Dfc-001b Rl

Application for Direct Equity Investment (DFC-001B)

OMB No. 3015-0004

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 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 the 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.

Information provided in this form will be deemed designated as “confidential commercial information” in accordance with Freedom of Information Act (FOIA) regulations at 22 C.F.R. Part 706, and will be treated as such to the extent permitted by applicable law.

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.

Paperwork Reduction Act Notice: This information is required to obtain or retain 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 90 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 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 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, DC 20503.

This Form and any attached supporting documentation will enable DFC personnel to make a preliminary determination of whether your proposal meets eligibility and basic underwriting requirements. Please click here to review the basic eligibility requirements. For a description of DFC’s Direct Finance origination process and answers to frequently asked questions (FAQs), please click here. For general questions or eligibility questions, please email equity@dfc.gov. If a particular question on this form is unclear, please email FormsSupport@dfc.gov.

QUESTION 1: IDENTIFY THE PROPOSED INVESTEE

In each DFC-supported transaction, DFC enters into a contractual relationship with an Investee. Please list the location and contact information for that party. If that party has not yet been formed/incorporated, please list approximate information that will allow us to create a placeholder for that party in our transaction tracking systems.

Proposal Date	DEFAULT
Main Point of Contact (First Name)	TEXT BOX
Main Point of Contact (Last Name)	TEXT BOX
Main Point of Contact (Email)	TEXT BOX
Main Point of Contact (Phone Number)	TEXT BOX
Name of Investee	TEXT BOX
Address of Investee	TEXT BOX
City of Investee	TEXT BOX
Postal Code of Investee1	TEXT BOX
Country of Investee	TEXT BOX
Other Investee Locations (cities)	TEXT BOX
Website of Firm	TEXT BOX
SAM Registration Number (if available)	TEXT BOX (OPTIONAL)

QUESTION 2: DESCRIBE THE TRANSACTION

Please provide a brief description of the proposed transaction, making sure to address the following:

• What are the objectives – commercial-financial and social-developmental – of the proposed transaction?

• What factors or resources under the control of the involved parties will contribute most toward meeting those objectives and why?

• How would DFC’s participation in the transaction contribute to its success?

Please attach the following supporting documents:

Business Plan/Preliminary Information Memorandum [click here for guidance]	[Insert required button for attachment]
Financial Projections Model [click here for template and user guides]	[Insert required button for attachment]
Historical Financial Statements [click here for guidance]	[Insert required button for attachment]

QUESTION 3: IDENTIFY THE KEY PARTIES INVOLVED WITH THE TRANSACTION

Evaluating the business entities and/or individuals that will own, manage or make other critical contributions to the transaction being financed is an important part of DFC’s investment process.

Please attach detailed chart(s)/schematic(s) showing the structure of the proposed transaction and key relationships. These may include ownership capitalization table, organizational/ management structures, contractual relationship schematics, etc.

[Mandatory “Attach” button]

Please list and provide requested information on each of the following types of entities/individuals. If an entity/individual plays multiple roles in a transaction, only list them once and indicate their most important/primary role:

• Each business entity/individual that owns 10% or more (either directly or indirectly) of the Investee/transaction.

• Each business entity/individual that does or intends to provide credit support (e.g. a guarantor)

• Each business entity/individual that does or will have a significant managerial relationship with the Investee/transaction (e.g. executives/directors).

• Each business entity/individual that does or will have a primary contractual relationship with the Investee (e.g. construction contractor, operations and maintenance contractor, hotel management company, etc.)

Note: Certain governmental/multilateral parties that may be involved and shown in the attached charts need not be listed here. Please click here for a definition of such parties.

Name
Type of Entity	Two choices: Individual or Business Entity
Country of Citizenship (for Individuals) or Incorporation (for Business Entities)
Primary Relationship to Investee	Choices – Owner/Shareholder, Lender, Manager/Director, Contractor
Women Owned or Led?	Y/N
If yes, please provide:
% owned by women	%
# of women on Board of Directors	#
names and titles of women owners and executives:	Text box

QUESTION 4: TRANSACTION SOURCES AND USES

Please provide a list of the estimated sources and the uses of funding that will be used to cover them. Remember to include both hard/physical asset uses (e.g. buildings or equipment) and soft/implementation uses (e.g. legal or consultant services, fees, contingency etc.) in the use estimate. The total use amount in Column A must equal the total sources amount in Column B. For an example, please click [here].

