OPIC-248 (blackline cop)

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.

OFFICE OF INVESTMENT POLICY QUESTIONNAIRE

OPIC-248

OMB 3420-0032

Expiration Date: 12/31/2018

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 application 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. 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 2.8 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.

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 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” are defined 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.

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.

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 SUMMARY

INVESTMENT

FUNDS

REINSURANCE

INSURANCE

FINANCE

Please click on the appropriate OPIC product line:

PROJECT INFORMATION
A	Applicant (or Financial Intermediary) Name:
B	Project Name:
C	Target percentage ownership of Applicant (or Financial Intermediary) in the Project.		____%
D	Please provide the estimated percentage of local ownership of the Project, if any.		____%
E	Is any of the local ownership comprised of Small & Medium Enterprises (SMEs)?	Yes	No
	If Yes, please provide what percentage of local ownership is accounted for by Small & Medium Enterprises.		____%
F	Is there or will there be any female ownership of the Project?	Yes	No
	If Yes, please provide the percentage of the Project that is or will be female-owned.		____%
G	Please provide the current or projected number of members of the Project’s Board of Directors or other governing body, if applicable.	Male	Female
H	Please provide the number of current or projected number of women in executive management positions		____#
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 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 DESCRIPTION
A	Please check appropriate box:	Financial Services		Non-Financial Services
B	Please check appropriate box:	New Enterprise (no existing facilities and/or operations)		Existing Enterprise
C	Project City and Country:
D	Describe the use of proceeds of this OPIC-supported investment:
E	Description of the Project and its operations:
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 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 female 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		#		#
	Number of patient consultations provided per year to women		#		#
	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 question:			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 System (NAICS) code
	What is the Project 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)			_________#

PROJECT SITING
A	Project Site Location (please include GPS coordinates and, if available, a map of site location):
B	Please indicate whether the Project 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 ENVIRONMENTAL AND SOCIAL CHARACTERISTICS
A	Please indicate if the Project 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 COUNTRY EFFECTS

(For Non-Financial Services Projects)

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 year five 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 is operational?

Yes

No

For physical construction

For administrative needs

For other operational needs

	2. PROJECT 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 employees during the construction phase.
			Employment (Construction Phase )
			Local			Foreign nationals
Managerial
Professional/Technical
Unskilled Labor
TOTAL
	C	Will the Project utilize workers employed by third parties (i.e., through contractors/subcontractors) during Project start-up or construction phase?						Yes	No
		For physical construction		For administrative needs		For other operational needs
	D	Will the Project require the establishment of temporary worker housing facilities?						Yes	No
		If Yes, how many workers are expected to be housed at these facilities? ____________

3. JOB QUALITY
A	Does or will the Project (or Project Company) offer employee development programs, such as tuition reimbursement or formal mentorships to both current and new non-management employees identified above in Question 1A above?	Yes				No
	If Yes, please describe what type of employee development programs will be available to professional/technical and/or unskilled personnel.
B	Does or will the Project (or Project Company) 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:
C	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
D	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 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	Does the Project specifically serve female clients or customers?		Yes		No
	If Yes, please provide the number of female clients that are currently served per year and projected to be served by the 5th year of operations.		Current: # per year		Projected by 5th year: # per year
C	As a result of this OPIC-supported investment, will the Project 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 clients engaging in activities which preserve the environment).

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

5. PROJECT HUMAN RESOURCE MANAGEMENT
A	Does (or will) the Project 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:
	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
	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.	Yes	No
	If Yes, please indicate the person who is (or will be) responsible for implementing the Project Company’s human resource policies.	Yes	No
D	Does (or will) the Project have management experience in applying international labor standards, such as those in the IFC Performance Standards?	Yes	No
	If Yes, please specify.

6. PROJECT LABOR-RELATED ISSUES
Does (or will) the Project involve the following?
A	Migrant or foreign workers (excluding foreign national management or highly-skilled non-manual workers).	Yes	No
B	Workers under the age of 18 (directly or indirectly employed by the Project).	Yes	No
C	Restructuring which results in a major retrenchment (i.e., lays off significant numbers of workers).	Yes	No
	If Yes, please describe.
D	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.
F	Labor-related lawsuits against the Project.	Yes	No
	If Yes, please describe.
G	Labor unrest in the last three years in the form of strikes or other general industrial disputes.	Yes	No
	If Yes, please describe.
H	Ongoing or unresolved issues/disputes with a Project 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. BUSINESS INNOVATION
Please indicate if the Project 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. Where applicable, please indicate whether any of these factors are 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 (if New or Uncommon, please describe).	New	Uncommon	No
	If New or Uncommon, please describe.
D	Will there be any technical assistance provided by the Project?		Yes	No
	If Yes, please describe.
E	Has (or will) the Project secure(d) voluntary sustainability certification from an internationally-recognized certifying authority?		Yes	No
	If Yes, please identify.

