OPIC_162_SMQ_OMB_APPROVED_FORM.pdf

PDF FOR REFERENCE ONLY – THIS IS NOT THE ACTUAL FORM.

THE ACTUAL FORM MUST BE COMPLETED ON-LINE. PAPER

SUBMISSIONS WILL NOT BE ACCEPTED.

OVERSEAS PRIVATE INVESTMENT CORPORATION

SELF-MONITORING QUESTIONNAIRE for Finance, Insurance, Reinsurance, and Investment Funds Projects

OPIC Form 162 OMB Number: 3420-0019 Expiration Date: 06/30/2019

Overseas Private Investment Corporation 1100 New York Avenue, NW Washington, DC 20527-0001 An Agency of the United States Government Please read the following information carefully. This form requests information from OPIC clients, which is required annually by OPIC’s governing legislation. The information provided in this questionnaire will allow OPIC to better assess the impact of OPIC-supported projects on the U.S. economy and employment, as well as the impact on host country economic development and the effects on the environment and workers’ rights abroad.

Complete responses to the collection of information in this form are mandatory, per the Foreign Assistance Act of 1961, as amended, Section 231(k)(2). Client information contained in this questionnaire will be designated as confidential commercial information in accordance with OPIC’s Freedom of Information Act (FOIA) regulations (22 CFR part 706) and will be treated as confidential commercial information to the extent permitted by applicable law. As a federal agency, OPIC may not collect, or sponsor the collection of, information unless it displays a valid OMB Control Number with an expiration date that has not expired.

Paperwork Reduction Act Notice: This information is required to retain benefits. Public reporting burden for this collecting of information is estimated to average 4.7 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 aspect of this collection of information, including suggestions for reducing this burden to Agency Forms Officer, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

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

GETTING STARTED

Welcome to OPIC’s Self-Monitoring Questionnaire (SMQ). As the U.S. Government’s development finance institution, OPIC takes its developmental mission seriously. The SMQ is an integral part of the OPIC monitoring and oversight function as it enables OPIC to collect data on the environmental, social, and long-term development impacts of each OPIC-supported project. Additionally, data collected in the SMQ are aggregated and used to satisfy OPIC’s U.S. Congressional reporting requirements.

OPIC’s Office of Investment Policy reviews each OPIC-supported project for its: 1) environmental, health, and safety risks; 2) labor-related risks; 3) impact on the U.S. economy and U.S. employment; and 4) development impact in the host country. For a description of OPIC’s Office of Investment Policy, please click here:

http://www.opic.gov/doing-business-us/OPIC-policies.

The SMQ must be completed on-line (click button below). To submit the SMQ on-line, you will be asked to enter the project type, contract number, and password. The OPIC contract number is provided annually in reminder e-mails sent to you by OPIC staff, and the password is created by each individual SMQ respondent. If you do not know your contract number, have forgotten your password, or encounter any other difficulties with the SMQ process, please e-mail the SMQ Helpdesk at SMQ@opic.gov.

Please answer all questions as completely as possible. If space is inadequate, please supply additional information on separate sheets of paper and attach them to your electronic submission in Part IV of the process.

For all questions, the terms “Project” and “Financial Intermediary” refer to the investment supported by the OPIC insurance or reinsurance contract and/or finance agreement identified by contract number herein.

Some questions and bolded terms found in the SMQ may not be familiar. Should you need it, the document entitled, “Guidelines for completing the OPIC Self-Monitoring Questionnaire” provides detailed instructions and definitions of terms. If you do not have a copy of this document, please e-mail the SMQ Helpdesk at SMQ@opic.gov.

For your reference, a PDF of the entire SMQ can be found here.

To initiate the on-line process, please click on the “Self-Monitoring Questionnaire” button below.

SELF MONITORING QUESTIONNAIRE START BUTTON

SELF MONITORING QUESTIONNAIRE START BUTTON

The Self-Monitoring Questionnaire (SMQ) is divided into two sections: Section A and Section B. Please note that only one of these sections needs to be completed . The electronic form will automatically direct you to the relevant section, depending on your response to question 2A in Part I (this question distinguishes the industry of the OPIC-supported project as Financial Services or Non-Financial Services).

Section A is to be completed by all OPIC Finance, Insurance and Reinsurance projects, and by all OPIC Investment Fund portfolio companies and framework agreement/on-lending facilities unless this is a Financial Intermediary transaction (see below).

Section B is to be completed for Financial Intermediary transactions. As such, the term “Financial Intermediary” refers to, but is not limited to, general-lending banks, specialized-lending institutions, mortgage facilities, microfinance institutions, private equity funds, and other capital market transactions.

The terms “Project” and “Financial Intermediary” are based on definitions given to them in Appendix D of OPIC’s Environmental and Social Policy Statement, as referenced below:

Project – All facilities owned or controlled within a physical project boundary that constitute a commercially viable business unit eligible for OPIC support.

Financial Intermediary – Investment funds, banks or other financial institutions including insurance companies, or other entities or vehicles that receive financing, guaranties or insurance from OPIC and provide debt or equity investment directly to projects or enterprises (“s”).

– A project or enterprise that receives financing, investment, or insurance from an OPIC-supported Financial Intermediary.

