Form DFC‐012 Economic Screening Questionnaire

DFC Economic Questionnaire (DFC-012)
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
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
in this document must be accurate as of the date of submission. Anyone who knowingly makes a
false statement with the intent to influence DFC’s guarantees, loans, or other investments may
be criminally prosecuted. Such false statements are also grounds for DFC to terminate a
commitment or declare a contract default. These rights are in addition to any other rights or
remedies available to United States government. Neither submission nor acceptance of this
application implies that the proposed transaction is eligible for support or that support will be
provided.
When trade secrets or confidential commercial or financial information are submitted to the
agency in this collection, they will be held in confidence to the extent permitted by applicable
law including the Freedom of Information Act (“FOIA”) at 5 U.S.C. § 552(b)(4) and the agency’s
implementing regulations at 22 C.F.R. Part 706.
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 2
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 aspects of this collection
of information, including suggestions for reducing this burden, to Agency Clearance Officer,
Records Management, United States International Development 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.

DFC Economic Questionnaire
This questionnaire is to be used on an as needed basis to collect information about potential
exports of DFC-supported projects.
1. Project company name:
2. Location of the project (country):
3. SIC/NAICS/HTS Code for each product produced: (www.census.gov/epcd/www/naics.html;
www.census.gov/epcd/www/sic.html; www.usitc.gov/tata/hts/bychapter/index.htm)
Indicate: ☐ SIC ☐ NAICS ☐ HTS code
Product description

SIC/NAICS/HTS Code

Please provide any additional information on specific details about the product(s) below:

4. Will the project result in a reduction of employment (i.e., replacement of production
overseas or outsourcing of goods and services)? If so, please explain:

5. Current and incremental increase in annual production capacity at completion of
the project (by 5th year after completion), both domestic sales and export:
Product

Current value
($)

Current volume
Incremental
(indicate units) sales value ($)

$

$

$

$

$

$

$

$

Note: For volume, use the appropriate units for the product – metric tons, number of items, etc.
Incremental refers to the amount developed due to the DFC provided support

Incremental
volume
(indicate units)

6. Current and incremental increase in annual exports at completion of the project (by
5th year after completion):
Product

Country

Current value
($)

Current
Incremental
volume
sales value ($)
(indicate units)

$

$

$

$

$

$

$

$

Note: For volume, use the appropriate units for the product – metric tons, number of items, etc.
Incremental refers to the amount developed due to the DFC provided support

Incremental
volume
(indicate
units)