Form DFC‐012 Economic Screening Questionnaire

DFC Economic Questionnaire (DFC-012)

OMB No. 3015-0001

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.

Paperwork Reduction Act Notice: This information is voluntary. Federal agencies may not collect information unless a valid OMB Control Number with an expiration date that has not expired is displayed. The public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to Agency Clearance Officer, Records Management, United States International Development Corporation, 1100 New York Avenue, NW, Washington, DC, 20527 and to the DFC Desk Officer at the Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

DFC Economic Questionnaire

This questionnaire is to be used on an as needed basis to collect information about potential exports of DFC-supported projects.

1. Project company name:

2. Location of the project (country):

3. SIC/NAICS/HTS Code for each product produced: (www.census.gov/epcd/www/naics.html; www.census.gov/epcd/www/sic.html; www.usitc.gov/tata/hts/bychapter/index.htm)

Indicate: ☐ SIC ☐ NAICS ☐ HTS code

Product description	SIC/NAICS/HTS Code

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

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

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

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

Note: For volume, use the appropriate units for the product – metric tons, number of items, etc.

Incremental refers to the amount developed due to the DFC provided support

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

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

Note: For volume, use the appropriate units for the product – metric tons, number of items, etc.

Incremental refers to the amount developed due to the DFC provided support