All projects that OPIC supports are subject to OPIC’s Environmental and Social Policy Statement and applicable International Finance Corporation Environmental, Health, and Safety Guidelines.

PART I – PROJECT SUMMARY

for which you are applying

1. PROJECT INFORMATION

A Project Name:

B Contract/loan #:

C Please provide the percentage of local ownership of the project, if any. ____% D

Is any of the local ownership comprised of Small & Medium Enterprises (SME)? 1

Yes No

If “Yes”, please provide the percentage of local ownership comprised of Small & Medium Enterprises.

E

Do women-owned businesses account for any local ownership? Yes No If “Yes”, please provide the percentage of local ownership that is comprised of women-owned and/or managed businesses. ____%

F

Does the project iinvolve other Development Finance Institutions (DFIs)? Yes No

1DEFINITION OF A LOCAL SMALL, MEDIUM ENTERPRISE: OPIC uses the IFC definition for local SMEs, which are defined as a firm with two out of the following three characteristics: total employees of up to 300, total assets of up to $15 million, and total annual sales of up to $15 million.

F If “Yes,” please indicate which DFIs below (please check all that apply) African Development Bank (AfDB) Asian Development Bank (AsDB) Belgium Investment Company for Developing Countries (BIO) Banque Ouest Africaine de Developpement (BOAD) Black Sea Trade and Development Bank (BSTDB) Commonwealth Development Corporation (CDC Group) Compañía Española de Financiación del Desarollo (COFIDES) European Bank for Reconstruction and Development (EBRD) European Investment Bank (EIB) Finish Fund for Industrial Cooperation (FINNFUND) German Development Finance Company (DEG) International Finance Corporation (IFC) Investment Fund for Developing Countries (IFU) Inter-American Development Bank (IDB) Islamic Corporation for the Development of the Private Sector (ICD) Multilateral Investment Guarantee Agency (MIGA) Netherlands Development Finance Company (FMO) Norwegian Investment Fund for Developing Countries (NORFUND) Oesterreichische Entwicklungsbank (OeEB) The Private Infrastructure Development Group Trust (PIDG) Swedfund International AB (SWEDFUND) Swiss Investment Fund for Emerging Markets (SIFEM) Société de Promotion et de Participation pour la Coopération Economique (PROPARCO) Other (please specify):

G Do any of the U.S. investors in the project (or one of its subsidiaries or affiliates) currently produce the same product(s) as that produced by this project?

Yes

No

If “Yes,” has the number of U.S. employees engaged in the U.S. production of this product been reduced as a result of this OPIC-supported investment?

2. PROJECT DESCRIPTION

A Project Type

Financial Services2

Non-Financial Services

B Describe the use of proceeds of this OPIC-supported investment.

C Has the project description changed since it was originally approved by

OPIC?

If “Yes”, please indicate the changes below:

New Business

Lines Exited markets

New products or services

Exited product lines or services

New international markets

Other

D Project Site Region(s): (select all that apply) Asia & Pacific Europe & Eurasia Latin America & Caribbean Middle East & North Africa Sub-Saharan Africa Global

E Project City and Country

Project Site Location (please include GPS coordinates):3

F Has the project become operational?

If “Yes”, please provide the date the project became fully operational.

Month / Year

If “No”, please specify the use(s) of the project funds during the reporting period. (select all that apply)

Engineering

Consulting

Construction (non-production)

Marketing

2 DEFINITION OF “FINANCIAL SERVICES”: Including, but not limited to commercial banks, non-bank banks, insurance companies, re-insurance companies, investment funds (e.g. microfinance, SME, venture capital, private equity), lending facilities and financial intermediaries engaged in specialized financial transactions (e.g. ABS).

3 If the site’s GPS coordinates are unknown, please visit maps.google.com and enter the site’s full address or find your project site (using either the “Earth” or “Map” views). When Google Maps has found your site (or you have identified it on the map), please right-click on the site and select “What’s here?” The site’s GPS coordinates will then be displayed at the bottom of your address listing in the upper left corner of the screen - for example in decimal degrees (38.900333, - 77.027203) or degrees, minutes, seconds (38054’01.2”N, 77001’37.9”W). If your Project site spans a large area, please provide the coordinates for the approximate center of your project. If your Project spans multiple sites, please provide the coordinates for all sites.

Other (please specify)

G Please provide the number of direct competitors currently operating in the project market

H Please specify the project’s most recently completed fiscal year and use data from this year to complete the rest of this form.

Starting Date

MM/YYYY

Ending Date

MM/YYYY

I What is the total value of remittances (dividends, profits, loans/interest, royalties, etc.) from the project during the reporting period?

To the United States $

To other countries, excluding the U.S. and the project country

J What was the value of the project’s revenues over the reporting period:

(If multiple product lines, please provide information on each product on a separate sheet.)

N/A

The project country $

The U.S. $

Other countries (in descending order of value)

K If the project is Financial Services, (as indicated in Question 2A) please proceed to Part II B.

If the project is Non-Financial Services (as indicated in in Question 2A), please check the appropriate project sector Classification.

