83-I Questionnaire for OMB for DFC-005 - signed by DAH

OMB Information Collection Request (83-I information)
1.
2.
3.
4.

Is this a new form? No
OMB Control Number: 1 OMB-3015-0007
Agency Tracking Number: DFC-005
Form Title: Personal Financial Statement

5. Is this a “common form” that was developed in conjunction with other agencies? 2 No (default)
6. Is this a “generic form” that is part of an earlier umbrella clearance? No (default)
7. Abstract. Please describe the needs and uses for the information collection in 4000 characters or
less: 3
The Personal Financial Statement is used by the agency to determine if individuals who are
providing equity investment in or credit support to a proposed transaction have sufficient financial
wherewithal to meet their expected obligations under the proposed terms of the agency’s financing.
8. Type of Information Collection:
a. ☐ New information collection
b. ☒ Renewal of existing information collection with no changes
c. ☐ Renewal of existing information collection with changes
d. ☐ Reinstatement of expired information collection with no changes
e. ☐ Reinstatement of expired information collection with changes
9. Type of Review Requested:
a. ☒ Regular review
b. ☐ Emergency review
10. Requested expiration date:
a. ☒ Three years (maximum)
b. ☐ Other time period: _____
11. Does the form contain surveys or censuses that employ statistical methods? 4 No (default)
12. Does the Supporting Statement serve as a joint Paperwork Reduction Act filing and a Privacy Impact
Assessment? 5 No (default)
13. Is this form related to the Affordable Care Act? No (default)
14. Is this form related to the Dodd-Frank Act? No (default)
15. Is this form related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No (default)
16. Authorizing Statutes: 6
Leave blank for new forms. For form renewals, the OMB Control Number should be at the top of the DFC form
and also at the top of both the 60 Day and 30 Day Notices.
2
Items 5-6 should be no unless indicated otherwise by the Administrative Attorney. If you believe one of these
items should be answered “yes,” please consult with the Administrative Attorney.
3
You may reuse the abstract from your 60 Day and 30 Day Notices.
4
Items 6-10 should be no unless indicated otherwise by the Administrative Attorney. If you believe one of these
items should be answered “yes,” please consult with the Administrative Attorney.
5
OCIO determines whether Privacy Impact Assessments (PIAs) are necessary whenever there is a new or changed
collection of personally identifiable information (PII). When you submitted a Privacy Threshold Analysis (PTA) to
the CISO, he should have informed you if a PIA was necessary. If it was not necessary, answer NO. If it was
necessary, consult with the Administrative Attorney and the CISO on whether you are filing your PIA with OMB at
this time as a joint package (YES) or as two separate packages (NO).
6
This is the same as the “Authority for Information Collection” in the 60 and 30 Day Notices.
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OMB Information Collection Request (83-I information)

17.
18.
19.
20.

21.

22.
23.
24.

25.
26.

The Better Utilization of Investments Leading to Development Act of 2018 (the “BUILD Act”), Public
Law 115-254.
Does this form propose the creation of a new agency regulation? No (default)
Citation & date for the publication of the 60 Day Notice: 7 87 FR 30209, May 18, 2022
Citation & date for the publication of the 30 Day Notice 8: 87FR 43799, July 22, 2022
A. Total number of responses: 9
75
B. Time it takes DFC staff member to review one response (in hours):
1
C. The GS-14 step 1 hourly rate in the DC metro area: 10
$60.49
The total cost to the government (A*B*C):
$4,536.75
Obligation to Respond:
a. ☐ Mandatory – criminal or civil penalties imposed for failure to respond
b. ☒ Required to obtain or retain benefits – not mandatory, but respondents will be unable to
obtain or retain a government benefit (like a loan or insurance coverage) if they do not
complete the information collection. Most of DFC’s forms fall into this category.
c. ☐ Voluntary – purely voluntary, no negatives associated with a failure to respond. This
most commonly refers to surveys.
If this collection is required or authorized by agency regulation rather than a statute, provide the
CFR citation. 11 Click here to enter text.
Line of Business:
a. International Affairs & Commerce - International Development
Privacy Act System of Records:
a. ☐ Not applicable. The CISO informed me upon completion of a Privacy Threshold Analysis
(PTA) that a Privacy Impact Assessment (PIA) was not necessary.
b. ☒ Not applicable. The CISO performed a Privacy Impact Assessment (PIA), but informed me
that this form would not be part of a system of records.
c. ☐ Applicable. The CISO performed a Privacy Impact Assessment (PIA) and informed me
that this form would be part of a system of records. A system of records notice (SORN) was
published in the Federal Register. The name of the system is Click here to enter text. And
the Federal Register citation for the notice is Click here to enter text.
Total Number of respondents per year: 12 75
Will this information collection have a significant economic impact on a substantial number of small
entities? No (default) If yes, number of respondents for small entities: Click here to enter text.

