Form DFC-008 Development Outcomes Survey

DEVELOPMENT OUTCOMES SURVEY (DFC-008)

OMB [ ]

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 Project officer’s knowledge and belief. Statements of fact provided to DFC 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.

Information contained in this form will be deemed designated as “confidential commercial information” in accordance with Freedom of Information Act (FOIA) regulations at 22 C.F.R. Part 706, and will be treated as such to the extent permitted by applicable law.

Paperwork Reduction Act Notice: This information is required to retain benefits. 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 2.0 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 Finance Corporation 1100 New York Ave., 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, D.C. 20503.

Rights Under the Privacy Act of 1974

 

The Privacy Act of 1974, as amended (5 U.S.C. § 552a), prohibits the disclosure without consent of information about individuals that the federal government maintains in a system of records. Agencies are required to give the public notice of their systems of records by publication in the Federal Register. The Act also provides individuals with a means by which to seek access to and amendment of their records, although such requests are subject to exemptions as set forth in the Privacy Act. In addition, the Act allows individuals to bring suit against an agency for violating the Privacy Act.

 

The Development Outcomes Survey (DOS) Form 008 is the principal document used by the DFC to review and update a client’s developmental impact profile and determine the project’s compliance with environmental, labor, and economic policies, as consistent with DFC’s authorizing legislation. As part of the DOS we are required to collect privacy information related to U.S. Citizens, lawful permanent resident, or a non-U.S. Citizens.  If we store information about you in a system of records from which we retrieve that information by personal identifier (e.g., name, personal email address, home mailing address, personal or mobile phone number, etc.), we will safeguard your information in accordance with the Privacy Act. DFC adheres to Privacy Act requirements with respect to all information about individuals that it collects, maintains, uses, or disseminates in a System of Records, regardless of whether the information pertains to a U.S. Citizen, lawful permanent resident, or a non-U.S. Citizen. However, the rights to seek access to and amendment of covered records, and to bring suit for alleged violations of the Privacy Act, only extend to U.S. citizens and legal permanent residents (as defined in 5 U.S.C. § 552a(a)(2)) and citizens of designated foreign countries or regional economic organizations (as defined under the Judicial Redress Act of 2015, 5 U.S.C. § 552a note). Nonetheless, because we have an interest in maintaining records that are accurate and complete, non-U.S. citizens may seek amendment of records under the procedures described in the DFC’s Privacy Act Regulation.

 

DFC’s Privacy Act regulations can be found at 22 C.F.R. Part 706.  Instructions on submitting a Privacy Act request are located at 22 C.F.R. § 707.21.

 

Personally identifiable information not contained in a system of records is protected under the Federal Information Security Modernization Act of 2014.  44 U.S.C. §§ 3554(a)(1)(A)(i), 3552(b)(3)(B).

 

For the general contact information that may be submitted through www.dfc.gov, we have completed a System of Records Notice (SORN) providing details about the privacy protections and redress options for information we collect from the public.  For further information, please reference the documentation below.

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

1. PROJECT DESCRIPTION AND OWNERSHIP PROFILE [Q101 – Q110 TO BE COMPLETED BY PROJECT OFFICER]

The information in this section will ask for you to confirm some background and descriptive information about the Project. For this section, “applicant” can refer to investors, lenders, insurers, reinsurers, Project sponsors, financial intermediaries, or fund managers who seek DFC support. “Project” refers to direct investments, subprojects, or investment funds who use DFC-supported financial intermediaries that will benefit from DFC support.

[PROGRAMMER NOTE: PREFILL VARIABLES FOR SECTION 1. ALLOW RESPONDENTS TO EDIT INFORMATION. NEW DATA STORED IN SEPARATE VARIABLE].

Q101 Applicant Name:

Q102 Project Name:

Q103 Does this Project operate in a single country, in multiple countries, throughout a region, or will it be global?

1. Single Country

2. Multiple Countries

3. Regional

4. Global

Q104 [IF Q103=1, ASK]: A. In what country does this Project operate? _________

[IF Q103=1, ASK]: B. What is the total amount the Project has spent or invested in this country? _____$ (In US Dollars)

Q105 [IF Q103=2, ASK]: A. What is the first country the Project operated in? _____________

[IF Q103=2, ASK]: B. What is the total amount the Project has spent or invested in this country? ________$ (In US Dollars)

[IF Q103=2, ASK]: C. What is the next country the Project operated in? _____________

[IF Q103=2, ASK]: D. What is the total amount the Project has spent or invested in this country? ________$ (In US Dollars)

[IF Q103=2, ASK]: E. Are there more countries where this Project will operate? Yes / No

(PROGRAMMING NOTE: Repeat C and D until respondent says “No” to E.)

Q106 [IF Q103=3, ASK]: In what region does the Project operate? _________

[IF Q103=3, ASK]: What is the total amount the Project spent or invested in this region? _____$ (In US Dollars)

Q107 In what city is the Project’s headquarters or main office located? ___________________

Q108 Project Site Location (please include GPS coordinates and a map of the site location, if available):

Q109Does Will this Project operate or invest in any of the following sectors?

Yes No

1. Agriculture, Forestry, Fishing and Hunting

2. Mining, Quarrying, and Oil and Gas Extraction

3. Utilities

4. Construction

5. Manufacturing

6. Wholesale Trade

7. Retail Trade

8. Transportation and Warehousing

9. Information

10. Finance and Insurance

11. Real Estate and Rental and Leasing

12. Professional, Scientific, and Technical Services

13. Management of Companies and Enterprises

14. Administrative and Support and Waste Management and Remediation Services

15. Educational Services

16. Health Care and Social Assistance

17. Arts, Entertainment, and Recreation

18. Accommodation and Food Services

19. Other Services (except Public Administration)

20. Public Administration

Q110A Please specify the DFC product(s) being requested for this Project: (Multiple Responses Allowed, Select All That Apply)

1. Debt – direct loan

2. Debt – investment guarantee

3. Equity

4. Political risk insurance

5. Technical Development

6. MTU Loan Guarantees

[IF Q110A=5, ASK]: Q110B Is this technical development a Grant, Technical Assistance, or a Feasibility Study?

Q110C Is this Project considered a Financial Intermediary? Yes / No

[IF Q110C=YES, ASK]: Q110D Is this Project an investment fund? Yes / No

Q110E Is this Project information still current and accurate? Yes / No

[IF Q110E=“No”, then stop survey and SHOW NOTE]: Please get in touch with your Project Officer to update any inaccurate information BEFORE filling out the rest of the 008.

[Q112 – Q124 TO BE COMPLETED BY APPLICANT]

The information in this section will ask for background and descriptive information about the Project. Questions will cover Project ownership, leadership, and profile of the target market.

Q112 Is this Project owned or managed (either completely or partially) by any individuals or enterprises located in the host country? Yes / No

[IF YES TO Q112, ASK]: Q112 A. How many host country owners are men?

[IF YES TO Q112, ASK]: Q112 B. How many host country owners are women?

[IF YES TO Q112, ASK]: Q112 C. How many host country executive level managers are men?

[IF YES TO Q112, ASK]: Q112 D. How many host country executive level managers are women?

Q113 Is this Project overseen by a Board of Directors in the host country? Yes / No

[IF Q113=YES, ASK]: A. How many host country board of directors members are men?

[IF Q113=YES, ASK]: B. How many host country board of directors members are women?

Q114 [IF Q110B = YES] A. How many of the Project’s Investment Committee members are male?

[IF Q110B = YES] B. How many of the Project’s Investment Committee members are female?

Q119 What is the percentage of local ownership of the Project? Not Applicable

[IF 0 OR NOT APPLICABLE, SKIP TO Q201]

Q120 What percentage of local ownership is comprised of Small & Medium Enterprises (SMEs)?

Q121 Has the Project description changed since it was originally approved by DFC? Yes / No

[IF Q121=YES, ASK] Q121a. Please select the type of changes below:

Yes No

New business lines

Exited markets

New products or services

Exited product lines or services

New international markets

Other

Q122 Has the Project become operational? Yes / No

[IF Q122=YES, ASK] Q122a Please enter the date when the Project became operational? Month/Year

[IF Q122=NO, ASK] Q122b Please specify the use(s) of the Project funds during the past 12 months. Select all that apply.

Engineering

Construction (non-production)

Consulting

Marketing

Other, please specify:

Q123 Please specify the Project’s most recently completed fiscal year and use data from this year to complete the rest of this form.

Start Date (Month/Year)

End Date (Month/Year)

Q124 What is the Project’s target client or customer?

2. PROJECT ENVIRONMENTAL AND SOCIAL CHARACTERISTICS [TO BE COMPLETED BY APPLICANT]

The information in this section will ask about programs and management characteristics for the Project. Questions will cover your Environment and Social Management System (ESMS), trade unions, collective bargaining agreements, and onsite security.

Q201 Does your Project currently have: Yes / No

1. An Environmental and Social Policy Document

2. An organizational structure showing who is responsible for each part of your Environmental and Social Policy

3. An Occupational Health and Safety Plan

4. An Environmental and Social Management Plan

5. An Emergency Preparedness and Response Plan

6. A Stakeholder Engagement Plan

7. A formal Grievance Mechanism for Communities with concerns about the Project

[IF YES TO ANY Q201A – Q201G, ASK]: Q202A – Q202G Please click here to upload this document. For the grievance mechanism, include information about past and ongoing complaints not previously reported to DFC and whether the mechanism undergoes a regular third party audit to assess its effectiveness.

Q202H Is the Project currently in compliance with all conditions in the DFC contract or consent with respect to environment, social impacts, health

and safety? Yes/No

[IF Q202H=NO, ASK] Q202I Please describe the areas of non-compliance:

Q202J Has the Project been cited or fined for any violation of local or host country environmental, human rights, health or safety laws during the

past 12 months? Yes/No

[IF Q202J=YES, ASK] Q202K Please explain:

Q207 Does the Project have onsite security? Yes / No

[IF Q207 = YES, ASK]: Q207A Are security guards armed? Yes / No

[IF Q207 = YES, ASK]: Q207B Is security publicly or privately contracted? Yes (Publicly) / Yes (Privately) / No, not contracted

Q209 Has the Project submitted all DFC-required reports on environment, health and safety during the past 12 months? Yes/No

[IF Q209=YES, ASK] Q209A Please list the 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.

Q210 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 past 12 months? Yes/No

[IF Q210=YES, ASK] Q210A Please describe:

Q211 Have any accidents occurred that resulted in loss of human life or material impacts on the environment during the past 12 months? Yes/No

[IF Q211=YES, ASK] Please describe:

3. PROJECT HUMAN RESOURCES MANAGEMENT AND JOB QUALITY [TO BE COMPLETED BY APPLICANT]

The information in this section will ask about human resource policies, labor standards, and employee benefits.