Agriculture/Agribusiness

If “Agriculture/Agribusiness”, please answer the following:

Average agricultural yield (tonne/hectare)4

Number of farmers that are linked to the project as:

Employees

4 Please use metric tonnes per hectare

Suppliers

Buyers

Contractors

Education

If “Education” please answer the following

Number of students enrolled5

Number of local students enrolled (excluding children of foreign nationals) 6

Number of needs-based scholarships for local students (per year)

Energy

If “Energy”, please answer the following questions

Please identify the type(s) of energy generated (check all that apply):

Wind Solar Geothermal Biofuels Thermal (coal) Thermal (natural gas) Thermal (oil) Hydro Other (please specify):

Energy delivered to offtaker(s) in gigawatt hours (GWh)

_____(GWh) Energy Access

If “Energy Access” please answer the following:

Number of new on-grid connections

5 Including both full-time and part-time, where each discrete student is counted regardless of number of courses.

6 Including both full-time and part-time, where each discrete student is counted regardless of number of courses.

Number of new micro-grid connections

Number of new household power systems installed

Number of new modern lighting devices sold

Health

If “Health” please answer the following:

Number of patient consultations during the reporting period

Housing

If “Housing” please answer the following

Number of new residential dwellings

Number of refurbished residential dwellings

Information & Communications Technologies

If “Information & Communications Technologies”, please answer the following:

Number of mobile subscriptions, including voice and/or data7

Number of fixed data subscriptions8

Number of fixed voice (telephone) subscriptions9

Transportation

If “Transportation”, please answer the following:

Units of cargo containers transported through the road/railway/port/airport per year in twenty foot equivalent units (TEUs)10

____#TEUs

7 Examples include: GSM, CDMA, BGAN, VSAT, EDGE, UMTS, WiMax, 3G, 4G, or LTE. Include both post-pay and pre-pay subscriptions.

8 Examples include: ADSL, Broadband, or Fibre. Include both post-pay and pre-pay subscriptions.

9 Include both post-pay and pre-pay subscriptions.

10 The twenty-foot equivalent unit (often TEU or teu) is an inexact unit of cargo capacity often used to describe the capacity of container ships and container terminals

Tonnes of bulk cargo transported through the road/railway/port/airport per year11

___#tonnes

Number of Passengers using transportation services per year ____#

Waste & Sanitation

If “Waste & Sanitation”, please answer the following:

Amount of waste disposed per year (in tonnes)12 _____#tonnes

Volume of wastewater treated per year (in m3) ____#m3

Water

If “Water”, please answer the following:

Volume of potable water produced per year ____#m3

Other

If “Other”, please answer the following:

Please describe the project sector, with appropriate North American Industry Classification code.

https://www.naics.com/sic-codes-industry-drilldown/

K What is the project target client or customer?13

Please provide the total number of clients or customers served by the project during the reporting period

11 Please use metric tonnes.

12 Please use metric tonnes.

13 Examples include: Off-takers of a electricity generation unit, patients of a hospital, bank clients, or number of residents at a housing development.

PART II A – PROJECT COUNTRY EFFECTS

(For Non-Financial Services Projects)

1. INITIAL SOURCES OF PROJECT PROCEEDS (NON-FINANCIAL PROJECTS ONLY)

DEBT EQUITY OTHER TOTAL

A OPIC $ N/A $ $

B Project $ $ $ $

What amount, if any, was from an offshore non-U.S. source?

C U.S. sources other than sponsor. (Please specify source and amounts per source)

What amount, if any is from a U.S. public source (please specify source, examples:

USAID, Export-Import Bank, U.S. Trade and Development Agency)

D Project Country sources (please specify sources, countries, and amounts per country)

E Non-U.S. and non-project country sources (please specify, sources)

F Development Finance Institutions (International Finance Corporation, Inter- American Development Bank, etc) (please specify)

G Other sources (please specify) $ $ $ $

H INITIAL PROJECT PROCEEDS TOTAL: $ $ $ $

2. INITIAL USES OF PROJECT PROCEEDS (NON-FINANCIAL PROJECTS ONLY)

Refers to expenditures financed by the Project Proceeds Total included in 3H above.

A Purchased or spent in the Project Country

Of the amount in 3A above, how much will be spent on the procurement of goods and services from domestic suppliers?

B Purchased from the U.S. $ C Purchased from countries other than the Project Country or the U.S. (please specify countries and amounts per country)

D Miscellaneous Project costs, including costs not related to the procurement of assets/services (please specify what these costs represent, the countries in which these costs are incurred, and amount per country):

E TOTAL INITIAL PROJECT PROCEEDS USES: $

3. PROJECT EMPLOYMENT

A

Please provide the total current number of project direct employees for operations & management and during the construction phase (if applicable).14

Total Current Direct Employment (Operations & Management)

Local Foreign Nationals

Male Female Male Female

Managerial Professional/Technical Unskilled Labor Total B

Has the project utilized workers employed by third parties (i.e., through contractors/subcontractors) over the reporting period?

For physical construction

For administrative needs

For other operational needs

4. PROJECT CONSTRUCTION AND TEMPORARY EMPLOYMENT (if applicable) A

If your project has a construction phase and utilizes or utilized temporary construction workers, please provide the following below. Please also provide the same information for seasonal employees as listed.