PART IIB – PROJECT COUNTRY EFFECTS

(For Financial Services Projects)

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)	%
	# of clients that are women or women-owned businesses	%

PROJECT PORTFOLIO – TRANSACTION TYPE & PORTFOLIO INFORMATION
Please identify the type of Project 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 transactions	# (per year)	# (total over next five years)
	Number of Project clients	#	# (total over next five years)
	Value of Project 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	Purpose of the transactions as a percentage of the outstanding value of the Microfinance portfolio in A above.	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 outstanding value of the applicable 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	Project’s impact on Female Borrowers
	Does (or will) the Financial Intermediary serve female borrowers?	Yes	No
	If Yes, number of female clients	Current Portfolio #	5-year Projections #
	If Yes, value of portfolio to female clients	Current Portfolio US$	5-year Projections US$
	Will the OPIC-supported investment increase lending to female clients?	Yes	No
	If Yes, please indicate the US$ value of the OPIC-supported investment that will be specifically earmarked for lending to female borrowers (if applicable).		US$
	If Yes, how many new female borrowers are projected to be served by the OPIC-supported investment (total over next five years)?		#
	Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to female borrowers (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).
E	Demographic distribution of clients as a percentage of the number of clients in the applicable portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
	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 transactions	# (per year)	# (total over next five years)
	Number of Project clients	#	# (total over next five years)
	Value of Project 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	Project’s impact on women-owned and/or led SMEs
	Does (or will) the Financial Intermediary serve women-owned and/or managed SMEs?	Yes	No
	If Yes, number of women-owned and/or led SMEs	Current Portfolio #	5-year Projections #
	If Yes, value of SME portfolio to women-owned and/or led enterprises	Current Portfolio US$	5-year Projections US$
	Will the OPIC-supported investment increase lending to women-owned and/or led SMEs?	Yes	No
	If Yes, please indicate the US$ value of the OPIC-supported investment that will be specifically earmarked for investment to women-owned and/or led SMEs (if applicable).		US$
	If Yes, how many new women-owned and/or led SMEs are projected to be served by the OPIC-supported investment (total over next five years)?		#
	Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations.)
E	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
	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 transactions		# (per year)	# (total over next five years)
	Number of Project clients		#	# (total over next five years)
	Value of Project 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		Project’s impact on Female Borrowers
		Does (or will) the Financial Intermediary serve female borrowers?	Yes	No
		If Yes, number of female clients	Current Portfolio #	5-year Projections #
		If Yes, value of portfolio to female clients	Current Portfolio US$	5-year Projections US$
		Will the OPIC-supported investment increase lending to female clients?	Yes	No
		If Yes, please indicate the US$ value of the OPIC-supported investment that will be specifically earmarked for lending to female borrowers (if applicable).		US$
		If Yes, how many new female borrowers are projected to be served by the OPIC-supported investment (total over next five years)?		#
		Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to female borrowers (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).
D		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
		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 transactions	# (per year)	# (total over next five years)
	Number of Project clients	#	# (total over next five years)
	Value of Project 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	Project’s impact on Female Homeowners
	Does (or will) the Financial Intermediary serve female homeowners?	Yes	No
	If Yes, number of female homeowners	Current Portfolio #	5-year Projections #
	If Yes, value of portfolio to female homeowners	Current Portfolio US$	5-year Projections US$
	Will the OPIC-supported investment increase lending to female homebuyers?	Yes	No
	If Yes, please indicate the US$ value of the OPIC-supported investment that will be specifically earmarked for lending to female homebuyers (if applicable).		US$
	If Yes, how many new female homebuyers are projected to be served by the OPIC-supported investment (total over next five years)?		#
	Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to female homebuyers (i.e., tailored financial products/services, trainings, seminars, outreach to women).
E	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
	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 transactions	# (per year)	# (total over next five years)
	Number of Project clients	#	# (total over next five years)
	Value of Project 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	Project’s impact on women-owned and/or led enterprises
	Does (or will) the Financial Intermediary invest in women-owned and/or led enterprises?	Yes	No
	If Yes, number of women-owned and/or led enterprises	Current Portfolio #	5-year Projections #
	If Yes, value of portfolio to women-owned and/or managed enterprises	Current Portfolio US$	Current Portfolio US$
	Will the OPIC-supported investment increase investment in women-owned and/or led enterprises?	Yes	No
	If Yes, please indicate the $US value of the OPIC-supported investment that will be specifically earmarked for investment to women-owned and/or led enterprises (if applicable).	US$
	If Yes, how many new women-owned and/or led enterprises are projected to be served by the OPIC-supported investment (total over next five years)?	#
	Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).
F	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
	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 transactions	# (per year)	# (total over next five years)
	Number of Project clients	#	# (total over next five years)
	Value of Project 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	Project’s impact on women-owned and/or led enterprises
	Does (or will) the Financial Intermediary serve women-owned and/or led enterprises?	Yes	No
	If Yes, number of women-owned and/or led enterprises	Current Portfolio #	5-year Projections #
	If Yes, value of portfolio to women-owned and/or led enterprises	Current Portfolio US$	Current Portfolio US$
	Will the OPIC-supported investment increase leasing to women-owned and/or led enterprises?	Yes	No
	If Yes, please indicate the $US value of the OPIC-supported investment that will be specifically earmarked for leasing to women-owned and/or led enterprises (if applicable).		US$
	If Yes, how many new women-owned and/or led enterprises are projected to be served by the OPIC-supported investment (total over next five years)?		#
	Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).
E	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
	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 transactions	# (per year)	# (total over next five years)
	Number of Project clients	#	# (total over next five years)
	Value of Project 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	Project’s impact on women-owned and/or led enterprises
	Does (or will) the Financial Intermediary serve women-owned and/or led enterprises?	Yes	No
	If Yes, number of women-owned and/or led enterprises	Current Portfolio #	5-year Projections #
	Value of portfolio to women-owned and/or led enterprises	Current Portfolio US$	Current Portfolio US$
	Will the OPIC-supported investment increase insurance to women-owned and/or led enterprises?	Yes	No
	If Yes, please indicate the US$ value of the OPIC-supported investment that will be specifically earmarked for insurance to women-owned and/or led enterprises (if applicable).		US$
	If Yes, how many new women-owned and/or led enterprises are projected to be served by the OPIC-supported investment (total over next five years)?		#
	Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to women-owned and/or led enterprises (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).
E	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
	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 transactions	# (per year)	# (total over first five years)
	Number of Project clients	#	# (total over first five years)
	Value of Project 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	Project’s impact on Female Borrowers
	Does (or will) the Financial Intermediary serve female borrowers?	Yes	No
	If Yes, number of female clients	Current Portfolio #	5-year Projections #
	If Yes, value of portfolio to female clients	Current Portfolio US$	5-year Projections US$
	Will the OPIC-supported investment increase lending to female clients?	Yes	No
	If Yes, please indicate the US$ value of the OPIC-supported investment that will be specifically earmarked for lending to female borrowers (if applicable).		US$
	If Yes, how many new female borrowers are projected to be served by the OPIC-supported investment (total over next five years)?		#
	Please describe current and/or future initiatives that will increase the Financial Intermediary’s outreach and/or service to female borrowers (i.e., tailored financial products/services, trainings, seminars, outreach to women entrepreneur associations).
F	Demographic distribution of clients as a percentage of the number of clients in the portfolio in A above.	Current Portfolio	Projected OPIC-supported portfolio
		#
	Rural	%	%
	Other (please specify):      	%	%