Q301 Does the Project (or the organization running the Project) have a written human resources policy? Yes / No

[IF Q301=YES, ASK] Q301A Have there been any significant changes to the human resources policies during the past 12 months? Yes/No

[IF Q301A=YES, ASK] Q301B Please describe the changes that occurred:

[IF Q301 = YES, ASK]: Q302 Does the Project’s human resources policy include any of the following: Yes / No

1. Policies prohibiting child labor

2. Policies prohibiting forced labor

3. Non-discrimination and Equal Opportunity policies

4. Sexual Harassment policies

5. Collective Bargaining/workers organizations policies

6. Disciplinary procedures

7. Policies for Hours of Work

8. Overtime arrangements and overtime compensation

9. Wages and benefits

10. Wage deductions

11. Breaks, Rest days, Leave for illness, maternity, vacation, or holiday policies

12. Established process for workers’ to express grievances (grievance mechanisms)

13. Dedicated staff member who is the point of contact for these policies

14. Healthcare

15. Pension Plan

16. Extended paid maternity leave

17. Extended pay paternity leave

18. Child care

19. Flexible work schedules

20. Advanced education stipends

21. Other higher education opportunities

[IF YES TO Q302S, ASK:] Q302S_1 Please provide the number of host country (local) employees with flexible work schedules. _______#

[IF YES TO Q302R, ASK:] Q302R_1 Please provide the number of host country (local) employees receiving child care benefits. _______#

[IF YES TO Q302P or Q302Q, ASK:] Q302PQ_1 Please provide the number of host country (local) employees receiving extended paid maternity/paternity leave. _____# Paternity_____# Maternity

[IF YES TO Q302T, ASK:] Q302T_1 Please provide the gender breakdown for the number of host country (local) employees receiving advanced education stipends or other higher education opportunities.

Female Male

Stipends # #

Other higher education # #

Q303 Please click here to upload a copy of the human resources policies (in English).

Q304 Are terms of employment communicated to workers verbally, in writing, or both?

1. Verbally

2. In writing

3. Both

Q305 [IF Q304 = 2 or 3, ASK] Please click here to upload a copy of a sample employment contract (in English).

Q306 Does the Project currently meet any international labor standards or certifications? Yes / No

[IF Q306 = YES, ASK]: Q306A Please specify the standard or certification ______

[IF Q306 = YES, ASK]: Q306B Please describe how it will be applied on this Project _______

[IF Q306 = YES, ASK]: Q306C Any more? Yes / No

Q307 Does the Project plan to meet [any/additional] international labor standards or gain certifications in the future? Yes / No

[IF Q307 = YES, ASK]: Q307A Please specify the standard or certification ______

[IF Q307 = YES, ASK]: Q307B Please describe how it will be applied on this Project _______

[IF Q307 = YES, ASK]: Q307C Any more? Yes / No

Q308 Does the Project offer employee career development programs, such as tuition reimbursement or mentorships to any NEW NON-MANAGEMENT employees in the host country? Yes / No

[IF Q308 = YES, ASK]: Q308A Does the Project offer education stipends to NEW NON-MANAGEMENT employees? Yes / No

[IF Q308 = YES, ASK]: Q308B Does the Project offer any other education opportunities to NEW NON-MANAGEMENT employees? Yes / No

[IF Q308B = YES, ASK]: Q308C Please describe the opportunities offered:

[IF Q110D=YES, SHOW: “For these next questions, we want to know about policies in the host country where the fund headquarters are located. You do not need to take into consideration all of the other countries where the fund may be investing.]

Q309 Does the Project offer non-management employees benefits that go beyond the host country’s legal requirements? Yes / No

[IF Q309 = YES, ASK]: Q309A Which benefits for non-management employees go beyond what is legally required by the host country?

Q310 Does the Project offer employees any Family Friendly Benefits that go beyond what is legally required by the host country? Please check all that apply:

1. Flexible work schedules

2. Extended paid maternity leave

3. Paid paternity leave

4. Access to child care or child care stipends through the Project

5. Family healthcare

Q311 Does the Project include any initiatives to advance women in their workforce beyond what is legally required by the host country ? Yes / No

[IF Q311=YES, ASK] Q311A Do these initiatives include any of the following: [SELECT ALL THAT APPLY]

A written policy on diverse representation and a system to monitor compliance

Flexible work arrangements for female employees

A written policy to combat and prevent sexual harassment and a system to monitor compliance

A written policy to compensate employees fairly and equitably and a system to monitor compliance

A written policy to support progression/promotion of employees fairly and a system to monitor compliance

A written anti-discrimination policy for its employees and a system to monitor compliance

Employment benefits

Employee training program(s)

Other [PLEASE SPECIFY]:

Q312 How many employees have been promoted during the past 12 months?

[IF Q312>0, ASK] Q312A How many of these promotions were from unskilled positions to professional or technical positions?

[IF Q312>0, ASK] Q312B How many of these promotions were from professional or technical positions to managerial positions?

Q313 Has there been a significant change over the past 12 months in the number of employees, composition of employees, demographics (gender, skill level, nationality/place of origin, etc.) of the workforce? Yes/No

[IF Q313=YES, ASK] Q313A Please describe: _________

Q314 Has the Project caused layoffs of workers in the past 12 months? Yes / No

[IF YES TO Q314, ASK]: Q314A How many workers were laid off? ______#

[IF YES TO Q314, ASK]: Q314B Please describe what caused these layoffs.

[IF YES TO Q314, ASK]: Q314C How many layoffs were female employees? _______#

[IF YES TO Q314, ASK]: Q314D Please provide the national origin(s) of the employees laid off.

[IF YES TO Q314, ASK]: Q314E Please indicate how many layoffs occurred for each of the following:

1. Managers #

2. Professional/Technical #

3. Entry Level #

[IF YES TO Q314, ASK]: Q314F Did the Project develop and implement a retrenchment plan? Yes/No

[IF YES TO Q314, ASK]: Q314G Please click here to attach a copy of the plan.

Q314H Does the Project expect additional layoffs in the next reporting year? Yes/No

Q315 Is the Project working with an onsite trade union? Yes / No

[IF YES TO Q315, ASK]: Q316 What percentage of Project workers are covered by a collective bargaining agreement? ________ %

[IF Q316 > 0, ASK]: Q316A Please click here to upload a copy of the collective bargaining agreement.

Q317 To the best of your knowledge, has the Project experienced any of the following? This can be self-diagnosed, or as a result of official inspections or other audits. Yes / No

A. Violation of host country (local) laws or other labor standards

B. Labor-related lawsuits and grievance mechanism complaints against the Project

C. Strikes or other labor disputes in the last 3 years

D. Ongoing or unresolved disputes with a trade union

E. DFC labor-related requirements

Q318. Was the Project required to submit to DFC any reports on employment or labor practices or systems during the past 12 months? Yes/No

[IF Q318=YES, ASK]: Q318A Please list the 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.

4. PROJECT BENEFITS TO THE ENVIRONMENT AND THE COMMUNITY [TO BE COMPLETED BY APPLICANT.]

This section will ask about the Project’s efforts to help the environment and local communities.

[IF Q110D=YES, SKIP Q401 – Q405 AND ONLY ASK Q406]

Q401 Has the Project taken any actions to help restore or preserve the environment? (Do NOT include actions required by law or permit in the host country)? Yes / No

[IF Q401 = YES, ASK]: These next questions will ask about specific actions related to the environment the Project plans to take. If the Project has taken more than one action to help restore of preserve the environment, list each action separately.

Q401A What action was taken to help restore or preserve the environment?

Q401B How did this action help restore or preserve the environment?

Q401C How did the Project measure the impact this action will have on the environment?

Q401D Will any other actions be taken to help restore or preserver the environment? Yes / No

(PROGRAMMING NOTE: Repeat Q401A – Q401D until respondent says “No” to Q401D.)

Q402 Does the Project currently meet any international environmental standards or certifications? Yes / No

[IF Q402 = YES, ASK]: These next questions will ask about international environmental standards or certifications the Project currently meets. If the Project meets more than one standard, list each separately.

Q402A Please specify the standard or certification ______

Q402B Please describe how it is applied on this Project _______

Q402C Does the Project currently meet any additional environmental standards? Yes / No

(PROGRAMMING NOTE: Repeat Q402A – Q402C until respondent says “No” to Q402C.)

Q403 Does the Project plan to meet [any/additional] international environmental standards or gain certifications in the future? Yes/No

[IF Q403 = YES, ASK]: These next questions will ask about international environmental standards or certifications the Project plans to meet in the future. If the Project plans to meet more than one standard, list each separately.

Q403A Please specify the standard or certification ______

Q403B Please describe how it will be applied on this Project _______

Q403C Will the Project meet any additional environmental standards? Yes / No

(PROGRAMMING NOTE: Repeat Q403A – Q403C until respondent says “No” to Q403C.)

Q404 Does the Project currently have a voluntary sustainability certification from an internationally-recognized authority? Yes / No

[IF Q404 = YES, ASK]: These next questions will ask about voluntary sustainability certifications the Project currently has. If the Project currently meets more than one standard, list each separately.

Q404A Please specify the standard or certification ______

Q404B Please describe how it is applied on this Project _______

Q404C Does the Project currently have any additional sustainability certifications? Yes / No

(PROGRAMMING NOTE: Repeat Q404A – Q404C until respondent says “No” to Q404C.)

Q405 Does the Project plan to meet [any/additional] voluntary sustainability certifications in the future? Yes / No

[IF Q405 = YES, ASK]: These next questions will ask about sustainability certifications the Project plans to meet in the future. If the Project plans to receive more than one certification, list each separately.

Q405A Please specify the certification ______

Q405B Please describe how it was applied on this Project _______

Q405C Has the Project receive any additional sustainability certifications? Yes / No

(PROGRAMMING NOTE: Repeat Q405A – Q405C until respondent says “No” to Q405C.)

Q406 Does the Project support any charitable activities to benefit the local community in which they operate? (Do NOT include the goods and/services the Project will produce for customers in the local community.) Yes / No

[IF Q406 = YES, ASK]:

Q406A How much money was spent on these charitable activities in the past 12 months? _____$/year

Q406B Please describe the charitable activities the Project supports:

Q406C Were these charitable activities developed or administered in collaboration with local stakeholders in the host country? Yes/No

[IF Q406C = YES, ASK]: Q406D Please describe who the Project collaborates with and what this collaboration involves:

5. BUSINESS INNOVATION AND TECHNICAL ASSISTANCE [TO BE COMPLETED BY APPLICANT.]

The information in this section will ask about innovative aspects of the Project, including financial structures, new products or services, and/or operational/production processes that create efficiencies.

[IF Q110D=YES, SHOW: “For investment funds answering the following questions, please think about investments into portfolio companies you expect the fund will make and the impacts of those investments. Please think of portfolio companies as the fund’s customers for this section.”]

Q501 Does the Project use a new or uncommon financial structure or business model that has not been used in this market before in order to mobilize private capital or increase competition in the market? Yes / No

[IF Q501 = YES, ASK]: Q501A Please describe the new or uncommon financial structure being used.