Temporary Employees Construction Employees Seasonal Employees

14 Number of full-time equivalent employees as per local definition working for the client company or project at the end of the reporting period. This includes directly hired individuals and individuals hired through third party agencies as long as those individuals provide on-site services related to the operations of the client company. Also, this includes full-time equivalent worked by seasonal, contractual and part time employees. Part-time jobs are converted to full-time equivalent jobs on a pro rata basis, based on local definition (e.g., if working week equals 40 hours, a 24 hr/week job would be equal to 0.6 FTE job). Seasonal or short-term jobs are prorated on the basis of the portion of the reporting period that was worked (e.g., a full-time position for three months would be equal to a 0.25 FTE job if the reporting period is one year). If the information is not available, the rule-of-thumb is two part-time jobs equal a full-time job. Note: employment for the purpose of the construction of the client company's hard assets is not to be included in this indicator. For such jobs, please use the indicator Direct Employment – Construction Phase.

Number of full-time equivalent construction workers employed for the construction of the company or project's hard assets during the reporting period. Part-time jobs for construction are converted to full-time equivalent jobs on a pro rata basis, based on local definition (e.g., if working week equals 40 hours, a 24 hr/week job would be equal to 0.6 FTE job; a full-time position for three months would be equal to a 0.25 FTE job if the reporting period is one year). If the information is not available, the rule-of-thumb is two part-time jobs equal a full-time job.

Note: employment for the client company's operations and maintenance is not to be included in this indicator. For such jobs, please use the indicator Direct Employment – Operations and Maintenance.

Male Female Male Female Local Foreign National

Total

5. JOB QUALITY

A Does the project (or project company) offer employee development programs such as tuition reimbursement or formal mentorships to current non-management direct employees identified above in Question 1A of Part II?

If “Yes,” please describe what type of employee development programs are available to professional/technical and/or unskilled personnel.

B How many employees have been promoted during the reporting period?

Please indicate the number of employees promoted from unskilled positions to professional or technical positions

Please indicate the number of employees promoted from professional or technical positions to managerial positions

C Please provide the average monthly wage (in local currency) that is paid to full-time equivalent unskilled employees identified in Question 1A above.

http://www.xe.com/currencyconverter/

____local currency/month

D Please provide the average monthly wage (in local currency) that is paid to full-time equivalent professional/technical employees identified in Question 1A above.

http://www.xe.com/currencyconverter/

____local currency/month

6. PROJECT HUMAN RESOURCE MANAGEMENT

A Does the project have written human resources policies?

Have there been any significant changes to the human resources policies during the reporting period?

If “Yes,” please describe.

B Please indicate the areas covered by the human resources policies:

(Examples of Benefits: healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare, etc.)

Is/are mechanism(s) in place for workers to express grievances (e.g., direct access to supervisors and/or the human resources department, workers’ committees, and/or trade unions reps, or an anonymous hotline)?

Do general conditions of work at the minimum, comply with local applicable labor laws (e.g., limits on hours of work, wages (including premium or overtime pay), sick leave, collective bargaining agreements)?

Are disciplinary procedures in place? Yes

C Are terms of employment clearly communicated to each worker? Yes

If “Yes,” please describe how employment terms are communicated to each worker and attach verifying documentation, such as a sample employment contract.15

D Does the project management have experience in applying international labor standards, such as those in the IFC Performance Standards?

If “Yes,” please specify.

7. PROJECT LABOR-RELATED ISSUES

A Has there been a significant change since the beginning of the reporting period in the number of employees, composition of employees, demographics (gender, skill level, nationality/place of origin, etc.) of the workforce?

Did the project involve the following during the reporting period?

B Migrant or foreign workers (excludes foreign national management or highly-skilled non-manual workers)

Yes No

If yes, please provide the following information regarding the migrant or foreign workers: Number, National Origin, Skill Level, and Position and if they are living onsite at the project (foreign national management or highly skilled non-manual workers are exempt).

15 REMINDER

Please remember to attach a copy of the employment contract or terms before proceeding to the next page.

C Workers under the age of 18 directly or indirectly employed by the project

If “Yes,” please briefly describe the general duties of these workers and include the age of the youngest worker.

D Restructuring that resulted in a major retrenchment (i.e. layoffs of significant numbers of workers)

Yes No

If “Yes,” please describe the positions, skill levels, gender, and the national origins of the workers who were dismissed.

If “Yes,” did the project organization develop and implement a retrenchment plan?

If “Yes,” please describe and/or attach this plan.

Is there any foreseen possibility of a major retrenchment in the next reporting year?

Yes No

E Known non-compliance with local laws, OPIC labor-related requirements, or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits)

Yes No

F Is there an onsite trade union?

If “Yes,” what percentage of workers are covered by a collective bargaining agreement?

G Labor-related lawsuits against the project

H Labor unrest during the reporting period in the form of strikes or other general industrial disputes

I Ongoing or unresolved issues/disputes with a project trade union

J Is there onsite security?

If “Yes,” are security guards armed?

Is security publicly or privately contracted?

Publicly Contracted

Privately Contracted

K Was the project or project organization required to submit to OPIC any reports on employment or labor practices or systems during the reporting period?

Yes No

If “Yes,” please list reports and dates of transmission of the reports. If a required report has not yet been submitted, please leave the date field blank and specify in the comments section why it has not been submitted and when it is expected to be submitted.

