Form OPIC--253 Aligned Capital Investor Screener

Aligned Capital Investor Screener

Form: OPIC-253

OMB Number: 3420-0034

Expiration Date: [ ]

Instructions

The information in this form is used to determine if an investor may participate in OPIC’s Aligned Capital Program and, if an investor does, to place their information into the program. The Aligned Capital Program is designed to align development finance with other capital, including philanthropic, socially responsible and impact investment, to enable effective deployment of that capital towards projects in the countries and sectors in which OPIC works. 

In order to participate, investors must be U.S. entities and meet the additional specified criteria.

To begin, click below.

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Part A—Identifying Information

1. INVESTOR (This is the entity that will be making the investment or an investment advisor. For all purposes of this form, this entity is the “Investor.”)

Name:

Address (including city and country):

Phone Number(s):

2. AUTHORIZED REPRESENTATIVE (This is the individual who should receive potential investment information.)

Name of Representative:

Relationship to the Investor:

Address (including city and country):

Phone Number(s):

E-mails(s):

Part B—Investor Screening Questions

The information requested in this section will determine the Investor’s eligibility to enroll in this program.

Is the Investor an entity organized under the laws of a U.S. state or territory?

____ Yes ____ No

Is the Investor an “accredited investor” within the meaning of Rule 501 of Regulation D under the U.S. Securities Act of 1933, as amended (the “Securities Act”)?

____ Yes ____ No

Is the Investor an agency of the U.S. Government?

____ Yes ____ No

Check the box or boxes below that are next to the categories under which the Investor qualifies as an accredited investor. (Please mark each category that applies.)

FOR CORPORATIONS, FOUNDATIONS, ENDOWMENTS, PARTNERSHIPS, LIMITED LIABILITY COMPANIES OR SIMILAR BUSINESS TRUSTS:

A legal entity with total assets in excess of $5,000,000 not formed for the specific purpose of making an investment in a specific company.

An entity all of the equity owners of which are Accredited Investors.

FOR INVESTMENT COMPANIES, AND BROKER-DEALERS:

		An investment company registered under the Investment Company Act of 1940, as amended (the “1940 Act”).
		A business development company as defined in Section 2(a)(48) of the 1940 Act.
		A Small Business Investment Company licensed by the U.S. Small Business Administration under Section 301(c) or (d) of the Small Business Investment Act of 1958, as amended.
		A private business development company as defined in Section 202(a)(22) of the Investment Advisers Act of 1940, as amended (the “Advisers Act”).
		A broker or dealer registered pursuant to Section 15 of the Securities Exchange Act of 1934, as amended.

Select the description below that applies to the Investor.

		Foundation with an endowment of at least $5M
		Non-Profit Entity (that is not a foundation) with investment capacity of at least $5M OR with grant-making capacity of at least $1M
		Fund manager with assets under management of at least $15M AND with at least $5M of available capital
		Investment company with net current assets of at least $20M

Does the Investor have the knowledge and experience in financial and business matters to evaluate the merits and risks of an investment and make independent investment decisions?

____ Yes ____ No

Part C—Matching Questions

The information requested in this section will be used to identify potential investments that may be of interest to the Investor. Please indicate the types of investments the Investor is interested in considering.

Please select one or more applicable responses for each question:

1. Asset Classes/Types of Investments and Sizes of Investment (Select each type of investment the Investor would consider and the size per type of investment the Investor would consider for each class, not total amount of all investments Investor may consider as part of this program.)

(a)____ Equity

[Drop down with dollar ranges]

(b)____ Convertible Debt

[Drop down with dollar ranges]

(c)____ Subordinated/Mezzanine Debt

[Drop down with dollar ranges]

(d)____ Senior Debt

[Drop down with dollar ranges]

(e)____ Grants/Technical Assistance

[Drop down with dollar ranges]

2. Total Project Size (Select the total target size of investment, meaning the investment to be made by all investors in a given project, including debt.)

[Drop down with dollar ranges]

3. Preferred Investment Vehicle (Select the type(s) of investment vehicles that the Investor would consider.)

____ Any

____ Investing directly into a company that is building/operating a project—Operating Company/Project Company/Special Purpose Vehicle

____ Investing indirectly through another entity that invests (usually via equity) in companies—Investment Vehicle/Fund/Holding Company

____ Investing indirectly through another entity that invests (usually via debt) in companies—Financial Intermediary/Bank/Non-Bank Financial Institution

____     Investing indirectly through another entity that invests in companies in one or more ways—Hybrid Vehicles

4. Sectors (Identify sectors of interest to the Investor.)

[Drop down list of OPIC Sectors]

5. Regions and Countries (Identify regions and countries of interest to the Investor.)

[Drop down list of OPIC Regions and Countries]

6. Does the Investor have, or intend to have, a performance metric or other system for measuring social impact and/or environmental impact?

____ Yes ____ No

Part D—Disclaimers and Certifications

The person completing this form represents and warrants that you are authorized to register on behalf of the Investor described in this Aligned Capital Investor Screener and that all information provided is accurate and truthful.

The undersigned hereby certifies that the selections herein are consistent with any investment guidelines or limitations applicable to the Investor. The Investor is capable of evaluating the merits and risks of an investment and that purchase of any investment may be deemed to be a speculative investment and is not intended as a complete investment program.  The undersigned hereby certifies that the undersigned acknowledges that an investment is designed only for investors who have adequate means of providing for their needs and contingencies without relying on distributions or withdrawals from their investment accounts; who are financially able to maintain their investment; and who can afford the loss of their investment.  There can be no assurance that any investment will achieve its objective, and investors may lose all or a substantial portion of their investment.

OPIC does not control, is not responsible for, has not reviewed and does not endorse any investee that is participating in the Aligned Capital Program. OPIC does not warrant the accuracy, completeness or usefulness of the information provided by third parties. Participation by an investee in this program does not imply a commitment by OPIC to support the project.

The information provided does not constitute investment advice. Users need to consult with their own investment, accounting, legal and tax advisers to evaluate independently the risks, consequences and suitability of any investment made by them.

OPIC may terminate the program at any time, with or without notice.

Paperwork Reduction Act Notice: This is a voluntary information collection, however an investor may not participate in the Aligned Capital Program unless this form is completed. Public reporting burden for this collecting of information is estimated to average twenty 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 aspect of this collection of information, including suggestions for reducing this burden to the Records Manager, Overseas Private Investment Corporation, 1100 New York Avenue, NW, Washington, DC 20527; and to the OPIC Desk Office at the Office of Information and Regulatory Affairs, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503.

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