Q502 Does the Project use DFC support to offer a new product that is not currently produced or available in the host country, a new process that increases distribution or efficiency, or introduce any new technology into the host country? Yes / No

[IF Q502 = YES, ASK Q503 – Q505]: Did the Project introduce any of the following to the host country for the first time:

Q503 New products or services Yes / No

[IF Q503 = YES, ASK]: Q503A Please describe how the Project’s product or service is different from what is currently available:

Q504 New business processes Yes / No

[IF Q504 = YES, ASK]: Q504A Please describe how this business process impacts Project operations, customers, or the overall market:

Q505 New production or processing technology Yes / No

[IF Q505 = YES, ASK]: Please describe how this technology impacts Project operations, customers, or the overall market:

[IF Q110D=YES, SKIP Q507]

Q506 Does the Project provide technical assistance to customers? Yes / No

[IF Q506 = YES] Q506A Please describe this technical assistance including how it is funded and how its effectiveness is measured:

[IF Q506 = YES] Q506B How many customers does the Project provide technical assistance to? _______#

[IF Q506 = YES] Q506C How much money was spent on technical assistance for customers in the past 12 months?

Q507 Does the Project provide technical assistance to suppliers? Yes / No

[IF Q507 = YES] Q507A Please describe this technical assistance including how it is funded and how its effectiveness is measured:

[IF Q507 = YES] Q507B How many suppliers does the Project provide technical assistance to? _______#

[IF Q507 = YES] Q507C How much money was spent on technical assistance for suppliers in the past 12 months?

6. PROJECT COMPETITIVE POSITION [TO BE COMPLETED BY APPLICANT]

The information in this section will ask about Project market share and new legislation or regulations resulting from the Project.

Q601 Please estimate how many firms currently provide the same or similar products or services in the host country? _______#

[IF Q111=2, ASK]: Q602 What is the Project’s estimated current market share? ________%

Q604 Has the Project led to new host country reforms, new legislation, or new regulations in the past 12 months? Yes/No

[IF Q604 = YES, ASK]: Q604A Please explain what changes occurred and how the Project lead to these changes.

Q605 Please provide the number of direct competitors currently operating in the Project market.

Q606 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 past 12 months? Yes/No

[IF Q606=YES, ASK] Q606A 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:

7. PROJECT OPERATIONAL EMPLOYMENT [TO BE COMPLETED BY APPLICANT]

This section will ask about current Project employees for operations only. Do not include construction, buildout, or startup employees; those employees will be asked about later. We will ask about different types of employees including MANAGERS, PROFESSIONAL/TECHNICAL, ENTRY LEVEL STAFF, and UNSKILLED LABOR. We will ask about FULL TIME, PART TIME, SEASONAL, and CONTRACT employees separately.

• For Investment Funds, we are asking for the number of current employees at the Fund level who will be working at the fund’s offices.

• For other Financial Intermediaries, we are asking for the number of current employees that will service the DFC-supported portfolio(s).

We will ask several detailed questions about the operations staff you currently employ so you may need to refer to your employment records to answer questions in this section.

For this first section, please think about FULL TIME MANAGERS for this Project.

Q701 How many FULL TIME MANAGERS from the host country does the Project currently employ? _____

[Q701>0, ASK]: Q701A Of these FULL TIME MANAGERS in the host country, how many are FEMALE? _________

[Q701>0, ASK]: Q701B Of these FULL TIME MANAGERS in the host country, how many are YOUTH (15-24 years old)?

Q701C How many current FULL TIME MANAGERS are foreign nationals (not from the host country)? ___________

For the next set of questions, please think about FULL TIME PROFESSIONAL/TECHNICAL employees for this Project.

Q703 How many FULL TIME PROFESSIONAL/TECHNICAL employees from the host country does the Project currently employ? ___

[Q703>0, ASK]: Q703A Of these FULL TIME PROFESSIONAL/TECHNICAL employees in the host country, how many are FEMALE?

[Q703>0, ASK]: Q703B Of these FULL TIME PROFESSIONAL/TECHNICAL employees in the host country, how many are YOUTH (15-24 years old)? _____

Q703C How many current FULL TIME PROFESSIONAL/TECHNICAL employees are foreign nationals? _____

Q704C What is the average monthly wage (in local currency) that is paid to full-time equivalent professional/technical employees?$_

For the next set of questions, please think about FULL TIME UNSKILLED LABORERS for this Project.

Q707 How many FULL TIME UNSKLLED LABORERS from the host country does the Project currently employ? __

[Q707>0, ASK]: Q707A Of these FULL TIME UNSKLLED LABORERS in the host country, how many are FEMALE?

[Q707>0, ASK]: Q707B Of these FULL TIME UNSKLLED LABORERS in the host country, how many are YOUTH (15-24 years old)?__

Q707C How many current FULL TIME UNSKLLED LABORERS are foreign nationals? ____________

Q708C What is the average monthly wage (in local currency) that is paid to full-time equivalent unskilled employees? $___

For this next section, we will ask you about any PART TIME EMPLOYEES for this Project.

[ASK ALL]: Q709 Does the Project employ any PART TIME workers? Yes / No

For the next set of questions, please think about PART TIME MANAGERS for this Project.

[Q709=YES, ASK]: Q710 How many PART TIME MANAGERS from the host country does the Project currently employ? ____________

[Q709=YES AND Q710>0, ASK]: Q710A Of these PART TIME MANAGERS in the host country, how many are FEMALE? ____________

[Q709=YES AND Q710>0, ASK]: Q710B Of these PART TIME MANAGERS in the host country, how many are YOUTH (15-24 years old)? ____________

[Q709=YES, ASK]: Q710C How many current PART TIME MANAGERS are foreign nationals? ____________

For this next set of questions, please think about PART TIME PROFESSIONAL/TECHNICAL employees for this Project.

[Q709=YES, ASK]: Q712 How many PART TIME PROFESSIONAL/TECHNICAL employees from the host country does the Project currently employ? ____

[Q709=YES AND Q712>0, ASK]: Q712A Of these PART TIME PROFESSIONAL/TECHNICAL employees in the host country, how many are FEMALE?

[Q709=YES AND Q712>0, ASK]: Q712B Of these PART TIME PROFESSIONAL/TECHNICAL employees in the host country, how many are YOUTH (15-24 years old)? ____________

[Q709=YES, ASK]: Q712C How many current PART TIME PROFESSIONAL/TECHNICAL employees are foreign nationals? ____________

For the next set of questions, please think about PART TIME UNSKILLED LABORERS for this Project.

[Q709=YES, ASK]: Q716 How many PART TIME UNSKLLED LABORERS from the host country does the Project currently employ? ____________

[Q709=YES AND Q716>0, ASK]: Q716A Of these PART TIME UNSKLLED LABORERS in the host country, how many are FEMALE? ____________

[Q709=YES AND Q716>0, ASK]: Q716B Of these PART TIME UNSKLLED LABORERS in the host country, how many are YOUTH (15-24 years old)? ____________

[Q709=YES, ASK]: Q716C How many current PART TIME UNSKLLED LABORERS are foreign nationals? _______

[IF Q110D=YES, SKIP Q718 and GOTO Q728]

For this next section, we will ask you about any SEASONAL EMPLOYEES for this Project.

Q718 Does the Project employ any SEASONAL workers? Yes / No

For the next set of questions, please think about SEASONAL MANAGERS for this Project.

[IF Q718=YES, ASK]: Q719 On average, how many months per year do the Project’s seasonal employees work? _____

[Q718=YES, ASK]: Q720 How many SEASONAL MANAGERS from the host country does the Project currently employ? _________

[Q718=YES AND Q720>0, ASK]: Q720A Of these SEASONAL MANAGERS in the host country, how many are FEMALE? _________

[Q718=YES AND Q720>0, ASK]: Q720B Of these SEASONAL MANAGERS in the host country, how many are YOUTH (15-24 years old)?____________

[Q718=YES, ASK]: Q720C How many current SEASONAL MANAGERS are foreign nationals? ____________

For the next set of questions, please think about SEASONAL PROFESSIONAL/TECHNICAL employees for this Project.

[Q718=YES, ASK]: Q722 How many SEASONAL PROFESSIONAL/TECHNICAL employees from the host country does the Project currently employ? ___

[Q718=YES AND Q722>0, ASK]: Q722A Of these SEASONAL PROFESSIONAL/TECHNICAL employees in the host country, how many are FEMALE?

[Q718=YES AND Q722>0, ASK]: Q722B Of these SEASONAL PROFESSIONAL/TECHNICAL employees in the host country, how many are YOUTH (15-24 years old)? _____

[Q718=YES, ASK]: Q722C How many current SEASONAL PROFESSIONAL/TECHNICAL employees are foreign nationals? _______

For this next set of questions, please think about SEASONAL UNSKILLED LABORERS for this Project.

[Q718=YES, ASK]: Q726 How many SEASONAL UNSKLLED LABORERS from the host country does the Project currently employ?

[Q718=YES AND Q726>0, ASK]: Q726A Of these SEASONAL UNSKLLED LABORERS in the host country, how many are FEMALE?

[Q718=YES AND Q726>0, ASK]: Q726B Of these SEASONAL UNSKLLED LABORERS in the host country, how many are YOUTH (15-24 years old)? __

[Q718=YES, ASK]: Q726C How many current SEASONAL UNSKLLED LABORERS are foreign nationals? ________

Now we will ask about CONTRACTORS OR SUBCONTRACTORS employed by this Project.

[IF Q728=YES, ASK]: Q728A What type(s) of jobs do these workers complete? Please select all that apply.

1. Physical construction

2. Administrative work

3. Custodial work

4. Security services

5. Other operational needs

[IF Q728A = 1, SHOW] Physical construction[IF Q728A = 1, ASK]: How many contracts for physical construction has the Project issued in the past 12 months? _______#

[IF Q728A = 1, ASK]: How many contract workers in total are employed through these contracts? _______#

[IF Q728A = 1, ASK]: Of these contracted workers how many are unskilled laborers? _______#

[IF Q728A = 1, ASK]: Of these contracted workers how many are foreign nationals? _______#

[IF Q728A = 1, SHOW] Administrative work [IF Q728A = 2, ASK]: How many contracts for administrative work has the Project issued in the past 12 months? _______#

[IF Q728A = 2, ASK]: How many contract workers in total are employed through these contracts? _______#

[IF Q728A = 2, ASK]: Of these contracted workers how many are unskilled laborers? _______#

[IF Q728A = 2, ASK]: Of these contracted workers how many are foreign nationals? _______#

[IF Q728A = 1, SHOW] Custodial work

[IF Q728A = 3, ASK]: How many contracts for custodial work has the Project issued in the past 12 months? _______#

[IF Q728A = 3, ASK]: How many contract workers in total are employed through these contracts? _______#

[IF Q728A = 3, ASK]: Of these contracted workers how many are unskilled laborers? _______#

[IF Q728A = 3, ASK]: Of these contracted workers how many are foreign nationals? _______#

[IF Q728A = 1, SHOW] Security services

[IF Q728A = 4, ASK]: How many contracts for security services has the Project issued in the past 12 months? _______#

[IF Q728A = 4, ASK]: How many contract workers in total are employed through these contracts? _______#

[IF Q728A = 4, ASK]: Of these contracted workers how many are unskilled laborers? _______#

[IF Q728A = 4, ASK]: Of these contracted workers how many are foreign nationals? _______#

[IF Q728A = 1, SHOW] Other operational needs

[IF Q728A = 5, ASK]: How many contracts for other operational needs has the Project issued in the past 12 months? _______#

[IF Q728A = 5, ASK]: Please describe these operations related contracted jobs:

[IF Q728A = 5, ASK]: How many contract workers in total are employed through these contracts? _______#

[IF Q728A = 5, ASK]: Of these contracted workers how many are unskilled laborers? _______#

[IF Q728A = 5, ASK]: Of these contracted workers how many are foreign nationals? _______#

We will finish this section by asking about those employed by the Project who are disabled and/or disadvantaged.