Day / Month / Year

Day / Month / Year

Day / Month / Year

Day / Month / Year

8. BUSINESS INNOVATION

Please indicate if the project has operationalized a product, process, and/or technology that is new or not widely used in the domestic sector during the reporting period as a result of the OPIC-supported investment. Where applicable, please indicate whether any of these factors were new or uncommon in the project country and provide details.

A Products and/or Services

New Uncommon No

If “New” or “Uncommon”, please describe.

B Business Processes

C Production and/or processing technologies 16

D Has the project provided technical assistance (e.g. training of customers, industry counterparts, suppliers, technical expertise from fund manager) during the reporting period?

If “Yes”, please explain:

E Has the project secured voluntary sustainability certification from an internationally recognized certifying authority during the reporting period?

If “Yes”, please identify:

9. ENVIRONMENTAL AND COMMUNITY BENEFITS

As a result of the OPIC-supported investment, has the project implemented new initiatives (either corporate or project-related) that are directed at restoring and/or preserving the environment during the reporting period?

If “Yes” please explain (e.g. paperless banking, favorable financing terms for project clients engaging in activities which preserve the environment.

16 Examples may include, but are not limited to, equipment upgrades, creation of manufacturing technology efficiencies, or IT enhancements.

17 Examples may include, but are not limited to: Fairtrade International, International Sustainability and Carbon Certification, or International Standards Organization certificates.

B Did the project contribute money towards activities that benefit local communities (e.g. recreational facilities, schools, medical clinics, scholarship programs, other charitable activities) during the reporting period?

Yes No

If “Yes” please provide the value of these expenditures during the reporting period and describe these activities.

_____________$/year

C Does the project have an Environment and Social Management System (ESMS)?

If “Yes” please explain or attach a copy of the ESMS (in English)

10. ENVIRONMENTAL IMPACT

A Is the project currently in compliance with all conditions in the

OPIC contract or consent with respect to environment, health and safety?

If “No”, please describe the areas of non-compliance.

B Has the project been cited or fined for any violation of local or host country environmental, health or safety laws during the reporting period?

If “Yes”, please explain briefly below.

C Has the project submitted all OPIC-required reports on environment, health and safety during the reporting period?

Yes No N/A

If “Yes”, please list reports and dates of transmission of the reports. If a required report has not yet been submitted, please leave the date field blank and specify in the comments section why it has not been submitted and when it is expected to be submitted

Day / Month / Year

Day / Month / Year

Day / Month / Year

Day / Month / Year D Have there been any changes in the design or capacity of the project that result in increased hazards to workers, area residents, or the environment during the reporting period?

If yes, please describe briefly below.

E Have any accidents occurred that resulted in loss of human life or material impacts on the environment during the reporting period?

If so, describe briefly below.

11. PROJECT COUNTRY REGULATORY ENVIRONMENT

A Has the project resulted from or caused any project country reforms, new legislation, or new regulations during the reporting period?

If “Yes”, please explain.

B Has the project partnered with or received support from a public entity (i.e. – a local development bank/federal or local government/NGO) during the reporting period?

If “Yes,” please indicate the type of party involved and describe their involvement.

Project country government entity:

International non-governmental organization:

Local non-governmental organization:

U.S. entity:

Other:

12. PROJECT OPERATIONAL PROCUREMENT

A Has the project procured goods and services from project country sources

If “Yes,” please provide the average annual amount of operational procurement (excluding utilities, rent, tax payments, and labor) from project country sources during the reporting period.

Please also briefly describe the goods and/or services that have been procured by OPIC support.

13. PROJECT PAYMENTS TO HOST GOVERNMENT

A Please provide all taxes or transfers to the host government made by the project during the reporting period.18

B If the project is eligible for a tax holiday, indicate the duration of the tax holiday.

___ year(s)

C If duties and/or tax payments to project country government have been reduced as a result of the project, please estimate the amount lost during the reporting period.19

18 Payments include duties, taxes, sales tax, net VAT, royalties, dividends and related taxes, management and/or concession fees, license fees, tax on payment of interested, and other material payments net of any direct subsidies received.

19 For example, project production will substitute for imports subject to tariffs.

PART II B – PROJECT COUNTRY EFFECTS

(For Financial Services Projects)

1. FINANCIAL INTERMEDIARY – CURRENT TOTAL PORTFOLIO

A Please provide the following portfolio information on the Financial Intermediary’s total portfolio during the reporting period:

Total Portfolio

Number of transactions #

Number of clients #

Value of outstanding portfolio $

Average transaction amount per client $

Maximum transaction amount to single client $

Mimimum transaction amount to single client $

Average tenor (in months)20 # (months)

% of the portfolio (based on number of clients) that targets rural clients

% (based on number of clients)

% of the portfolio (based on number of clients) that are women or women-owned businesses

% (based on number of clients)

2. PORTFOLIO TRANSACTION TYPE

Please identify the type of project transactions supported by the OPIC-supported investment. Check all that apply.

A MICROFINANCE LOANS ONLY

Total Portfolio OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

Has the project received additional financing (public and/or private) during the reporting period?

20 Average (simple mean) initial tenor (in months) of all outstanding loans in the current portfolio.

If “Yes,” how much additional financing did the project receive during the reporting period?

SME LOANS ONLY

Total Portfolio OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

If “Yes,” how much additional financing did the project receive during the reporting period?