3.    PROJECT FINANCIAL INTERMEDIARY EMPLOYMENT

A

Please provide the current and projected number of Project employees for operations & management of the Financial Intermediary.

Current Employment (Operations and Management)

Projected Employment (Operations & Management) by 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 is operational?

For physical construction

For administrative needs

For other operational needs

4. JOB QUALITY
A	Does or will the Financial Intermediary offer employee development programs, such as tuition reimbursement or formal mentorships to both current and new non-management employees identified above in Question 1A above?	Yes				No
	If Yes, please describe what type of employee development programs will be available to professional/technical and/or unskilled personnel.
B	Does or 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:
C	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
D	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 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 this OPIC-supported investment, will the Project 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 clients engaging in activities which preserve the environment).
C	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
D	Does the Project have an Environmental and Social Management System (ESMS)?	Yes	No
	If Yes, please attach a copy of the ESMS (in English).

6. PROJECT HUMAN RESOURCE MANAGEMENT
A	Does (or will) the Project 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:
	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
	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.	Yes	No
	If Yes, please indicate the person who is (or will be) responsible for implementing the Project Company’s human resource policies.	Yes	No
D	Does (or will) the Project have management experience in applying international labor standards, such as those in the IFC Performance Standards?	Yes	No
	If Yes, please specify.