[ASK ALL]: Q739 Does the Project employ any disabled people? Yes / No

[Q739=YES, ASK]: Q739A How many disabled employees from the host country does the Project currently employ?

[Q739=YES, ASK]: Q739B How many disabled employees who are foreign nationals does the Project currently employ? ________

[ASK ALL]: Q740 Does the Project employ any disadvantaged people? Yes / No

[Q740=YES, ASK]: Q740A How many disadvantaged employees from the host country does the Project currently employ? ________

[Q740=YES, ASK]: Q740B How many disadvantaged employees who are foreign nationals does the Project currently employ? ______

Q741 Please provide the total amount currently paid each year to Project employees in the host country (total annual local payroll). Do not include foreign nationals working on the Project.

[ASK ALL]: Q743 Next, thinking about all people directly employed by the Project, how many are US Citizens? _____

8. MACROECONOMIC IMPACTS ON US, LOCAL, AND THIRD COUNTRY ECONOMIES [TO BE COMPLETED BY APPLICANT]

The information in this section will ask about Project benefits to the U.S. economy, Project funding, and operating expenditures.

[ASK ALL]: Q801 Please describe how the Project benefits U.S. businesses or the U.S. economy?

We would like to know more about funding for this Project. For these questions, please provide amounts in US Dollars.

[ASK ALL]: Q802 Did the Project received additional funding from other US government agencies, not including DFC support during the past 12 months? Yes/No

[IF Q802=YES, ASK]: Q802A What is the name of this funding source? [LIST OF USG AGENCIES ]

[IF Q802=YES, ASK]: Q802B How much funding did the Project receive from {INSERT SOURCE NAME} in US Dollars over the past 12 months? $_______

[ASK ALL]: Q803 Does the Project receive private-sector funding from US sources, including the Applicant organization? Yes/No

[IF Q803=YES, ASK]: Q803A What is the name of this funding source? ________________

[IF Q803=YES, ASK]: Q803B How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $_______

[ASK ALL]: Q804 Does the Project receive public-sector funding from US sources? Yes/No

[IF Q804=YES, ASK]: Q804A What is the name of this funding source? ________________

[IF Q804=YES, ASK]: Q804B How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $_______

[ASK ALL]: Q805 Does the Project receive funding from any other development finance or multilateral organizations? Yes/No

[IF Q805=YES, ASK]: Q805A What is the name of this funding source? [DROP DOWN LIST OF ORGANIZATIONS]

[IF Q805=YES, ASK]: Q805B How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $____

[ASK ALL]: Q806 Does the Project receive funding from private-sector sources within the host country? Yes/No

[IF Q806=YES, ASK]: Q806A What is the name of this funding source? ________________

[IF Q806=YES, ASK]: Q806B How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $_____

[ASK ALL]: Q807 Does the Project receive public-sector funding from sources within the host country? Yes/No

[IF Q807=YES, ASK]: Q807A What is the name of this funding source? ________________

[IF Q807=YES, ASK]: Q807B How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $_______

[ASK ALL]: Q808 Does the Project receive funding from private-sector sources located outside the host country, not including the United States? Yes/No

[IF Q808=YES, ASK]: Q808A What is the name of this funding source? ________________

[IF Q808=YES, ASK]: Q808B How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $______

[ASK ALL]: Q809 Does the Project receive public-sector funding from sources located outside the host country, not including the United States? YES/NO

[IF Q809=YES, ASK]: Q809A What is the name of this funding source? ________________

[IF Q809=YES, ASK]: Q809B How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $_______

[ASK ALL]: Q810 Does the Project receive initial funding from any other source not listed above? Yes / No

[IF Q810=YES, ASK]: Q810A What is the name of this funding source? ________________

[IF Q810=YES, ASK]: Q810B Is this a public source or private source of funding? Public / Private

[IF Q810=YES, ASK]: Q810C How much funding does the Project receive from {INSERT SOURCE NAME} in US Dollars? $______

9. IMPACT ON CURRENT U.S. EMPLOYMENT [TO BE COMPLETED BY APPLICANT FOR PROJECTS PROVIDING NON-FINANCIAL PRODUCTS/SERVICES]

The next few questions will ask about Project business procedures such as outsourcing.

[IF Q110C=NO, ASK]: Q901 Do any U.S. investors in the Project currently produce the same product as this Project? Yes / No

[IF Q110C=NO AND Q901=YES, ASK]: Q902 How many people are currently employed by this U.S. company or subsidiaries that currently produces the product and are investing in this Project?

[IF Q110C=NO AND Q901=YES, ASK]: Q903 Have there been fewer employees of this U.S. company or subsidiaries making the product(s) in the U.S. as a result of this Project? Yes / No

[IF Q903=YES, ASK]: Q903A How many fewer employees of this U.S. company or subsidiaries now make the product(s) in the U.S. as a result of this Project? ____________employees

[IF Q110C=NO AND Q901=YES, ASK]: Q904 Has the Project allowed this U.S. company or subsidiaries to outsource any business process that was previously done in the United States? Yes / No

[IF Q110C=NO, ASK]: Q905 Not including the U.S. investors to this Project we just asked about, do any other U.S. companies currently produce the same product as this Project? Yes / No

[IF Q110C=NO AND Q905=YES, ASK]: Q906 Which U.S. companies currently produce the same product as this Project?

[IF Q110C=NO AND Q905=YES, ASK]: Q907 How many people are currently employed by these other U.S. companies that currently produces the product?

[IF Q110C=NO AND Q905=YES, ASK]: Q908 Have there been fewer employees at these other companies making the product(s) in the U.S. as a result of this Project? Yes / No

[IF Q110C=NO AND Q905=YES, ASK]: Q909 Have any of these other companies outsourced any of these business processes that were previously done in the US since the Project started operation? Yes / No

10. SPENDING ON PROCUREMENT OF GOODS AND SERVICES, TAXES [TO BE COMPLETED BY APPLICANT FOR PROJECTS THAT ARE NON-FINANCIAL INTERMEDIARY]

For this next section, we would like to know more about how and where Project funds will be spent. First, we would like to know us how much will be spent on goods and services.

[IF Q110C=NO, ASK]: Q1001 How much was spent on goods and services from companies in the United States over the past year?$

[IF Q110C= NO, ASK]:Q1002 How much was spent on goods and services from companies in the host country over the past year? _$

[IF Q110C= NO, ASK]:Q1003 How much was spent on goods and services from companies not in the United States or host country over the past year? $

[IF Q110C= NO AND Q1001>0]: You estimated that ${FILL Q1001 RESPONSE} of the Project’s funding was spent on goods or services from U.S. companies over the past year. For the next questions, please think only about NEW products -- do not include any USED products. Answer for one product at a time. If the Project purchased more than one product from US companies, we will ask about each product separately.

[IF Q110C= NO AND Q1001>0, ASK]: Q1004 What is the name of the product or service that was purchased from a US company?

[IF Q110C= NO AND Q1001>0, ASK]: Q1005 From what US company was this product or service purchased? ____________

[IF Q110C= NO AND Q1001>0, ASK]: Q1006 Where is the US company that produces this product or service located?

A City:_________________

B State: (DROP DOWN LIST OF STATES)

[IF Q110C= NO AND Q1001>0, ASK]: Q1007 What is the total amount this Project spent on this good or service? $_____

[IF Q110C= NO AND Q1001>0, ASK]: Q1007 Did the Project purchase any other goods or services from US companies? Yes / No

(PROGRAMMING NOTE: REPEAT Q1001 – Q1007 UNTIL RESPONDENT SAYS “NO” TO Q1007.)

[Q110C= NO AND Q1002>0]: You estimated that ${FILL Q1002 RESPONSE} of the Project’s funding was spent on goods or services in the host country. We would like to know more about your current local suppliers.

[Q110C= NO AND Q1002>0, ASK]: Q1008 How many local suppliers do you purchase goods and services from?

[Q110C= NO AND Q1002>0, ASK]: Q1009 How many local suppliers are women owned or led enterprises?

[Q110C= NO AND Q1002>0, ASK]: Q1010 How many local suppliers are classified as microenterprises (companies with fewer than 10 employees)?

[Q110C= NO AND Q1002>0, ASK]: Q1011 How many local suppliers are classified as SMEs by the local government?

[Q110C= NO AND Q1002>0, ASK]: Q1012 How many local suppliers are smallholder farmers?

[Q110C= NO AND Q1002>0, ASK]: Q1013 How many local suppliers are owned or led by disadvantaged populations?

[IF Q110C= NO AND Q1003>0]: Q1013A You estimated that ${FILL Q1002 RESPONSE] of the Project’s funds were spent on goods and services outside the United States and host country. Where is the company that produces this product or service located?

Q1013B What is the total amount this Project spent on this good or service? $_____

Q1013C Did the Project purchase goods or services from other companies not in the United States or the host country? Yes/No

[Q110=X, ASK]: Q1015 How much in total does the Project currently pay the host country government in taxes, royalties, concessions, or other fees? $______

[Q110=X, ASK]: Q1015a How much in total does the Project currently pay to other countries in taxes, royalties, concessions, or other fees? $______

Q1017 Is the Project eligible for a tax holiday? Yes/No

[IF Q1017=YES, ASK] Q1017A For how many years is the duration of the tax holiday?

11. SALES AND REVENUE [TO BE COMPLETED BY NON-FINANAICIAL INTERMEDIARY PROJECT APPLICANTS]

Now we will ask a few questions about the Project’s current and projected revenue.

