/or preserving the environment during the reporting period?		Yes		No
	If “Yes”, please describe (e.g.. paperless banking, favorable financing terms for project clients engaging in activities which preserve the environment).
C	Did the project contribute money towards activities that benefit local communities (e.g. recreational facilities, schools, medical clinics, scholarship programs, other charitable activities) during the reporting period?		Yes		No
	If “Yes,” please provide the actual value of these expenditures during the reporting period and describe these activities.	__________$/year
D	Does the project have an Environmental and Social Management System (ESMS)?			Yes		No
	If “Yes” please explain or attach a copy of the ESMS (in English).

8. ENVIRONMENTAL IMPACT
A	Is the project currently in compliance with all conditions in the OPIC contract or consent with respect to environment, health and safety?	Yes		No
	If “No”, please describe the areas of non-compliance.
B	Has the project been cited or fined for any violation of local or host country environmental, health or safety laws during the reporting period?	Yes		No
	If “Yes”, please explain briefly below.
C	Has the project submitted all OPIC-required reports on environment, health and safety during the reporting period?	Yes		No
	If “Yes”, please list reports and dates of transmission of the reports. If a required report has not yet been submitted, please leave the date field blank and specify in the comments section why it has not been submitted and when it is expected to be submitted
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
			_____/______/____ Day / Month / Year
D	Have there been any changes in the design or capacity of the project that result in increased hazards to workers, area residents, or the environment during the reporting period?	Yes		No
	If yes, please describe briefly below.
E	Have any accidents occurred that resulted in loss of human life or material impacts on the environment during the reporting period?	Yes		No
	If so, describe briefly below.

9. PROJECT COUNTRY REGULATORY ENVIRONMENT
A		Has the project resulted from or caused any project country reforms, new legislation, or new regulations during the reporting period?				Yes	No
		If “Yes”, please explain.
	B	Has the project partnered with or received support from a public entity (i.e. – a local development bank/federal or local government/NGO) during the reporting period?				Yes	No
		If “Yes,” please indicate the type of party involved and describe their involvement.
			Project country government entity:      		International non-governmental organization:      
			Local non-governmental organization:      		U.S. entity:      
			Other:      

10. PROJECT PAYMENTS TO HOST GOVERNMENT
	Please provide all taxes or transfers to the host government made by the project during the reporting period.	$______________
B	If the project is eligible for a tax holiday, indicate the duration of the tax holiday.	___ year(s)
C	If duties and/or tax payments to project country government have been reduced as a result of the project, please estimate the amount lost during the reporting period.	$____

PART III – U.S. Supplier and Procurement Information

Did the project procure any products and/or services from the United States during the reporting period?

Yes

No

As indicated on the cover page, the client data you provide is privileged business information that OPIC treats as confidential to the extent permitted by law. However, it is important for OPIC to be able to demonstrate some of the effects of your project. The historical supplier and procurement information is useful for OPIC to illustrate the specific benefits of your project for the U.S. economy. OPIC will not identify which specific project was associated with the U.S. supplier without your prior consent. Unless you provide an attached sheet with a compelling reason why this information should not be made public, OPIC intends to use the information in public statements and releases. It is important that you fill out each field for each U.S. supplier you list. If fields are missing, blank, or unclear, OPIC staff may follow up with you for additional information.

Please check all that apply below

Name of U.S. Supplier

City

State

Zip Code

Minority-owned business

Woman- owned business

U.S. small business

Type of Good or Service Please indicate if used (refurbished)

Amount Procured During the Reporting Period

Example: Acme, Inc.

Any town

NY

12345

Widgets

$ 100,000

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

     

     

  

  

     

$     

Remaining Procurement

$     

Totals

$     

PART IV – Investor / Representative Certification

Section A - Investor/Representative Certification (for Non-financial Services Projects)

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

Section B - Investor/Representative Certification (for Financial Services Projects)

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

Page 43 of 44