The citation can be found on the Federal Register posting for your Notice and is in the sidebar on the right side of
the screen. Alternately you can refer to the PDF version of the Federal Register posting, placing the volume
number before the “FR” and the page number of the first page of your notice after the “FR.” 69 FR 9783 is
shorthand for Federal Register, volume 69, page 9783.
8
This citation will not be available until the 30 Day Notice is published and therefore this field cannot be
completed until right before OMB submission.
9
Same as question 25.
10
The GS schedule can be found at http://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/
11
This will be blank unless indicated otherwise by Administrative Attorney.
12
This should be the same as the “Number of Responses” field on your 60 and 30 Day Notices
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OMB Information Collection Request (83-I information)
27. Affected public:
a. ☐ Federal Government
b. ☒ Individuals or households
c. Private Sector
i.
☐ Businesses or other for profits
ii.
☐ Farms
iii.
☐ Not-for-profit institutions
d. ☐ State, Local and Tribal Governments
28. Percentage of respondents reporting electronically: 0%
29. Number of responses per respondent per year 13: 1
30. Type of Collection and Burden on the public
A. Reporting (filling out the form) 15
B. Recordkeeping (new record maintenance costs
incurred in order to answer questions on form) 16
C. Third party disclosure (public disclosures such as SEC
filings or drug warning labels) 17
D. Total burden per response (sum lines A-C)
E. Total number of respondents (question 25)
F. Number of responses per respondent (question 29)
Total annual burden (line D times line E times line F).

Time per response
(hours)
1

Cost per
response 14
$75

1
75
1
75

$75
75
1
$5,625 18

31. If the total annual burden is an increase or decrease in the previously claimed burden, 19 please
explain why in 4000 characters or less.
Click here to enter text.

Note that the OMB system does not allow time periods smaller than one year. If your form is filled out only once
per project or investor, then type “1” here and explain under item 12 in the Supporting Statement.
14
Please use $75.00/hour to determine the public cost. This will ensure consistency in our calculations for OMB.
Therefore if it takes the average respondent 2 hours to fill out the form, you would write $150.00 on line A.
($75.00 x 2)
15
This refers to the time actually spent completing the form.
16
This refers to time spent maintaining records that they would not otherwise maintain except that the records
are needed to complete your information collection. For example, if you require them to maintain special financial
statements in order to complete your information collection, but they would not otherwise create and maintain
these special statements. This is usually zero.
17
This refers to time spent creating and publishing new disclosures that they would not otherwise publish except
that your form requires them to. For example, if your form requires them to publish their yearly accident rates.
This is usually zero.
18
This number should match the answer to question 12 in your supporting statement
19
The previously claimed burden is what OMB previously approved for your form. You can obtain these numbers
from the previous OMB submissions or from http://www.reginfo.gov/public/do/PRAMain (Select ”United States
International Development Finance Corporation“ under the “Current Inventory” menu.) If your form is new, then
this is zero and your increase is due to this being a new information collection.
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OMB Information Collection Request (83-I information)
On behalf of this Federal agency, I certify that the collection of information encompassed by this request
complies with 5 CFR 1320.9.
The full text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of this
document. The certification is to be made with reference to those regulatory provisions as set forth in
the instructions.
The following is a summary of the topics, regarding the proposed collection of information that the
certification covers:
a.
b.
c.
d.

