DFC-003 Application for Political Risk Insurance

FOR REFERENCE ONLY – THIS FORM IS TO BE COMPLETED ONLINE – PAPER SUBMISSIONS WILL NOT BE ACCEPTED

Application for Political Risk Insurance (DFC-003)

OMB No. 3015-0003

Expiration Date: 8/31/2022

United States International Development Finance Corporation

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

Responses to questions which call for estimates or projections should take the form of good faith statements made to the best of the applicant’s knowledge and belief. Statements of fact provided in this document must be accurate as of the date of submission. Anyone who knowingly makes a false statement with the intent to influence DFC’s guarantees, loans, or other investments may be criminally prosecuted. Such false statements are also grounds for DFC to terminate a commitment or declare a contract default. These rights are in addition to any other rights or remedies available to United States government. Neither submission nor acceptance of this application implies that the proposed transaction is eligible for support or that support will be provided.

When trade secrets or confidential commercial or financial information are submitted to the agency in this collection, they will be held in confidence to the extent permitted by applicable law including the Freedom of Information Act (“FOIA”) at 5 U.S.C. § 552(b)(4) and the agency’s implementing regulations at 22 C.F.R. Part 706.

The Better Utilization of Investments Leading to Development (BUILD) Act of 2018 (P.L. 115-254) and the Inspector General Act of 1978 (P.L. 95-452) (as amended) (the “IG Act”) require DFC to have an Inspector General. The Office of the Inspector General’s mission is to provide independent oversight of DFC’s programs and operations for increased efficiency and effectiveness, and to prevent fraud, waste, and abuse. The Office of the Inspector General conducts audits, investigations, and other reviews of DFC programs, transactions, and operations.  The IG Act gives the Office of the Inspector General unrestricted access to all records in the possession and control of DFC, and requires that DFC provide the Office of the Inspector General unrestricted access to all DFC project data and systems in response to any request from the Office of the Inspector General. See 5 U.S.C. Appendix 3. The Office of the Inspector General may contact you, your organization, or your personnel in connection with an Office of the Inspector General audit, investigation, or other review and expects that you, your organization and your personnel will cooperate with requests for information from the Office of the Inspector General. More information about the Office of the Inspector General can be found here: https://www.dfc.gov/oig.

Paperwork Reduction Act Notice: This information is required to obtain or 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 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to Agency Clearance Officer, Records Management, United States International Development Corporation, 1100 New York Avenue, NW, Washington, DC, 20527 and to the DFC Desk Officer at the Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

Application for Political Risk Insurance (Form 003)

INSTRUCTIONS:

1. All applicants must fill out a complete application.

2. All applicants must provide the certifications requested.

3. If you use an attachment to answer any of the questions in this application, please write “see Attachment” in the appropriate answer block and indicate the corresponding question number on your attachment.

4. All applicants applying for DFC insurance must sign this application. If an Investor is applying for DFC insurance on behalf of other eligible Investors, DFC also will require the ultimate beneficiary Investors to sign this application.

QUESTION 1: Identify the Investor(s)* Name of Investor:

DFC Project ID:

(See Request for Registration for Political Risk Insurance (DFC Form 002))

Address:

City:

State:

Zip/Postal Code¹:

Country:

Telephone:

E-Mail:

Website:

Occupation (if individual):

Location of registration/incorporation (if entity):
Unique Entity ID (UEI) from SAM.gov:

QUESTION 2: Identify the Authorized Representative Name of Person DFC should contact for information: Title:

Company: Address: City:

State:

Zip/Postal Code:

Country:

Telephone:

E-Mail:

QUESTION 4a: If private political risk insurance is available, is it in the amount necessary and on terms sufficient for the project’s viability?

• Yes

• No

QUESTION 4b: If Yes, please explain why political risk insurance is being sought from DFC. If No, please explain.

QUESTION 5: Project Description

• Briefly describe the project and investment structure.

• Please attach a copy of information memoranda, business plans, investment structure diagram or other descriptions of the project that would be helpful to DFC’s understanding of the project. Please also include a description (or a copy) of the project’s plans for 1) environmental and social due diligence, mitigation, and monitoring processes; 2) consultation with project-affected communities (including disadvantaged and vulnerable groups); and 3) access to accountability and remedy for negative project impacts on individuals and communities. Also provide copies of any project documentation such as company charter, joint venture documents, loan agreements, technical assistance agreements, management service agreements, lease agreements, loan guaranties, licenses or agreements with the host government, etc. All documentation must be in English.

• If entering into a contract to provide goods/services to a foreign government, please indicate total amount, date contract was/will be signed, and approximate date work will commence. Please attach a copy of the contract as well.

QUESTION 6: Please specify whether this project is:

• An expansion of an existing enterprise

• A new (greenfield) enterprise

• A privatization of a state-owned company

• Other (please explain)

QUESTION 7: Where is the project located? (If in a remote location, please include GPS coordinates or attach a map showing the location.)

QUESTION 9: Government Involvement

• Describe any host government involvement in the project such as any contracts, concession, or licenses from the government, any planned government purchasing or supplying, or any form of joint venture with the government.

• If entering into a contract to provide goods/services to a foreign government, give the name and address of the department or agency involved. Briefly describe any previous experience the Investor has had with this foreign government.

QUESTION 10: Current and Past Disputes

Please identify and describe briefly any current or past disputes with respect to this project that involve any agency or instrumentality of the host government. Include all disputes that involved or currently involve the Investor, the Foreign Enterprise, or any participants in the project.

QUESTION 11: Type of Investment to be Insured (check all that apply)
Equity	$
Leases	$
Loans or Loan Guaranties	$
Technical Assistance/Management/Supply/or Contractors and Exporters Agreements	$
Performance Guaranty/Advance Payment Guaranty/Other Guaranty/Contract Disputes	$
Other (please explain)	$

Question 13: Term of DFC Contract: years

Question 15: May we share your information with other DFIs?

May DFC share the following information with other development finance institutions (DFIs) who may be interested in working with DFC on the type of project/transaction you are proposing?

1. The Name of the Investor and Location from Question 1.

2. The Authorized Representative name, Title, and E-mail address from Question 2.

3. The DFC-designated sectoral category (e.g. financial services, power generation) that corresponds with the nature of your project/transaction.

Please note that this is not a guarantee that DFC will share your information nor a guarantee that recipients of the information will provide additional support to the transaction.

QUESTION 14: Investment Schedule
Initial Investment	Date	Amount
Subsequent Investments
Expected date that commercial operations will begin

1 For U.S. addresses, the zip code+4 is required for the postal code/zip code field in the address.

1