[Q110=X, ASK]: Q1101 How much of the Project’s CURRENT revenue comes from exports to the United States? $_

[Q110=X, ASK]: Q1102 How much of the Project’s CURRENT revenue comes from sales inside the host country? $

[Q110=X, ASK]: Q1103 How much of the Project’s CURRENT revenue comes from exports to countries other than the United States or the host country? $___________

[Q110=X, ASK]: Q1104 What is the Project’s CURRENT, annual gross revenue? $__________

[Q110=X, ASK]: Q1105 What is the Project’s CURRENT, annual net profit? $__________

[IF Q110=X, ASK]: Q1108 Did the Project increase Host Country exports over the past 12 months? Yes / No

[IF Q110=X AND Q1108=YES, ASK]: Q1108A What goods did the Project export?

[IF Q110=X AND Q1108=YES, ASK]: Q1108B To which countries did the Project export these goods? _________

[IF Q110=X AND Q1108=YES, ASK]: Q1108C How many units of the product did the Project export? _____ [DROP DOWN UNITS]

[IF Q110=X, ASK]: Q1109 Did the Project reduce the Host Country’s need to import certain goods over the past 12 months? Yes / No

[IF Q110=X AND Q1109=YES, ASK]: Q1109A What goods did the Project provide that are currently being imported?

[IF Q110=X AND Q1109=YES, ASK]: Q1109B Which countries are currently importing these goods to the host country?

12. ENVIRONMENTAL AND SOCIAL CHARACTERISTICS [TO BE COMPLETED BY ALL APPLICANTS]

The next few questions will ask about Project impacts on the environment and regulatory agency auditing or monitoring of the Project.

Q1201 Has the Project engaged with communities impacted by the Project throughout every stage of Project design and implementation (including disadvantaged and vulnerable groups) over the past 12 months?Yes/No

[IF Q1201=YES, ASK] Q1201a If available, please upload documentation of these activities.

Q1202 Has the Project been involved in a community dispute or complaint resolution process over the past 12 months, including at an Independent Accountability Mechanism of an International Financial Institution? Yes / No

[IF Q1202=YES, ASK] Q1202a Please describe the dispute or complaint and list steps being taken to resolve it.

Q1202-1 Is the Project, applicant, any related party or affiliate of the applicant, or any supplier to the Project currently or previously associated with an OECD National Contact Point complaint? Yes/No

Q1202-2 Does the Project have a protocol to prevent and address threats of or actual retaliation against grievance mechanism complainants and those associated with Project complaints or concerns? Yes / No

[IF Q1202-2= YES, ASK] Q1202-2a Please describe the Project’s protocol and attach supporting documentation. Discuss any instances or threats of reprisals related to the Project and the steps taken to address them.

Q1203 Is the Project located in or with the potential to adversely impact:

Q1203a Natural forest areas Yes / No

Q1203b Areas on the United Nations List of Natural Parks, World Heritage Sites, or other protected areas Yes / No

Q1204c Sensitive locations of national or regional importance Yes / No

Q1204 Does the Project involve:

Q1204a Construction of a dam or weir Yes / No

Q1204b Production or trade of a product or activity that is illegal under the host country’s laws or international agreements (this includes international phase-outs or bans). Yes / No

Q1204c Land acquisition Yes / No

Q1204d Physical displacement and resettlement of people in the host country Yes / No

[IF Q1204d=YES, ASK] Q1204d1 How many households were displaced in the past 12 months? ____________

Q1204e Disruption of people’s livelihoods, jobs, or income in the host country Yes / No

[IF Q1204e=YES, ASK] Q1204e1 Please estimate the number of people whose livelihoods, jobs, or income were affected

[IF Q1204e=YES, ASK] Q1204e2 Please describe the cause of these impacts:

Q1204f Use of previously contaminated sites Yes / No

Q1204g Production or trade in radioactive materials Yes / No

Q1204h Production, trade, or use of unbounded asbestos fibers Yes / No

Q1204i Fishing practices which may harm vulnerable or protected species or may damage biodiversity or habitats Yes / No

Q1205 Have any government regulatory agencies monitor or audit the Project’s impacts in the past 12 months? These may include environmental, social, labor, performance, or construction impacts. Yes / No

[IF Q1205=YES, ASK] Q1205a What agency performed this audit?

[IF Q1205=YES, ASK] Q1205b Describe how they monitored or audited the Project?

[IF Q1205=YES, ASK] Q1205c Did any other agencies audit the Project? Yes / No

[PROGRAMMING NOTE: Repeat series of follow up questions until respondent says “No” to final question].

13. SECTOR-SPECIFIC METRICS

[START NEW SECTION. TO BE COMPLETED BY APPLICANT FOR PROJECTS PROVIDING NON-FINANCIAL PRODUCTS/SERVICES]

[IF Q110C=NO, ASK SECTION 13]:

The next few questions will ask about sector specific projects. For each sector, we will ask for detailed information about services provided and the number of people who benefit from these services.

PROJECTS IN AGRICULTURAL SECTOR [IF Q109A=YES, ASK Q1301-Q1302]

Q1301 What is the current average annual yield from this Project? ___________# of tons per hectare

PROJECTS IN EDUCATION SECTOR [IF Q109O=YES, ASK Q1303-Q1310]

These next questions are about the enrollment of students and scholarships offered through the Project. For these questions, count ALL part time and full time students, regardless of their course load.

	Current
Q1303 Total number of students enrolled	A
Q1304 Number of LOCAL students enrolled (excluding children of expatriates)	A
Q1305 Number of LOCAL FEMALE students enrolled (excluding children of expatriates)	A
Q1306 Number of LOCAL LOW INCOME students enrolled	A
Q1307 Number of LOCAL POOR students enrolled	A
Q1308 Number of LOCAL DISABLED students enrolled	A
Q1309 Number of LOCAL DISADVANTAGED students enrolled	A
Q1310 Number of needs-based scholarships for local students offered (per year)	A

PROJECTS IN ENERGY PROVISION SECTOR [IF Q109C=YES, ASK Q1311-Q1313]

The next questions are about the energy the Project is and will be delivering in Gigawatt hours (GWh) to energy offtakers. Please provide the annual amount of non-renewable energy, renewable energy and the total energy the Project currently delivers.

	Current Annual GWh
Q1311 Non-Renewable Energy	A
Q1312 Renewable Energy	A
Q1313 Total energy	A

PROJECTS IN ENERGY ACCESS SECTOR [IF Q109C=YES, ASK Q1314-Q1317]

The next questions are about increasing access to electricity and electrical devices. Please provide the number of on-grid connections, micro-grid connections, and household power systems the Project currently has.

	Current Number
Q1314 On-Grid connections	A
Q1315 Micro-grid connections	A
Q1316 Household power systems installed	A
Q1317 Modern lighting devices sold	A

PROJECTS IN ENERGY ACCESS SECTOR [IF Q109C=YES, ASK Q1317A-Q1317D]

Q1317A Please identify the type(s) of energy generated. Please check all that apply.

Wind

Solar Geothermal Biofuels Thermal (coal)

Thermal (natural gas) Thermal (oil)

Hydro

Other (please specify):___________

PROJECTS IN HEALTH SECTOR [IF Q109P=YES, ASK Q1318-Q1323]

These next questions are about health services. For each service listed below, tell us how many the Project currently provides each year.

	Current Number per year
Q1318 Number of patient beds	A
Q1319 Patient consultations provided	A
Q1320 Female patient consultations provided	A
Q1321 Low-income patient consultations	A
Q1322 Poor patient consultations	A
Q1323 Disadvantaged populations	A

PROJECTS IN HOUSING SECTOR [IF Q109K=YES, ASK Q1324-Q1331]

These next questions are about housing. For each type of dwelling listed below, tell us how many the Project currently builds each year.

	Current Number
Q1324 Total new residential dwellings	A
Q1325 New residential dwellings eligible for government assistance for poor homebuyers	A
Q1326 New residential dwellings eligible for government assistance for low-income homebuyers	A
Q1327 New residential dwellings eligible for government assistance for middle-income homebuyers	A
Q1328 Refurbished residential dwellings	A
Q1329 Refurbished residential dwellings eligible for government assistance for poor homebuyers	A
Q1330 Refurbished residential dwellings eligible for government assistance for low-income homebuyers	A
Q1331 Refurbished residential dwellings eligible for government assistance for middle-income homebuyers	A

[IF ANY Q1325-1327 or Q1329-1331 >0, ASK]: Q1332 Please specify which poor, low-income, or middle-income government assistance programs the Project’s homebuyers are eligible for:

PROJECTS IN INFORMATION AND COMMUNICATIONS TECHNOLOGIES SECTOR [IF Q109K=YES, ASK Q1333-Q1338]

These next questions are about communications technology. For each item listed below, tell us how many the Project currently has. We will also ask about the number of poor and low income subscribers separately. Poor individuals make less than the host country’s poverty line. Low income individuals make less than the median income but more than the poverty line in the host country.

	Current Number
Q1333 Number of cell towers	A
Q1334 Number of mobile subscriptions (include both voice and data subscribers)	A
Q1335 Number of fixed data (wired connection) subscriptions	A
Q1336 Number of fixed voice (landline telephone) subscriptions	A
Q1337 Number of low-income subscribers	A
Q1338 Number of poor subscribers	A

PROJECTS IN TRANSPORTATION SECTOR [IF Q109H=YES, ASK Q1339-Q1344]

These next questions are about transportation and shipping improvements. For each item listed below, tell us how many the Project currently produces.

	Current Number per year
Q1339 New road construction (a) current km	A # km
Q1340 Road improvement construction	A # km
Q1341 Number of cargo containers transported through the road/railway/port/airport	A # TEU
Q1342 Tons of bulk cargo transported through the road/railway/port/airport	A metric tons
Q1343 Passengers using transportation service	A people
Q1344 Number of warehouses or storage units	A units

PROJECTS IN WASTE AND SANITATION SECTOR [IF Q109N=YES, ASK Q1345-Q1347]

These next questions are about waste water and potable water. In the table below, tell us how much waste water the Project currently disposes of each year. Then tell us how many metric tonnes of wastewater the Project currently treats each year. Last, tell us how many metric tonnes of potable water are currently being produced.

	Current Number per year
Q1345 Amount of waste disposed per year	A MT	B MT
Q1346 Volume of wastewater treated per year	A MT	B MT
Q1347 Volume of potable water produced per year	A MT	B MT
Q1347A Volume of water delivered per year	A MT	B MT

[ASK FOR ALL PROJECTS]

Please tell us about any other products or services the Project will provide that were not asked about in the previous sections.

