DFC-005 Personal Financial Statement

PERSONAL FINANCIAL STATEMENT (DFC-005)

OMB No. 3015-0007

Expiration: 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.

Information provided 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. Personal information belonging to an individual will not be released under the FOIA unless the information is already public or if the public interest is greater than the private interest under 5 U.S.C. § 552(b)(6).

You are not required to provide your social security number. DFC evaluates the financial status of those providing equity or collateral support to a transaction to determine whether it is financially sound. Providing your social security number will assist DFC in verifying your financial status by running a credit check. If you choose not to provide your social security number, DFC may be unable to fully evaluate your transaction’s financial soundness.

This is notice of DFC’s right to access financial records held by financial institutions that are or have been doing business with you or your business under the Right to Financial Privacy Act of 1978. The law provides that DFC shall have a right of access to your financial records in connection with its consideration or administration of assistance to you in the form of a loan or loan guaranty to your project. DFC is required to provide a certificate of its compliance with the Act to a financial institution in connection with its first request for access to your financial records, however no further certification is required for subsequent access. DFC’s access rights continue for the term of any approved loan or guaranty agreement. No further notice to you of DFC’s access rights is required during the term of any such agreement. The law also authorizes DFC to transfer to another Government authority any financial records included in an application for a loan, or concerning an approved loan or guarantee, as necessary to process, service, or foreclose on a loan guaranty or collect on a defaulted loan guaranty.

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

Please retain a copy for your records.

I acknowledge that I have read the disclosure and notices above.

Individual Identification and Contact Information

Full Legal Name (required)
Social Security Number:
Residence Address (required):
Business Phone:
Residence Phone:
Mobile Phone:
Email Address (required):

Assets and Liabilities Summary as of [date]

Assets

Asset Description	USD Equivalent Value	Owned Jointly?1 (Y/N) (Check if yes)
1. Cash on hand and in Banks (liquid accounts)
2. IRA(s) or Other Retirement Account(s)
3. Stocks and Bonds (Publicly Traded)
4. Equity Ownership Interests (Private Companies)
5. Accounts and Notes Receivable
6. Life Insurance – Cash Surrender Value Only
7. Real Estate (current market value)
8. Vehicles and other Personal Property
9. Other Assets
Total Assets	$ 0.00

Liabilities and Net Worth

Liability Description	USD Equivalent Value	Joint Obligation? (Y/N) (check if yes)
1. Accounts Payable
2. Notes Payable to Banks and Others
3. Mortgages Loans on Real Estate
4. Taxes Payable
5. Other Liabilities
Total Liabilities	$ 0.00
6. Net Worth	$ 0.00
Total Liabilities and Net Worth	$ 0.00

¹ If any assets are co-owned with another party or any liabilities are joint liabilities, please attach a separate sheet listing the joint assets/liabilities and the names of the co-owners/co-obligors.

Assets Detail: Please provide detail for each asset class listed in the summary.

1. Cash In Banks
Name and Location of Bank	Balance in USD
Total	$ 0.00

2. IRA(s) and Other Retirement Account(s)
Account Fiduciary Institution	Balance in USD
Total	$ 0.00

3. Stocks and Bonds (Publicly Traded)
Name of Security	Fiduciary Institution	Value in USD
Total		$ 0.00

4. Equity Ownership Interests (Private Companies)
Name of Company	Portion of Equity Owned (%)	Are the shares/interests freely transferable2? (check if yes)	Value in USD
	0.00%
	0.00%
	0.00%
	0.00%
	0.00%
	0.00%
Total			$ 0.00

5. Accounts and Notes Receivable
Name of Debtor	Balance in USD
Total	$ 0.00

6. Life Insurance – Cash Surrender Value Only
Name of Issuing Firm	Value in USD
Total	$ 0.00

7. Real Estate
Address	Description	Value in USD
Total		$ 0.00

²If shares/ownership interests are “freely transferable,” that means that the owner may sell or transfer them without getting permission from other parties. Some private companies have restrictions on sales or transfers, which limits the liquidity of the asset.

8. Vehicles and Other Personal Property
Description	Current Location	Value net of liens in USD
Total		$ 0.00

9. Other Assets
Description	Value in USD
Total	$ 0.00

Liabilities Detail: Please provide detail for each liability class in the summary.

1. Accounts Payable
Name of Creditor	Balance in USD
Total	$ 0.00

2. Notes Payable to Banks and Others
Name of Creditor	Balance in USD
Total	$ 0.00

3. Mortgages on Real Estate
Address of Property	Name of Creditor	Balance in USD
Total		$ 0.00

4. Taxes Payable
Taxing Authority	Balance in USD
Total	$ 0.00

5. Other Liabilities
Description	Balance in USD
Total	$ 0.00

Contingent Liabilities

A contingent liability is a potential obligation that may be incurred depending upon the outcome of a future event. For instance, if an individual has co-signed/guaranteed a loan or is the defendant of litigation, they have a contingent liability. Please list all contingent liabilities and the estimated amount of the potential obligation. If there are no contingent liabilities, list “None.”

Contingent Liabilities
Description	Est. Potential Obligation in USD
Total	$ 0.00

Source(s) of Income

Please provide information regarding your income for the most recent three (3) calendar years.

Source(s) of Income (in USD equivalent)
	20	20	20
Salary
Net Investment Income
Real Estate Income
Other (description: )
Total	$ 0.00	$ 0.00	$ 0.00

Signature Page

I consent to DFC and its agents running a report of my credit record.

I certify that the above information, submitted to obtain DFC support, gives a correct representation of my financial condition as of this date. I further certify that the above representations and all supporting documentation are true, accurate, and complete. This Personal Financial Statement has been made for the purpose of applying for DFC support and may be relied upon by DFC as a true statement of the facts contained herein. If I become aware that any of the information in this Personal Financial Statement was incorrect at the time of submission, I agree to provide the updated information in writing to DFC immediately.

Printed Name of Individual

Signature of Individual

Date

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