B MICROFINANCE OR SME LOAN PORTFOLIO INFORMATION

If the OPIC investment supports Microfinance or SME loans, please provide the following total portfolio information for the reporting period:

Total Portfolio OPIC-supported portfolio

Number of project transactions # #

Number of project clients # #

Value of project outstanding portfolio $ $

Average transaction amount per client21 $ $

Maximum transaction amount to a single client

Minimum transaction amount to a single client

Average tenor (in months)22 # in months #in months

Purpose of the transactions as a percentage of the outstanding value of portfolio A above.

Total Portfolio OPIC-supported portfolio

Start-up Capital % %

Working Capital % %

Expansion Capital % %

Equipment Purchase % %

21 If “Microenterprises” was selected in question 2 above AND the average transaction size exceeds $10,000 OR If “SME” was selected AND the average transaction size exceeds $2 million, then the following warning appears:

The average transaction size exceeds the typical average value for microfinance or SME transactions. Please verify that your response reflects the average transaction size for the OPIC-supported portfolio.

22 Average (simple mean) initial tenor (in months) of all outstanding loans in the current portfolio.

Business activities/sectors of clients as a percentage of the outstanding value of portfolio 1 A above.

Total Portfolio OPIC-supported portfolio

Manufacturing % %

Agriculture % %

Construction % %

Transportation % %

Communication % %

Tourism % %

Trade/Retail % %

Energy % %

Services (please specify)

Demographic distribution of clients as a percentage of the outstanding value of portfolio A above.

Total Portfolio OPIC-supported portfolio

Women (or women-managed businesses)

Not Applicable

We Do Not Track

Rural Not Applicable

We Do Not Track

We Do Not Track

C EQUITY INVESTMENTS

How much capital has been invested in the project as of the end of the reporting period?

Has the project received additional financing (public and/or private) during the reporting period?

If “Yes,” how much additional financing did the project receive during the reporting

SME loans and Microfinance loans combined

How much capital has been invested in the project as of the end of the reporting period?

Has the project received additional financing (public and/or private) during the reporting period?

If “Yes,” how much additional financing did the project receive during the reporting

EQUITY INVESTMENT OR OTHER PORTFOLIO INFORMATION

If the OPIC investment supports Equity Investments and/or Other Investments, please provide the following portfolio information for the reporting period.

Total Portfolio OPIC-supported portfolio

Number of project transactions # #

Number of project clients # #

Value of project outstanding portfolio $ $

Average transaction amount per client $ $

Maximum transaction amount to a single client

Minimum transaction amount to a single client

Average tenor (in months)23 #_______(months) #_______(months)

Economic segments of clients as a percentage of the outstanding value of portfolio A above

23 Average (simple mean) initial tenor (in months) of all outstanding loans in the current portfolio.

Microenterprises24 ___________% ___________%

Small & Medium Enterprises25 ___________% ___________%

Large Corporations ___________% ___________%

Other (please specify

Purpose of the transactions as a percentage of the outstanding value of portfolio A above

Total Portfolio OPIC-supported portfolio

Start-Up Capital __________% __________%

Working Capital __________% __________%

Expansion Capital __________% __________%

Equipment Purchase __________% __________%

Business activities/sectors of clients as a percentage of the outstanding value of portfolio 1 A above

Total Portfolio OPIC-supported portfolio

Manufacturing __________% __________%

Agriculture __________% __________%

Construction __________% __________%

Transportation __________% __________%

Communication __________% __________%

Tourism __________% __________%

Trade/Retail __________% __________%

Energy __________% __________%

24 OPIC uses the IFC definition for microenterprises, which are defined as enterprises with two of the following three characteristics: total employees of up to 10, total assets of up to $100,000 and total annual sales of up to $100,000.

25 OPIC uses the IFC definition for SME’s which are defined as firms with two out of the following three characteristics:

total employees of up to 300 employees, total assets of up to $15 million, and total annual sales of up to $15 million.

Demographic distribution of clients as a percentage of the outstanding value of portfolio A above

We Do

Track

Rural Not Applicable

We Do

Other (please specify) Not Applicable

We Do

D LEASING CONTRACTS

Total Portfolio OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

If “Yes,” how much additional financing did the project receive during the reporting

LEASING PORTFOLIO INFORMATION26

If the OPIC investment will support Leasing, please provide the following total portfolio information and projections for the reporting period.

26 If “Leasing” or “Insurance Contracts” are checked in Question 2 above, these following dropdown questions appear for each category.

Number of project transactions # #

Number of project clients # #

Value of project outstanding portfolio $ $

Average transaction amount per client $ $

Maximum transaction amount to a single client $ $

Minimum transaction amount to a single client $ $

Average tenor (in months)27 #______ in months #______ in months

Please provide the economic segments of clients as a percentage of the outstanding total value of portfolio

A above

Total Portfolio OPIC-supported portfolio

Microenterprises28 ___________% ___________%

Small & Medium Enterprises29 ___________% ___________%

Large Corporations ___________% ___________%

Other (please specify

Please provide the business activities/sectors of clients as a percentage of the total outstanding value of portfolio A above

Total Portfolio OPIC-supported portfolio

Manufacturing __________% __________%

Agriculture __________% __________%

Construction __________% __________%

Transportation __________% __________%

27 Average (simple mean) initial tenor (in months) of all outstanding loans in the current portfolio.

28 OPIC uses the IFC definition for microenterprises, which are defined as enterprises with two of the following three characteristics: total employees of up to 10, total assets of up to $100,000 and total annual sales of up to $100,000.

