DFC-007 Impact Assessment Questionnaire

IMPACT ASSESSMENT QUESTIONNAIRE (DFC-007)

OMB 3015-0009

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.

Paperwork Reduction Act Notice: This information is required to obtain 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 1.5 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.

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 

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

1. PROJECT DESCRIPTION AND OWNERSHIP PROFILE

The questions in this section will ask for background and descriptive information about the Project and the company managing the Project (i.e., the DFC client company).

"Project" refers to the Project or portion of your business that would be supported through DFC financing. For Project finance loans, "Project" refers to the specific Project being financed with DFC funds. For corporate finance loans, “Project” may refer to a specific DFC-supported portfolio or, if the support is provided for the business as a whole, may refer to the entire business. For cases of DFC support for a specific project or portfolio of financial services (e.g. loans, equity investments, etc.) please enter data ONLY for that portfolio, fund, or business line (and not for the whole business). For cases of corporate finance loans in which the DFC is supporting the specific use of the financing, enter data for that specific support, or in case of business as whole, please enter data for the entire business.

Q101 Applicant Name:

Q102 Project Name:

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.

Q103 Will the Project provide financial services (loans, equity investments, etc.)? (SELECT ONE: Yes / No)

Q104 Please select any additional sectors in which the Project will operate:

A. Agriculture

B. Education

C. Energy

D. Financial Services

E. Healthcare

F. Housing

G. Information and Communications Technology

H. Transportation

I. Waste, Water, and Sanitation

J. Other

Q105 Is the Project, or the company that manages the Project (i.e. the DFC client company) overseen by a board of directors? (SELECT ONE: Yes / No)

• [IF Q105=YES, ASK] Q105A What is the total number of Board of Directors members? (NUMBER)

• [IF Q105=YES, ASK] Q105B How many Board of Directors members are women? (NUMBER)

Q106 Does the Project, or the company that manages the Project (i.e. the DFC client company), have an Investment Committee?” (SELECT ONE: Yes / No)

• [IF Q106 = YES, ASK] Q106A What is the total number of Investment Committee members? (NUMBER)

• [IF Q106 = YES, ASK] Q106B How many Investment Committee members are women? (NUMBER)

Q107 Was the Project or the company managing the Project (i.e. the DFC client company) founded by a woman? (SELECT ONE: Yes / No)

2. PROJECT HUMAN RESOURCES MANAGEMENT AND JOB QUALITY

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

Q201 Does the Project or company managing the Project offer employees any of the following family friendly benefits that go beyond what is legally required by the country or countries of operations? If the Project does not yet have employees, please leave blank. Please check all that apply:

1. Flexible work schedules

2. Extended paid maternity leave

3. Paid paternity leave

4. Access to childcare or childcare stipends through the Project

5. Family healthcare

6. Other (please describe):

Q202 Does the Project include any initiatives to advance women in the workforce beyond what is legally required by the country or countries of operations? If the Project does not yet have employees, please leave blank. (SELECT ONE: Yes / No)

3. PROJECT BENEFITS TO THE ENVIRONMENT AND THE COMMUNITY

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

Q301 Will the Project or the company managing the Project, help restore or preserve the environment? (Do NOT include actions required by law or permit in the host country)? (SELECT ONE: Yes / No). If applicable, please describe.

Q302 Will the Project, or the company managing the Project, support any charitable activities to benefit the local community in which the Project operates? (Do NOT include the goods and/services the Project will produce for customers in the local community.) (SELECT ONE: Yes / No). If applicable, please describe.

4. BUSINESS INNOVATION AND TECHNICAL ASSISTANCE

The information in this section will ask about the Project’s support for innovation and provision of technical assistance.

Q401 Will the Project introduce or disseminate an innovative product or service (including innovative financial services and financing structures)? (SELECT ONE: Yes / No). If applicable, please describe.