Q1348A First, does the Project produce any products or provide any services that have not been counted in previous questions? Yes/No

[IF Q1348A=YES, ASK]: Q1348B Please describe the product or service the Project produces:

[IF Q1348A=YES, ASK Q1349-1358]: Please tell us how many customers currently use the Project’s products or services. For each type of customer listed below, tell us how many the Project currently sells to or provide services to per year:

	Current Number per year	Does Not Apply
Q1349 Number of clients or customers per year	A
Q1350 Poor clients or customers	A
Q1351 Low-income clients or customers	A
Q1352 Disabled clients or customers	A
Q1353 Small and Medium Enterprise (SME) clients or customers	A
Q1354 Rural clients or customers (not smallholder or microenterprises)	A
Q1355 Microenterprises	A
Q1356 Smallholder farmers	A
Q1357 Female clients or customers per year	A
Q1358 Other customers from marginalized populations	A

14. PROJECT CONSTRUCTION/BUILDOUT/STARTUP

[START NEW SECTION. TO BE COMPLETED BY STAFF FOR PROJECTS PROVIDING NON-FINANCIAL PRODUCTS/SERVICES]

The next few questions ask about Project-related construction including timelines, the number of employees hired, and temporary housing for construction workers.

[IF Q109D=YES, ASK]: Q1404 How many Project employees were directly involved in construction, build-out, or startup in the past 12 months? ___#

[IF Q109D=YES, ASK]: Thinking about all of the Project employees involved in construction, buildout, or startup, how many were managerial, professional or technical, and unskilled labor? For each of these categories, please tell us how many were host country employees and how many were foreign nationals.

Employment	Local (Host Country)	Foreign Nationals
Q1405 Management	A	B
Q1406 Professional/Technical	A	B
Q1407 Unskilled Labor	A	B
Q1408 TOTAL	A	B

[IF Q109D=YES, ASK]: Q1409 Did the Project utilize workers employed by third parties (i.e., through contractors/subcontractors) for construction, build-out, and startup in the past 12 months? Yes / No

[IF Q109D=YES, ASK]: Q1410 What jobs did third party employees complete for the Project? (Select all that apply)

Management

Professional / Technical

Unskilled labor including physical construction

Other (Please specify:____________________)

[IF Q109D=YES, ASK]: Q1411A Did the Project require the establishment of temporary construction worker housing facilities? Yes/No

[IF Q109D=YES, ASK AND Q1411A=YES, ASK]: Q1411B How many workers were housed at these facilities over the past 12 months? #______

QUESTIONS ONLY FOR PROJECTS PROVIDING FINANCIAL PRODUCTS/SERVICES

15. FINANCIAL INTERMEDIARY– OPERATIONAL METRICS

[IF Q110C=YES, ASK THIS SECTION. TO BE COMPLETED BY APPLICANT FOR PROJECTS PROVIDING FINANCIAL PRODUCTS/SERVICES]

The next few questions will ask about Project investments over the past 12 months. [IF Q110D=YES, SHOW: “For investment funds, please answer based on the fund’s investment strategy and the types of projects you expect to invest in. Consider the host country to be any country you expect the fund to make investments in.”

[IF Q110C=YES, ASK]: Q1501 How much Project funding was invested in the host country over the past 12 months, not including fees, transaction costs, or contingency funds? $

[IF Q110C=YES, ASK]: Q1502 How much Project funding was used for direct loans or investments in the host country to businesses or consumers in the past 12 months? $

[IF Q110C=YES, ASK]: Q1503 How much Project funding was used for improvements such as product development, building new branches, installing new ATMs, technology improvements or other uses other than direct loans or investments to businesses or consumers in the past 12 months? $

[IF Q110C=YES, ASK]: Q1504 Were DFC funds used for other activities to expand financial product portfolios in the past 12 months? [Please DO NOT include on-lending, leasing, or investing equity in portfolio companies, such as branch expansion or establishing new distribution techniques.] Yes / No

[IF Q1504=NO, ASK] Q1504a For DFC funds NOT used to expand financial product portfolios, please describe in detail how those funds were used:

[IF Q110C=YES, ASK]: Q1505 How much capital has been invested in the Project over the past 12 months? ___$

[IF Q110C=YES, ASK]: Q1506 Has the Project received additional financing (public and/or private) during the past 12 months? Yes/No

[IF Q1506=YES, ASK] Q1506A How much additional financing did the Project receive during the past 12 months? __$

16. CURRENT PORTFOLIO AND CLIENTS

The next section will ask about current portfolio and clients for the Project.

Please think about the number of clients, number of transactions, number of branches, and the number of portfolio investments the Project currently has. Then think about the Project’s financial asset portfolio. Tell us the current size of the portfolio and provide estimates for the amount of that portfolio lent to women and rural customers currently. Then tell us the current average transaction amount. And last, tell us the current maximum transaction amount.

	Current
Q1601 Number of active clients	#
Q1602 Number of transactions	#
[IF Q110D=YES, SKIP Q1603 through Q1604d] Q1603 Number of branches	#
Q1604 Total value of financial assets portfolio	$US
Q1604a Amount of the portfolio lent to female clients	$US
Q1604b Amount of the portfolio lent to rural clients	$US
Q1604c Amount of the portfolio lent to low income clients	$US
Q1604d Amount of the portfolio lent to disabled clients	$US
Q1605 Average transaction amount per client	$US
Q1606 Maximum transaction amount to a single client	$US
Q1607 Minimum transaction amount to a single client	$US
Q1608 Average tenor (in months)	__months

17. FINANCING TYPES OFFERED [START NEW SECTION. TO BE COMPLETED BY STAFF FOR PROJECTS PROVIDING FINANCIAL PRODUCTS/SERVICES]

[IF 110C=YES, ASK]: The next section will ask for information regarding different loans that may be offered by the Project. For each type of loan the Project offers, we will ask about the number of clients, number of loans, and values of the loans. If the Project acts as a financial intermediary, please only think about the final loan recipients for each loan type listed.

[IF Q110D=YES, SKIP TO Q1719]

[IF 110C=YES, ASK]: Q1701 Does the Project offer microfinance loans? Yes / No

[Q1701=YES, ASK]: Q1701a How many microfinance clients does the Project currently serve? ______#

[IF Q1701=YES, ASK]: Q1701c How many microfinance transactions does the Project currently administer each year? ____#

[IF Q1701=YES, ASK]: Q1701e What is the current value of all microfinance loans under the Project portfolio? ____$

[IF Q1701=YES, ASK]: Q1701g What is the current average loan size for microfinance loans? ______$

[IF Q1701=YES, ASK]: Q1701i What is the current average loan period for microfinance loans? ___months

[IF Q1701=YES, ASK]: Q1702 Does the Project offer microfinance loans to women-owned or led microenterprises? Yes/No

[IF Q1702=YES, ASK]: Q1702a How many women microenterprise clients does the Project currently serve? ______#

[IF Q1702=YES, ASK]: Q1702c How many transactions for women microenterprise clients does the Project currently administer each year? ______#

[IF Q1702=YES, ASK]: Q1702e What is the current value of all for microenterprise loans to women under the Project portfolio? ___$

[IF Q1702=YES, ASK]: Q1702g What is the current average loan size for microenterprise loans to women? ______$

[IF Q1702=YES, ASK]: Q1702i What is the current average loan period for microenterprise loans to women? ______months

[IF Q1701=YES, ASK]: Q1703 Does the Project offer rural (not smallholder) microfinance loans? Yes / No

[IF Q1703=YES, ASK]: Q1703a How many rural microfinance clients does the Project currently serve? _____#

[IF Q1703=YES, ASK]: Q1703c How many rural microfinance transactions does the Project currently administer each year? _#

[IF Q1703=YES, ASK]: Q1703e What is the current value of all rural microfinance loans under the Project portfolio? ______$

[IF Q1703=YES, ASK]: Q1703g What is the current average loan size for rural microfinance loans? ______$

[IF Q1703=YES, ASK]: Q1703i What is the current average loan period for rural microfinance loans? ______months

[IF Q1701=YES, ASK]: Q1704 Does the Project offer smallholder microfinance loans? Yes / No

[IF Q1704=YES, ASK]: Q1704a How many smallholder microfinance clients does the Project currently serve? ______#

[IF Q1704=YES, ASK]: Q1704c How many smallholder microfinance transactions does the Project currently administer each year? ______#

[IF Q1704=YES, ASK]: Q1704e What is the current value of all smallholder microfinance loans under the Project portfolio? _$

[IF Q1704=YES, ASK]: Q1704g What is the current average loan size for smallholder microfinance loans?______$

[IF Q1704=YES, ASK]: Q1704i What is the current average loan period for smallholder microfinance loans? ______months

[IF Q110c=YES, ASK]: Q1705 Does the Project offer small and medium enterprise (SME) loans? Yes / No

[IF Q1705=YES, ASK]: Q1705a How many SME clients does the Project currently serve? ______#

[IF Q1705=YES, ASK]: Q1705c How many SME transactions does the Project currently administer each year? ______#

[IF Q1705=YES, ASK]: Q1705e What is the current value of all SME loans under the Project portfolio? ______$

[IF Q1705=YES, ASK]: Q1705g What is the current average loan size for SME loans? ______$

[IF Q1705=YES, ASK]: Q1705i What is the current average loan period for SME loans? ______months

[IF Q1705=YES, ASK]: Q1706 Does the Project offer small and medium enterprise (SME) loans to women clients? Yes/ No

[IF Q1706=YES, ASK]: Q1706a How many women SME clients does the Project currently serve? ______#

[IF Q1706=YES, ASK]: Q1706c How many SME transactions to women does the Project currently administer each year? ____#

[IF Q1706=YES, ASK]: Q1706e What is the current value of all SME loans to women under the Project portfolio? ______$

[IF Q1706=YES, ASK]: Q1706g What is the current average loan size for SME loans to women? ______$

[IF Q1706=YES, ASK]: Q1706i What is the current average loan period for SME loans to women? ______months

[IF Q1705=YES, ASK]: Q1707 Does the Project offer rural (not including smallholder) small and medium enterprise (SME) loans? Yes/No

[IF Q1707=YES, ASK]: Q1707a How many rural SME clients does the Project currently serve? ______#

[IF Q1707=YES, ASK]: Q1707c How many rural SME transactions does the Project currently administer each year?______#

[IF Q1707=YES, ASK]: Q1707e What is the current value of all rural SME loans under the Project portfolio? ____$

[IF Q1707=YES, ASK]: Q1707g What is the current average loan size for rural SME loans? ______$

[IF Q1707=YES, ASK]: Q1707i What is the current average loan period for rural SME loans? _____months

[IF Q1705=YES, ASK]: Q1708 Does the Project offer smallholder small and medium enterprise (SME) loans? Yes / No

[IF Q1708=YES, ASK]: Q1708a How many smallholder SME clients does the Project currently serve? _____#

[IF Q1708=YES, ASK]: Q1708c How many smallholder SME transactions does the Project currently administer each year?#

[IF Q1708=YES, ASK]: Q1708d What is the current value of all smallholder SME loans under the Project portfolio?______$

[IF Q1708=YES, ASK]: Q1708f What is the current average loan size for smallholder SME loans? ______$

[IF Q1708=YES, ASK]: Q1708h What is the current average loan period for smallholder SME loans? _____months