29 OPIC uses the IFC definition for SME’s which are defined as firms with two out of the following three characteristics:

total employees of up to 300 employees, total assets of up to $15 million, and total annual sales of up to $15 million.

Communication __________% __________%

Tourism __________% __________%

Trade/Retail __________% __________%

Energy __________% __________%

Total Portfolio OPIC-supported portfolio

Women (or women-managed businesses)

We Do Not

Applicable

Other (please specify)

Not Applicable

E CONSUMER LOANS

Total Portfolio OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

CONSUMER LOANS PORTFOLIO INFORMATION

If the OPIC investment supports Consumer Loans, please provide the following portfolio information for the reporting period:

Number of project transactions # #

Number of project clients # #

Value of project outstanding portfolio $ $

Average transaction amount per client $ $

Maximum transaction amount to single client $ $

Minimum transaction amount to a single client $ $

Average tenor (in months)30 #______ in months #______ in months

Demographic distribution of clients as a percentage of the outstanding value of portfolio A above

Total Portfolio OPIC-supported portfolio

We Do

Applicable

We Do

Applicable

We Do

F INSURANCE CONTRACTS

Total Portfolio OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

30 Average (simple mean) initial tenor (in months) of all outstanding loans in the current portfolio.

INSURANCE CONTRACTS PORTFOLIO INFORMATION

If the OPIC investment supports Insurance Contracts, please provide the following total portfolio information and projections for the reporting period.

Total Portfolio OPIC-supported portfolio

Number of project transactions # #

Number of project clients # #

Value of project outstanding portfolio $ $

Average transaction amount per client $ $

Maximum transaction amount to a single client $ $

Minimum transaction amount to a single client $ $

Average tenor (in months)31 #_______in months #______in months

Please provide the economic segments of clients as a percentage of the outstanding total value of portfolio

A above

Total Portfolio OPIC-supported portfolio

Microenterprises32 % %

Small & Medium Enterprises33 % %

Large Corporations % %

Other (Please specify) % %

Please provide the business activities/sectors of clients as a percentage of the total outstanding value of portfolio A above

Total Portfolio OPIC-supported

Manufacturing % %

31 Average (simple mean) initial tenor (in months) of all outstanding loans in the current portfolio.

32 OPIC uses the IFC definition for microenterprises, which are defined as enterprises with two of the following three characteristics: total employees of up to 10, total assets of up to $100,000 and total annual sales of up to $100,000.

33 OPIC uses the IFC definition for SME’s which are defined as firms with two out of the following three characteristics:

total employees of up to 300 employees, total assets of up to $15 million, and total annual sales of up to $15 million.

Agriculture % %

Construction % %

Transportation % %

Communication % %

Tourism % %

Trade/Retail % %

Energy % %

Total Portfolio OPIC-supported portfolio

Women (or women-managed businesses)

Not Applicable We Do Not

Rural Not Applicable We Do Not

Other (please specify)

Not Applicable We Do Not

G MORTGAGES

Total Portfolio OPIC-supported portfolio

How much capital has been invested in the project as of the end of the reporting period?

MORTGAGE PORTFOLIO INFORMATION

portfolio

Number of projects transactions # #

Number of projects clients # #

Value of project outstanding portfolio $ $

Average transaction amount per client $ $

Maximum transaction amount to a single client $ $

Minimum transaction amount to a single client $ $

Average tenor (in months)34 #_______in months #_____in months

How much capital has been invested in the project as of the end of the reporting period?

Please provide the purpose of the mortgages as a percentage of the outstanding value of portfolio A above

Total Portfolio OPIC-supported portfolio

Mortgages for new homeowners % %

Home improvement loans % %

Productive loan (e.g. home equity, loan/line of credit) % %

Other (please specify): % %

Please provide the target market of mortgages as a percentage of the outstanding value of portfolio A above

Total Portfolio OPIC-Supported Portfolio

Low-income homes % %

Middle-income homes % %

High-income homes % %

Residential rental properties % %

34 Average (simple mean) initial tenor (in months) of all outstanding loans in the current portfolio.

Commercial properties % %

Other (please specify): % %

Please provide the demographic distribution of clients as a percentage of the outstanding value of portfolio

A above

Total Portfolio OPIC-Supported Portfolio

Applicable

Applicable

3. PROJECT EMPLOYMENT

A Please provide the current total number of project direct employees for operations & management35

Total Current Direct Employment

(Operations and Management) Local Foreign Nationals

Male Female Managerial Professional/Technical Unskilled Labor

Total B Has the project utilized workers employed by third parties (i.e., through contractors/subcontractors) during the reporting period?