7. PROJECT LABOR-RELATED ISSUES
Does (or will) the Project involve the following?
A	Workers under the age of 18 (directly or indirectly employed by the Project).	Yes	No
	If Yes, please describe.
B	Restructuring which results in a major retrenchment (i.e., lays off significant numbers of workers).	Yes	No
	If Yes, please describe.
C	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.
D	Labor-related lawsuits against the Project.	Yes	No
	If Yes, please describe.
E	Labor unrest in the last three years in the form of strikes or other general industrial disputes.	Yes	No
	If Yes, please describe.
F	Ongoing or unresolved issues/disputes with a Project trade union.	Yes	No
	If Yes, please describe.

8. BUSINESS INNOVATION
Please indicate if the Project 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. Where applicable, please indicate whether any of these factors are new or uncommon in the Project Country and provide details.
A	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	Will there be any technical assistance provided by the Project?		Yes	No
	If Yes, please describe.
E	Has (or will) the Project secure(d) voluntary sustainability certification from an internationally-recognized certifying authority?		Yes	No
	If Yes, please describe.

PART III – EFFECTS OF PROJECT ON THE U.S. ECONOMY

PROJECT COUNTRY REGULATORY ENVIRONMENT
A	Does (or will) the Project 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 Country government have majority ownership or effective management control of the Project?	Yes	No
	If Yes, please explain.
C	Are there any Project Country performance requirements (e.g., local content requirements or incentives, minimum export requirements, maximum import requirements, or local hiring requirements) that might affect Project imports, exports, or employment?	Yes	No
	If Yes, please explain.
D	Does (or will) the Project result from or cause any Project Country reforms, new legislation, or new regulations?	Yes	No
	If Yes, please explain.

INITIAL SOURCES OF PROJECT 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 (e.g., USAID grants, Export-Import Bank financing, U.S. Trade and Development Agency grants)? (please specify)	$	$	$
D	Project Country sources (please specify source and amounts per source):	$	$	$	$
E	Non-U.S. and non-Project 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 FUNDING TOTAL :	$	$	$	$

INITIAL USES OF PROJECT FUNDING
Refers to expenditures financed by the Project Funding Total included in Question 2H 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 FUNDING USES:	$

INITIAL PROJECT 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 PROCUREMENT
A	Will the Project procure goods and services from the U.S on an on-going basis after the Project is fully operational?	Yes	No
B	Will the Project procure goods and services from Project Country sources on an on-going basis after the Project is fully operational?	Yes	No
	If Yes, please provide the average annual value of the Project’s purchases of goods and services (excluding internal labor and utility costs) from domestic suppliers as a result of this OPIC-supported investment. Projections should be annual averages over a five year time horizon after the Project is fully operational.	$
	Please briefly describe the goods and/or services that will be procured by these funds.

OPERATIONAL PROJECT U.S. PROCUREMENT
Please list items to be procured from the U.S. once the Project is fully operational. Figures provided below should be annual averages over a five year time horizon after the Project 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 SALES/PRODUCTION or INTEREST/FEE REVENUE (FOR FINANCIAL INTERMEDIARIES)

A

Please provide current annual sales (or interest and fee revenue if a financial intermediary) and projected increases in annual sales (or interest and fee revenue) 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 Projected Annual Production Capacity

Current Annual Gross Sales Value/Revenue ($US)

Current Annual Volume (Units)

Increase in Gross Annual Sales Value/Revenue ($US)

Increase in Annual Volume (Units)

Total Annual Gross Sales Value/ Revenue ($US)

Total Annual Volume (Units)

TOTAL

B

Does the Project currently export or plan to export any of its production?

Yes

No

C

If Yes, please provide current annual exports 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

Current Annual Export Sales

Projected Increase in Annual Export Sales as a result of this OPIC-Supported Investment

Total Projected Annual Exports by 5th year of operations

$US

Volume (Units)

$US

Volume (Units)

$US

Volume (Units)

TOTAL

$

$

$

D

Will the Project reduce dependency on imports?

Yes

No

If Yes, please explain.

8. PROJECT PAYMENTS TO HOST GOVERNMENT
A	Please provide all transfers to the host government made by the Project.
Project Country		Current Annual Payment Figure ($US)	Projected Increase in Annual Payment Figure as a result of this OPIC-Supported Investment ($US)	Total Projected Annual Payments ($US)
TOTAL
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 will be reduced as a result of the Project, please estimate the amount lost.			$____

9. FINANCIAL OUTFLOW FROM PROJECT COUNTRY
In each column, estimate the Project average annual financial outflow from the Project 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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