[IF Q110C=YES, ASK]: Q1709 Does the Project offer corporate loans? Yes / No

[IF Q1709=YES, ASK]: Q1709a How many corporate clients does the Project currently serve? ______#

[IF Q1709=YES, ASK]: Q1709c How many corporate transactions does the Project currently administer each year? _____#

[IF Q1709=YES, ASK]: Q1709e What is the current value of all corporate loans under the Project portfolio? ______$

[IF Q1709=YES, ASK]: Q1709g What is the current average loan size for corporate loans? ______$

[IF Q1709=YES, ASK]: Q1709i What is the current average loan period for corporate loans? ______months

[IF Q1709=YES, ASK]: Q1710 Does the Project offer rural (not including smallholder) corporate loans? Yes / No

[IF Q1710=YES, ASK]: Q1710a How many rural corporate clients does the Project currently serve? ______#

[IF Q1710=YES, ASK]: Q1710c How many rural corporate transactions does the Project currently administer each year? __#

[IF Q1710=YES, ASK]: Q1710e What is the current value of all rural corporate loans under the Project portfolio?______$

[IF Q1710=YES, ASK]: Q1710g What is the current average loan size for rural corporate loans? ______$

[IF Q1710=YES, ASK]: Q1710i What is the current average loan period for rural corporate loans? _____months

[IF Q1709=YES, ASK]: Q1710W Does the Project offer corporate loans to women owned or led enterprises? Yes / No

[IF Q1710=YES, ASK]: Q1710Wa How many women owned or led enterprise clients does the Project currently serve? ______#

[IF Q1710=YES, ASK]: Q1710Wc How many corporate transactions for women owned or led enterprises does the Project currently administer each year? ______#

[IF Q1710=YES, ASK]: Q1710We What is the current value of all corporate loans to women owned or led enterprises under the Project portfolio?______$

[IF Q1710=YES, ASK]: Q1710Wg What is the current average loan size for corporate loans to women owned or led enterprises?___$

[IF Q1710=YES, ASK]: Q1710Wi What is the current average loan period for corporate loans to women owned or led enterprises? _____months

[IF Q110C=YES, ASK]: Q1711 Does the Project offer consumer loans? Yes / No

[IF Q1711=YES, ASK]: Q1711a How many consumer clients does the Project currently serve? ______#

[IF Q1711=YES, ASK]: Q1711c How many consumer transactions does the Project currently administer each year? ___#

[IF Q1711=YES, ASK]: Q1711e What is the current value of all consumer loans under the Project portfolio? _____$

[IF Q1711=YES, ASK]: Q1711g What is the current average loan size for consumer loans? ___$

[IF Q1711=YES, ASK]: Q1711i What is the current average loan period for consumer loans? ______months

[IF Q1711=YES, ASK]: Q1712 Does the Project offer consumer loans for women? Yes / No

[IF Q1712=YES, ASK]: Q1712a How many consumer loans for women does the Project currently serve? _____#

[IF Q1712=YES, ASK]: Q1712c How many consumer loans for women does the Project currently administer each year?______#

[IF Q1712=YES, ASK]: Q1712e What is the current value of all consumer loans for women under the Project portfolio? ______$

[IF Q1712=YES, ASK]: Q1712g What is the current average loan size for consumer loans for women? _____$

[IF Q1712=YES, ASK]: Q1712i What is the current average loan period for consumer loans for women? ______months

[IF Q1711=YES, ASK]: Q1713 Does the Project offer consumer loans for low income borrowers? Yes / No

[IF Q1713=YES, ASK]: Q1713a How many consumer loans for low income borrowers does the Project currently serve? ______#

[IF Q1713=YES, ASK]: Q1713c How many consumer loans for low income borrowers does the Project currently administer each year? ______#

[IF Q1713=YES, ASK]: Q1713e What is the current value of all consumer loans for low income borrowers under the Project portfolio? ______$

[IF Q1713=YES, ASK]: Q1713g What is the current average loan size for consumer loans for low income borrowers? _____$

[IF Q1713=YES, ASK]: Q1713i What is the current average loan period for consumer loans for low income borrowers? ___months

[IF Q1711=YES, ASK]: Q1714 Does the Project offer consumer loans for rural (not including smallholder) borrowers? Yes / No

[IF Q1714=YES, ASK]: Q1714a How many consumer loans for rural borrowers does the Project currently serve? ______#

[IF Q1714=YES, ASK]: Q1714c How many consumer loans for rural borrowers does the Project currently administer each year? ____#

[IF Q1714=YES, ASK]: Q1714e What is the current value of all consumer loans for rural borrowers under the Project portfolio? ______$

[IF Q1714=YES, ASK]: Q1714g What is the current average loan size for consumer loans for rural borrowers? ______$

[IF Q1714=YES, ASK]: Q1714i What is the current average loan period for consumer loans for rural borrowers? ____months

[IF Q1711=YES, ASK]: Q1715 Does the Project offer consumer loans for smallholders? Yes / No

[IF Q1715=YES, ASK]: Q1715a How many consumer loans for smallholders does the Project currently serve? ______#

[IF Q1715=YES, ASK]: Q1715c How many consumer loans for smallholders does the Project currently administer each year?

[IF Q1715=YES, ASK]: Q1715e What is the current value of all consumer loans for smallholders under the Project portfolio? $

[IF Q1715=YES, ASK]: Q1715g What is the current average loan size for consumer loans for smallholders? ______$

[IF Q1715=YES, ASK]: Q1715i What is the current average loan period for consumer loans for smallholders? ______months

[IF Q110C=YES, ASK]: Q1716 Does the Project offer mortgage loans? Yes / No

[IF Q1716=YES, ASK]: Q1716a How many mortgage clients does the Project currently serve? ______#

[IF Q1716=YES, ASK]: Q1716c How many mortgage transactions does the Project currently administer each year? ____#

[IF Q1716=YES, ASK]: Q1716e What is the current value of all mortgage loans under the Project portfolio? ______$

[IF Q1716=YES, ASK]: Q1716g What is the current average loan size for mortgage loans? ______$

[IF Q1716=YES, ASK]: Q1716i What is the current average loan period for mortgage loans? ______months

[IF Q1716=YES, ASK]: Q1717 Does the Project offer mortgage loans for women? Yes / No

[IF Q1717=YES, ASK]: Q1717a How many mortgage loans for women does the Project currently serve? _____#

[IF Q1717=YES, ASK]: Q1717c How many mortgage loans for women does the Project currently administer each year? __#

[IF Q1717=YES, ASK]: Q1717e What is the current value of all mortgage loans for women under the Project portfolio? ____$

[IF Q1717=YES, ASK]: Q1717g What is the current average loan size for mortgage loans for women? _____$

[IF Q1717=YES, ASK]: Q1717i What is the current average loan period for mortgage loans for women? ____months

[IF Q1716=YES, ASK]: Q1718 Does the Project offer mortgage loans for low income borrowers? Yes / No

[IF Q1718=YES, ASK]: Q1718a How many mortgage loans for low income borrowers does the Project currently serve? ____#

[IF Q1718=YES, ASK]: Q1718c How many mortgage loans for low income borrowers does the Project currently administer each year? ______#

[IF Q1718=YES, ASK]: Q1718e What is the current value of all mortgage loans for low income borrowers under the Project portfolio? ______$

[IF Q1718=YES, ASK]: Q1718g What is the current average loan size for mortgage loans for low income borrowers? ______$

[IF Q1718=YES, ASK]: Q1718i What is the current average loan period for mortgage loans for low income borrowers? months

[IF Q110C=YES, ASK]: Q1719 Does the Project offer equity investments? Yes / No

[IF Q1719=YES, ASK]: Q1719a How many equity investment clients or companies does the Project currently serve? ____#

[IF Q1719=YES, ASK]: Q1719b How many equity investment clients have been exited or otherwise closed in the past year? #

[IF Q1719=YES, ASK]: Q1719c How many equity investment transactions does the Project currently administer each year?_#

[IF Q1719=YES, ASK]: Q1719e What is the current value of all equity investments under the Project portfolio? ___$

[IF Q1719=YES, ASK]: Q1719g What is the current average size for equity investments? ______$

[IF Q1719=YES, ASK]: Q1719i What is the current average period for equity investments? ______months

[IF Q1719=YES, ASK]: Q1720 Does the Project offer equity investments for large corporations? Yes / No

[IF Q1720=YES, ASK]: Q1720a How many equity investments for large corporations does the Project currently serve? ____#

[IF Q1720=YES, ASK]: Q1720c How many equity investments for large corporations does the Project currently administer each year? ______#

[IF Q1720=YES, ASK]: Q1720e What is the current value of all equity investments for large corporations under the Project portfolio? ______$

[IF Q1720=YES, ASK]: Q1720g What is the current average size of equity investments for large corporations? ______$

[IF Q1720=YES, ASK]: Q1720i What is the current average period for equity investments for large corporations? ______months

[IF Q1719=YES, ASK]: Q1720W Does the Project offer equity investments for women owned or led enterprises? Yes / No

[IF Q1720W=YES, ASK]: Q1720Wa How many equity investments for women owned or led enterprises does the Project currently serve? ____#

[IF Q1720W=YES, ASK]: Q1720Wc How many equity investments for women owned or led enterprises does the Project currently administer each year? ______#

[IF Q1720W=YES, ASK]: Q1720We What is the current value of all equity investments for women owned or led enterprises under the Project portfolio? ______$

[IF Q1720W=YES, ASK]: Q1720Wg What is the current average size of equity investments for women owned or led enterprises? ______$

[IF Q1720W=YES, ASK]: Q1720Wi What is the current average period for equity investments for women owned or led enterprises? ______months

[IF Q1719=YES, ASK]: Q1721 Does the Project offer mid-cap equity investments? Yes / No

[IF Q1721=YES, ASK]: Q1721a How many mid-cap equity investment clients does the Project currently serve? ____#

[IF Q1721=YES, ASK]: Q1721c How many mid-cap equity investments does the Project currently administer each year? _____#

[IF Q1721=YES, ASK]: Q1721e What is the current value of all mid-cap equity investments under the Project portfolio? ____$

[IF Q1721=YES, ASK]: Q1721g What is the current average size of mid-cap equity investments? ______$

[IF Q1721=YES, ASK]: Q1721i What is the current average period for mid-cap equity investments? ______months

[IF Q1719=YES, ASK]: Q1722 Does the Project offer small and medium enterprise (SME) equity investments? Yes/ No

[IF Q1722=YES, ASK]: Q1722a How many SME equity investments does the Project currently serve? ___#

[IF Q1722=YES, ASK]: Q1722c How many SME equity investments does the Project currently administer each year? _____#

[IF Q1722=YES, ASK]: Q1722e What is the current value of all SME equity investments under the Project portfolio? _____$

[IF Q1722=YES, ASK]: Q1722g What is the current average size of SME equity investments? _____$

[IF Q1722=YES, ASK]: Q1722i What is the current average period for SME equity investments? ____months