For physical construction For administration needs For other operational needs

35 Number of full-time equivalent employees as per local definition working for the Project. This includes directly hired individuals and individuals hired through third party agencies as long as those individuals provide on-site services related to the operations of the Project. Also, this includes full-time equivalent worked by seasonal, contractual and part time employees. Part-time jobs are converted to full-time equivalent jobs on a pro rata basis, based on local definition (e.g., if working week equals 40 hours, a 24 hr/week job would be equal to 0.6 FTE job). Seasonal or short-term jobs are prorated on the basis of the portion of the year that was worked (e.g., a full-time position for three months would be equal to a 0.25 FTE job). If the information is not available, the rule-of-thumb is two part-time jobs equal one full-time job.

4. HUMAN RESOURCE MANAGEMENT

A Does the project have written human resources policies? Yes No Have there been any significant changes to the human resources policies during the reporting period?

Please indicate the areas covered by the human resources policies:

(Examples of Benefits: healthcare, life insurance, pension plan, vacation, maternity/paternity leave, childcare, etc.)

B Is/are mechanism(s) in place for workers to express grievances(e.g., direct access to supervisors and/or the human resources department, workers’ committees, and/or trade unions reps, or an anonymous hotline)?

Yes No

Do general conditions of work at the minimum, comply with local applicable labor laws (e.g., limits on hours of work, wages (including premium or overtime pay), sick leave, collective bargaining agreements)?

C Are disciplinary procedures in place?

If “Yes,” please describe how employment terms are communicated to each worker and attach verifying documentation, such as a sample employment contract.36

D Does the project management have experience in applying international labor standards, such as those in the IFC Performance Standards?

If “Yes,” please specify.

36 REMINDER (if “yes” and document not attached before attempting to proceed to next page):

Please remember to attach a copy of the employment contract or terms before proceeding to the next page.

5. PROJECT LABOR-RELATED ISSUES

A Has there been a significant change since the beginning of the reporting period in the number of employees, composition of employees, demographics (gender, skill level, nationality/place of origin, etc.) of the workforce?

Yes No

Did the project involve the following during the reporting period?

B Workers under the age of 18 (directly or indirectly employed by the project).

Yes No

If “Yes,” please briefly describe the general duties of these workers and include the age of the youngest worker.

C Restructuring which results in a major retrenchment (i.e. lays off significant numbers of workers)

Yes No

If “Yes,” please describe the positions, skill level, gender, and the national origin of the workers who were dismissed.

If “Yes,” did the project organization develop and implement a retrenchment plan?

If “Yes,” please describe and/or attach this plan.

Is there any foreseen possibility of a major retrenchment in the next reporting year?

Yes No

D Known non-compliance with local laws, OPIC labor-related requirements, or other applicable labor standards (self-diagnosed, or as a result of official inspections or other audits)

E Labor-related lawsuits against the project

F Labor unrest during the reporting period in the form of strikes or other general industrial disputes

G Ongoing or unresolved issues/disputes with a project trade union

If “Yes,” please explain.

H Was the project or project organization required to submit to OPIC any reports on employment or labor practices or systems during the reporting period?

Yes No

If “Yes,” please list reports and dates of transmission of the reports. If a required report has not yet been submitted, please leave the date field blank and specify in the comments section why it has not been submitted and when it is expected to be submitted.

Day / Month / Year

Day / Month / Year

Day / Month / Year

Day / Month / Year

6. BUSINESS INNOVATION

Please indicate if the project operationalized a product, process, and/or technology that is new or not widely used in the domestic sector during the reporting period as a result of the OPIC-supported investment. Where applicable, please indicate whether any of these factors are new or uncommon in the project country and provide details.

New Financial Products and/or Services

B Business Processes37

C Innovative Financing Structures

D Has the project provided technical assistance (e.g., training of customers, industry counterparts, suppliers, technical expertise from fund manager) during the reporting period?

If “Yes”, please describe.

E Has the project secured voluntary sustainability certification from an internationally-recognized certifying authority during the reporting period? 38

If “Yes”, please identify.

7. PROJECT ENVIRONMENTAL & COMMUNITY EVENTS

A As a result of the OPIC-supported investment, has the project implemented new initiatives (either corporate or transactional) which are directed at restoring and/or preserving the environment

If “Yes”, please describe (e.g.. paperless banking, favorable financing terms for project clients engaging in activities which preserve the environment).

37 Examples may include, but are not limited to: methods used to deliver products or services; managerial practices to improve transparency or employee productivity.

38 Examples may include, but are not limited to: Fairtrade International, International Sustainability and Carbon Certification, or International Standards Organization certificates.

B Did the project contribute money towards activities that benefit local communities (e.g. recreational facilities, schools, medical clinics, scholarship programs, other charitable activities) during the reporting period?39

Yes No

If “Yes,” please provide the actual value of these expenditures during the reporting period and describe these activities.

__________$/year

C Does the project have an Environmental and Social Management System (ESMS)?40

If “Yes” please explain or attach a copy of the ESMS (in English).

8. ENVIRONMENTAL IMPACT

A Is the project currently in compliance with all conditions in the OPIC contract or consent with respect to environment, health and safety?

39 Philanthropic and/or charitable initiatives not directly related to the business operations of the Project Company

40 An ESMS typically includes the components listed below:

An Environmental and Social Policy that defines the environmental and social objectives of the Sponsor.

An organizational structure that defines the roles, responsibilities, and authority to implement a project’s environmental and social requirements.

An Occupational Health and Safety Plan that describes potential worker hazards, provides preventative and protective measures and…