It is necessary for the proper performance of agency functions;
It avoids unnecessary duplication;
It reduces burden on small entities;
It uses plain, coherent, and unambiguous terminology that is understandable to
respondents;
e. Its implementation will be consistent and compatible with current reporting and
recordkeeping practices;
f. It indicates the retention period for recordkeeping requirements;
g. It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
i. Why the information is being collected;
ii. Use of information;
iii. Nature of response (voluntary, required for a benefit, or mandatory);
iv. Nature and extent of confidentiality; and
v. Need to display currently valid OMB control number;
h. It was developed by an office that has planned and allocated resources for the efficient and
effective management and use of the information to be collected (see note in Item 19 of the
instructions);
i. It uses effective and efficient statistical survey methodology; and
j. It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item below and explain
the reason in item 18 of the Supporting Statement.

Digitally signed by
DEBORAH
DEBORAH HOWARD
Date: 2022.07.22 11:05:14
HOWARD
-04'00'
____________________________

Managing Director, Finance Program
Systems and Procedures

July 22, 2022

Signature of Senior Official

Title

Date

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OMB Information Collection Request (83-I information)
§ 1320.9 Agency certifications for proposed collections of information.
As part of the agency submission to OMB of a proposed collection of information, the agency (through
the head of the agency, the Senior Official, or their designee) shall certify (and provide a record
supporting such certification) that the proposed collection of information—
(a) Is necessary for the proper performance of the functions of the agency, including that the
information to be collected will have practical utility;
(b) Is not unnecessarily duplicative of information otherwise reasonably accessible to the agency;
(c) Reduces to the extent practicable and appropriate the burden on persons who shall provide
information to or for the agency, including with respect to small entities, as defined in the Regulatory
Flexibility Act (5 U.S.C. 601(6)), the use of such techniques as:
(1) Establishing differing compliance or reporting requirements or timetables that take into account
the resources available to those who are to respond;
(2) The clarification, consolidation, or simplification of compliance and reporting requirements; or
(3) An exemption from coverage of the collection of information, or any part thereof;
(d) Is written using plain, coherent, and unambiguous terminology and is understandable to those who
are to respond;
(e) Is to be implemented in ways consistent and compatible, to the maximum extent practicable, with
the existing reporting and recordkeeping practices of those who are to respond;
(f) Indicates for each recordkeeping requirement the length of time persons are required to maintain
the records specified;
(g) Informs potential respondents of the information called for under § 1320.8(b)(3);
(h) Has been developed by an office that has planned and allocated resources for the efficient and
effective management and use of the information to be collected, including the processing of the
information in a manner which shall enhance, where appropriate, the utility of the information to
agencies and the public;
(i) Uses effective and efficient statistical survey methodology appropriate to the purpose for which the
information is to be collected; and
(j) To the maximum extent practicable, uses appropriate information technology to reduce burden and
improve data quality, agency efficiency and responsiveness to the public.
§1320.8(b)(3)
[…]
(b) Such office shall ensure that each collection of information:
[…]

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OMB Information Collection Request (83-I information)
(3) Informs and provides reasonable notice to the potential persons to whom the collection of
information is addressed of—
(i) The reasons the information is planned to be and/or has been collected;
(ii) The way such information is planned to be and/or has been used to further the proper
performance of the functions of the agency;
(iii) An estimate, to the extent practicable, of the average burden of the collection (together with a
request that the public direct to the agency any comments concerning the accuracy of this burden
estimate and any suggestions for reducing this burden);
(iv) Whether responses to the collection of information are voluntary, required to obtain or retain a
benefit (citing authority), or mandatory (citing authority);
(v) The nature and extent of confidentiality to be provided, if any (citing authority); and
(vi) The fact that an agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number.
[…]

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