[IF Q110C=YES, ASK]: Q1723 Does the Project offer Leasing Contracts? Yes / No

[IF Q1723=YES, ASK]: Q1723a How many leasing clients does the Project currently serve? ____#

[IF Q1723=YES, ASK]: Q1723c How many leasing contracts does the Project currently administer each year? ______#

[IF Q1723=YES, ASK]: Q1723e What is the current value of leasing contracts under the Project portfolio? ______$

[IF Q1723=YES, ASK]: Q1723g What is the current average size for leasing contracts? ______$

[IF Q1723=YES, ASK]: Q1723i What is the current average period for leasing contracts? ______months

[IF Q1723=YES, ASK]: Q1724 Does the Project offer leasing contracts to women clients? Yes/ No

[IF Q1724=YES, ASK]: Q1724a How many female clients does the Project currently have leasing contracts with? ______#

[IF Q1724=YES, ASK]: Q1724c How many leasing contracts to female clients does the Project currently administer each year?__#

[IF Q1724=YES, ASK]: Q1724e What is the current value of all leasing contracts to female clients under the Project portfolio?$

[IF Q1724=YES, ASK]: Q1724g What is the current average size of leasing contracts to female clients? ______$

[IF Q1724=YES, ASK]: Q1724i What is the current average period for leasing contracts to female clients? ______months

[IF Q1723=YES, ASK]: Q1725 Does the Project offer leasing contracts to small or medium enterprises (SMEs)? Yes/No

[IF Q1725=YES, ASK]: Q1725a How many SMEs does the Project currently offer leasing contracts to? ____#

[IF Q1725=YES, ASK]: Q1725c How many leasing contracts to SMEs does the Project currently administer each year? _____#

[IF Q1725=YES, ASK]: Q1725e What is the current value of all leasing contracts to SMEs under the Project portfolio? ______$

[IF Q1725=YES, ASK]: Q1725g What is the current average size of leasing contracts to SMEs? _____$

[IF Q1725=YES, ASK]: Q1725i What is the current average period for leasing contracts to SMEs? ____months

[IF Q1723=YES, ASK]: Q1726 Does the Project offer rural leasing contracts (not including smallholder)? Yes / No

[IF Q1726=YES, ASK]: Q1726a How many rural leasing clients does the Project currently serve? _____#

[IF Q1726=YES, ASK]: Q1726c How many rural leasing contracts does the Project currently administer each year? ______#

[IF Q1726=YES, ASK]: Q1726e What is the current value of all rural leasing contracts under the Project portfolio? _____$

[IF Q1726=YES, ASK]: Q1726g What is the current average size of rural leasing contracts? ______$

[IF Q1726=YES, ASK]: Q1726i What is the current average period for rural leasing contracts? _____months

[IF Q1723=YES, ASK]: Q1727 Does the Project offer smallholder leasing contracts? Yes / No

[IF Q1727=YES, ASK]: Q1727a How many smallholder leasing clients does the Project currently serve? _____#

[IF Q1727=YES, ASK]: Q1727c How many smallholder leasing contracts does the Project currently administer each year? __#

[IF Q1727=YES, ASK]: Q1727e What is the current value of all smallholder leasing contracts under the Project portfolio? ____$

[IF Q1727=YES, ASK]: Q1727g What is the current average size of smallholder leasing contracts? ______$

[IF Q1727=YES, ASK]: Q1727i What is the current average period for smallholder leasing contracts? ______months

[IF Q1723=YES, ASK]: Q1728 Does the Project offer low income leasing contracts? Yes / No

[IF Q1728=YES, ASK]: Q1728a How many low income leasing clients does the Project currently serve? _____#

[IF Q1728=YES, ASK]: Q1728c How many low income leasing contracts does the Project currently administer each year? ___#

[IF Q1728=YES, ASK]: Q1728e What is the current value of all low income leasing contracts under the Project portfolio? _____$

[IF Q1728=YES, ASK]: Q1728g What is the current average size of low income leasing contracts? ______$

[IF Q1728=YES, ASK]: Q1728i What is the current average period for low income leasing contracts? _____months

[IF Q110C=YES, ASK]: Q1729 Does the Project offer insurance contracts? Yes / No

[IF Q1729=YES, ASK]: Q1729a How many insurance contract clients does the Project currently serve? ____#

[IF Q1729=YES, ASK]: Q1729c How many insurance contracts does the Project currently administer each year? ____#

[IF Q1729=YES, ASK]: Q1729e What is the current value of insurance contracts under the Project portfolio? ____$

[IF Q1729=YES, ASK]: Q1729g What is the current average size for insurance contracts? _____$

[IF Q1729=YES, ASK]: Q1729i What is the current average period for insurance contracts? ____months

[IF Q1729=YES, ASK]: Q1730 Does the Project offer insurance contracts for female clients? Yes/ No

[IF Q1730=YES, ASK]: Q1730A How many female insurance contract clients does the Project currently serve? ______#

[IF Q1730=YES, ASK]: Q1730C How many female insurance contracts does the Project currently administer each year? _____#

[IF Q1730=YES, ASK]: Q1730E What is the current value of insurance contracts for female clients under the Project portfolio?$

[IF Q1730=YES, ASK]: Q1730G What is the current average size for insurance contracts for female clients? ______$

[IF Q1730=YES, ASK]: Q1730I What is the current average period for insurance contracts for female clients? ______months

18. CLASSIFICATION OF DFC-SUPPORTED BUSINESS LOANS BY SECTOR AND USE

[START NEW SECTION. TO BE COMPLETED BY APPLICANT FOR PROJECTS PROVIDING FINANCIAL PRODUCTS/SERVICES]

The next question will ask about business loans and the business sectors where the loans will be provided.

Q1801. Thinking about your total DFC supported portfolio, please provide the percentage of these loans (or equity for investment funds) in each sector for the past year.

-Primary Agriculture, Forestry, Fishing

-Food Processing

-Restaurants

-Mining, oil and gas

-Renewable Energy (including home energy systems)

-Energy efficiency

-Non-Renewable Energy

-Water, Sanitation (including WASH loans)

-Housing Construction, Rental and Leasing

-Commercial Real Estate, Rental and Leasing

-Wholesale and Retail Trade

-Ag-related transportation and warehousing

-Other transportation and warehousing

-ICT Services and Products

-Educational Services and Products

-Healthcare Services and Products

-Hospitality Services

-Other Manufacturing

-Other Services

19. DEVELOPMENTAL IMPACTS OF DFC-SUPPORTED FINANCIAL ASSET PORTFOLIO

[START NEW SECTION. TO BE COMPLETED BY STAFF FOR PROJECTS PROVIDING FINANCIAL PRODUCTS/SERVICES]

[IF Q110C=YES AND Q110D=NO, ASK]: The next section will ask for specific information regarding the Project portfolio including percentages for those in rural areas, for women, and for underserved populations. We will also ask about current and future initiatives for these groups.

Q1901 Did the Project increase lending to rural borrowers in the past 12 months? Yes / No

[IF Q1901=YES, ASK]: Q1901a Please describe how the Project reached out to and improved products for rural borrowers. Include both current activities and activities planned for the future. If any activities directly relate to a specific product, please include that in your description.

Q1902 Did the Project increase lending to female borrowers in the past 12 months? Yes / No

[IF Q1902=YES, ASK]: Q1902a Please describe how the Project reached out to and improved products for female borrowers. Include both current activities and activities planned for the future. If any activities directly relate to a specific product, please include that in your description.

Q1903 Did the Project increase lending to underserved borrowers in the past 12 months? Yes / No

[IF Q1903=YES, ASK]: Q1903a Please describe how the Project reached out to and improved products for currently underserved borrowers. . If any activities directly relate to a specific product, please include that in your description.

Economic segments of clients as a percentage of the portfolio.	Current
Q1904a Consumers (not including mortgages). A consumer loan such as a car loan, credit card, signature loan, signature line of credit, or Certificate of Deposit.	%
Q1904b Microenterprises. Businesses which meet at least two of the following three characteristics: (1) total employees of up to 10, (2) total assets of up to $100,000, and/or (3) total annual sales of up to $100,000.	%
Q1904c Small & Medium Enterprises.	%
Q1904d Large Corporations	%
Q1904e Other (please specify):	%

Loan lengths as a percentage of your overall portfolio.	Current
Q1905a. < 6 months	%
Q1905b. 6 – 12 months	%
Q1905c. 13 – 24 months	%
Q1905d. 25 – 36 months	%
Q1905e. 37 – 60 months	%
Q1905f. > 60 months	%

Q1906 Please provide the following figures for the Project’s CURRENT portfolio from over the past 12 month:

Mortgage maturity period as a percentage of the mortgage portfolio.	Current Portfolio
Q1906a. < 5 years	%
Q1906b. 5-10 years	%
Q1906c. 11 - 15 years	%
Q1906d. 16 – 20 years	%
Q1906e. > 20 years	%
Purpose of the mortgages as a percentage of the mortgage portfolio.	Current Portfolio
Q1906f. Mortgages for new homeowners	%
Q1906g. Productive loan (e.g. home equity loan/line of credit)	%
Q196h. Home improvement
Q1906i. Other (please specify):	%
Target market of mortgages as a percentage of the mortgage portfolio.	Current Portfolio
Q1906i. Low-income homes	%
Q1906j. Middle-income homes	%
Q1906k. High-income homes	%
Q1906l. Residential rental properties	%
Q1906m. Commercial properties	%
Q1906n. Other (please specify):	%
Demographic distribution of clients as a percentage of the mortgage portfolio.	Current Portfolio
Q1906o. Percentage of clients that are women (or women-managed businesses).	%
Q1906p. Urban	%
Q1906q. Rural	%

[IF Q110C=YES AND Q110D=YES, ASK]: Q1907 Does the Project provide equity investments to rural projects? Yes / No

[IF Q1907=YES, ASK]: Q1907a Please describe how the Project reaches out and provides equity to rural projects. Include both current activities and activities planned for the future. If any activities directly relate to a specific Project, please include that in your description.

[IF Q110C=YES AND Q110D=YES, ASK]: Q1908 Does the Project provide equity investments to women owned or led businesses?

Yes / No

[IF Q1908=YES, ASK]: Q1908a Please describe how the Project reaches out to and improves equity available to women owned or led businesses. Include both current activities and activities planned for the future. If any activities directly relate to a specific Project, please include that in your description.

[IF Q110C=YES AND Q110D=YES, ASK]: Q1909 Does the Project provide equity investments to companies from any other traditionally underserved communities? Yes / No

[IF Q1909=YES, ASK]: Q1909a Please describe how the Project reaches out to and improves equity available to companies in underserved communities. Include both current activities and activities planned for the future. If any activities directly relate to a specific Project, please include that in your description.

Representative Certification

I hereby represent the information provided in this document is complete and accurate to the best of my knowledge.
Name:	Date:	Telephone:      
Title:      		Email address:      

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