Form DFC‐009 Aligned Capital Investor Screener

Aligned Capital Investor Screener
(DFC-009)
OMB No. [
]
Expiration Date: _______

United States International Development Finance Corporation
1100 New York Avenue, NW Washington, DC 20527-0001
An Agency of the United States Government

Paperwork Reduction Act Notice: This information is voluntary. Federal agencies may
not collect information unless a valid OMB Control Number with an expiration date that
has not expired is displayed. The public reporting burden for this collection of information
is estimated to average 20 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspects of this collection of information,
including suggestions for reducing this burden, to Agency Clearance Officer, Records
Management, United States International Development Finance Corporation, 1100 New
York Avenue, NW, Washington, DC, 20527 and to the DFC Desk Officer at the Office of
Information and Regulatory Affairs, Office of Management and Budget, New Executive
Office Building, Room 10202, Washington, DC 20503.

Aligned Capital Investor Screener
Form: DFC-010
OMB Number: XXXX-XXXX
Expiration Date: [

]

Instructions
The information in this form is used to determine if an investor may participate in DFC’s Aligned Capital
Program and, if an investor does, to place their information into the program. The Aligned Capital
Program is designed to align development finance and investment with other capital, including
philanthropic, socially responsible and impact investment, to enable effective deployment of that capital
towards projects in the countries and sectors in which DFC works.
In order to participate, investors must meet the specified criteria.
To begin, click below.

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Part A—Identifying Information

1. INVESTOR (This is the entity that will be making the investment or an investment advisor. For all
purposes of this form, this entity is the “Investor.”)
Name:
Address (including city and country):
Phone Number(s):

2. AUTHORIZED REPRESENTATIVE (This is the individual who should receive potential investment
information.)
Name of Representative:
Relationship to the Investor:
Address (including city and country):
Phone Number(s):
E-mails(s):

Part B—Investor Screening Questions
The information requested in this section will determine the Investor’s eligibility to enroll in this
program.
Is the Investor an entity organized under the laws of a U.S. state or territory?
____ Yes
____ No
Is the Investor an “accredited investor” within the meaning of Rule 501 of Regulation D under
the U.S. Securities Act of 1933, as amended (the “Securities Act”)?
____ Yes
____ No
Is the Investor an agency of the U.S. Government?
____ Yes
____ No

Check the box or boxes below that are next to the categories under which the Investor qualifies
as an accredited investor. (Please mark each category that applies.)

FOR CORPORATIONS, FOUNDATIONS, ENDOWMENTS, PARTNERSHIPS, LIMITED LIABILITY
COMPANIES OR SIMILAR BUSINESS TRUSTS:
A legal entity with total assets in excess of $5,000,000 not formed for the specific
purpose of making an investment in a specific company.
An entity all of the equity owners of which are Accredited Investors.

FOR INVESTMENT COMPANIES, AND BROKER-DEALERS:
An investment company registered under the Investment Company Act of 1940,
as amended (the “1940 Act”).
A business development company as defined in Section 2(a)(48) of the 1940
Act.
A Small Business Investment Company licensed by the U.S. Small Business
Administration under Section 301(c) or (d) of the Small Business Investment Act
of 1958, as amended.
A private business development company as defined in Section 202(a)(22) of
the Investment Advisers Act of 1940, as amended (the “Advisers Act”).
A broker or dealer registered pursuant to Section 15 of the Securities Exchange
Act of 1934, as amended.

Select the description below that applies to the Investor.
Foundation with an endowment of at least $5M
Non-Profit Entity (that is not a foundation) with investment capacity of at least
$5M OR with grant-making capacity of at least $1M
Fund manager with assets under management of at least $15M AND with at least
$5M of available capital
Investment company with net current assets of at least $20M

Does the Investor have the knowledge and experience in financial and business matters to
evaluate the merits and risks of an investment and make independent investment decisions?
____ Yes
____ No

Part C—Matching Questions
The information requested in this section will be used to identify potential investments that may be of
interest to the Investor. Please indicate the types of investments the Investor is interested in
considering.
Please select one or more applicable responses for each question:
1. Asset Classes/Types of Investments and Sizes of Investment (Select each type of investment the
Investor would consider and the size per type of investment the Investor would consider for
each class, not total amount of all investments Investor may consider.)
(a)____ Equity
[Drop down with dollar ranges]
(b)____ Convertible Debt
[Drop down with dollar ranges]
(c)____ Subordinated/Mezzanine Debt
[Drop down with dollar ranges]
(d)____ Senior Debt
[Drop down with dollar ranges]
(e)____ Grants/Technical Assistance
[Drop down with dollar ranges]
2. Total Project Size (Select the total target size of investment, meaning the investment to be made
by all investors in a given project, including debt.)
[Drop down with dollar ranges]

3. Preferred Investment Vehicle (Select the type(s) of investment vehicles that the Investor would
consider.)
____ Any
____ Investing directly into a company that is building/operating a project—Operating
Company/Project Company/Special Purpose Vehicle
____ Investing indirectly through another entity that invests (usually via equity) in
companies—Investment Vehicle/Fund/Holding Company
____ Investing indirectly through another entity that invests (usually via debt) in companies—
Financial Intermediary/Bank/Non-Bank Financial Institution

____ Investing indirectly through another entity that invests in companies in one or more
ways—Hybrid Vehicles
4. Sectors (Identify sectors of interest to the Investor.)
[Drop down list of DFC Sectors]
5. Regions and Countries (Identify regions and countries of interest to the Investor.)
[Drop down list of DFC Regions and Countries]
6. Does the Investor have, or intend to have, a performance metric or other system for measuring
social impact and/or environmental impact?
____ Yes

____ No

Part D—Disclaimers and Certifications
The person completing this form represents and warrants that you are authorized to register on behalf
of the Investor described in this Aligned Capital Investor Screener and that all information provided is
accurate and truthful.
The undersigned hereby certifies that the selections herein are consistent with any investment
guidelines or limitations applicable to the Investor. The Investor is capable of evaluating the merits and
risks of an investment and that purchase of any investment may be deemed to be a speculative
investment and is not intended as a complete investment program. The undersigned hereby certifies
that the undersigned acknowledges that an investment is designed only for investors who have
adequate means of providing for their needs and contingencies without relying on distributions or
withdrawals from their investment accounts; who are financially able to maintain their investment; and
who can afford the loss of their investment. There can be no assurance that any investment will achieve
its objective, and investors may lose all or a substantial portion of their investment.
DFC does not control, is not responsible for, has not reviewed and does not endorse any investee that is
participating in the Aligned Capital Program. DFC does not warrant the accuracy, completeness or
usefulness of the information provided by third parties. Participation by an investee in this program
does not imply a commitment by DFC to support the project.
The information provided does not constitute investment advice. Users need to consult with their own
investment, accounting, legal and tax advisers to evaluate independently the risks, consequences and
suitability of any investment made by them.
DFC may terminate the program at any time, with or without notice.

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