Q402 Will the Project provide advisory services (such as training or advice designed to improve business performance; this is also known as technical assistance) to customers, suppliers, or investees? (SELECT ONE: Yes / No). If applicable, please describe.

5. PROJECT EMPLOYMENT

Note: This section will only appear for respondents not providing financial services

Q501 Please complete the table below for all current employees of the Project. If the Project does not yet have any employees, please enter “0”.

	Full Time Local* Employees	Part-Time Local* Employees	Temporary/Seasonal Local* Workers
Total
Women
Young adults
Other disadvantaged groups

*Local employees are nationals of the country or countries of Project operations or investments

Q502 Please complete the table below for the projected number of employees of the Project in five years.

	Full Time Local Employees	Part-Time Local Employees	Temporary/Seasonal Local Workers
Total Projected Employees

6. PROJECT FUNDING

Q601 Please complete the table with currently available estimates, where applicable, for anticipated Project funding. Table should be completed in U.S. Dollars.

7. U.S. PROCUREMENT

Q701 Please complete the table below, if applicable, with expectations for the purchase of goods or services from U.S. companies.

Table: U.S. Procurement
Construction/Initial Development
Company	Product	Cost ($ millions)	City	State	New or Used (N or U)
4.
5.
Operations
3.
4.
5.

*If additional space needed, please include a separate spreadsheet.

8. TAXES, PROCUREMENT, AND EXPORTS

Note: This section will only appear for respondents not providing financial services

This section will ask about different ways that the Project is expected to have an impact on the economy.

Q801 Please complete the table below with currently available estimates.

Table: Local Taxes and Procurement (U.S. Dollars)
	Year 0	Year 1	Year 2	Year 3	Year 4	Year 5
Taxes to Government of Country/Countries of Operation	(USD)	(USD)	(USD)	(USD)	(USD)	(USD)
Procurement in Country/Countries of Operations	(USD)	(USD)	(USD)	(USD)	(USD)	(USD)

Q802 Will the Project procure goods or services from businesses representing any of the following groups? Select all that apply, or if not applicable, leave blank.

1. Women-owned or -led enterprises

2. Microenterprises

3. Small and Medium Enterprises (SMEs)

4. Smallholder farmers

5. Other disadvantaged groups

9. CUSTOMERS

Note: This section will only appear for projects not providing financial services

Q901 How many customers, on average, does the Project anticipate reaching on an annual basis over the next five years of operations? (NUMBER)

Q902 Will the Project specifically target customers from any of the following groups? Check all that apply.

1. Women-owned/women-led enterprises

2. Small and Medium Enterprises (SMEs)

3. Microenterprises

4. Women

5. Young Adults

6. Rural populations

7. Smallholder farmers

8. Low-income populations

9. Other disadvantaged groups (not included above): (Write in)

10. CURRENT PORTFOLIO AND CLIENTS

Note: This section only for projects that will provide financial services

Please complete the following tables representing the current portfolio that will be supported by the Project, as per the Client company’s last fiscal year or other annual reporting period.

Q1001 Please complete the following table representing the types of loans in the portfolio that will be supported by the Project.

	Number of Clients	Outstanding Number of Loans/Investments	Outstanding Portfolio Value (USD)
Microenterprise loans
SME loans
Consumer loans
Other loans
Equity investments
Other financial offerings

• [IF MICROENTERPRISE LOANS > 0, ASK] Q1002 How does the Project define microenterprises (in terms of revenue, assets, employees, loan size, etc.)? (OPEN-ENDED)

• [IF SME LOANS > 0, ASK] Q1003 How does the Project define SMEs (in terms of revenue, assets, employees, loan size, etc.)? (OPEN-ENDED)

Q1004 Please complete the following table representing the inclusion of the following groups as clients in the portfolio that will be supported by the Project.

	Number of Clients	Outstanding Number of Loans/Investments	Outstanding Portfolio Value (USD)
Women or women-owned/led enterprise clients
Rural clients
Smallholder farmer clients
Low-income clients
Clients from other disadvantaged groups

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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