	Column A			Column B
Uses	USD	%	Sources	USD	%
			Debt:
			DFC loan (indicate proposed term)
			Other term debt (indicate proposed term)
			Supplier financing
			Subordinated Debt:
			Third party subordinated debt
			Shareholder subordinated loans
			Equity:
			DFC Equity
			Preferred Equity
			Common Equity
			Cash
			In-kind contribution1
			Grants
			Other (please describe)
Total Uses:			Total Sources

Balance Sheet Comparison

Existing Balance Sheet	USD	%	Proposed Future Balance Sheet	USD	%
Total Assets			Total Assets
			DFC Debt
Total Debt/Liabilities			Non-DFC Debt/Liabilities
Net Worth			DFC Equity
			Non-DFC Net Worth

Would DFC equity be used to repay any existing debt? Yes/No

If yes, please describe the source and current terms of the debt that would be repaid and why the repayment is important to the overall objective of the transaction.

¹ An in-kind contribution could be a hard asset such as a building, land or equipment. In order for DFC to credit it as an equity contribution, it must be titled to the Borrower, and DFC must receive reasonable documentation of its market value (e.g. a recent appraisal, sales invoice, etc.)

QUESTION 5: MANAGEMENT EXPERIENCE AND TRACK RECORD

Briefly describe relevant experience (in the sector, in the market, etc.) that the key parties (individually or as a team) may contribute towards the success of the proposed transaction.

Please attach a document compiling CVs or other documentation that demonstrates this experience: [insert required attach button]

Question 6: PROVIDE INFORMATION ON PRIVATE SECTOR SOURCES OF FINANCING

DFC does not compete with private sector providers of financing. Therefore, DFC requires that applicants: (a) evaluate the possibility of obtaining financing from private sources and (b) decide to pursue DFC financing because private financing is not available on terms sufficient to make the investment viable or because of specific benefits DFC participation will bring to the investment.

Have you evaluated the possibility of obtaining financing for this transaction from private sector sources?	Yes	No
Have you determined that private sector financing is not a viable option in this case?	Yes	No
If Yes, please list the private sector funding source(s) you have approached regarding this transaction and explain why private financing is not a viable option (i.e. country capacity limits, unworkable tenor and/or pricing).

QUESTION 7: CONSIDERATION FOR GRANT/TECHNICAL ASSISTANCE FUNDING

In situations where the investment being proposed is highly developmental and requires a grant or similar funding for feasibility studies, training or other investment development activities, DFC may be able to provide such funding. If the investment is successful to the extent that it becomes capable of repaying this funding to DFC, then it would be required to do so.

Would you like to be considered for this type of funding? Yes/No If Yes, please provide the following:

Amount Requested: USD_________

Description of the activities on which the funds would be used and how those activities are required for the successful development of the overall investment:

QUESTION 8: HOW DID YOU LEARN ABOUT DFC?

DFC is interested in knowing what types of communications about its programs are most effective. If this is the first time you are applying for a DFC product, please select the source of your initial information about DFC:

N/A – This is not my first application to DFC

____ DFC’s website or other social media (Twitter, Facebook, etc.)

____ DFC-sponsored workshop or event (Name of event )

____ DFC speaker at an industry event (Name of event )

____ Other US Government Agency (e.g. State/Embassy, Commerce, Treasury, TDA, DOD, USEXIM, etc.) (insert a dropdown box with choices)

____ Referred by financial or legal advisor (Name of advisor )

____ Referred by portfolio facility manager (Name of facility manager )

____ Past or present DFC client. (Name of client )

____ Other (describe: )

QUESTION 9: MAY WE SHARE YOUR INFORMATION WITH OTHER DFIS?

Yes

No

May DFC share the following information with other development finance institutions (DFIs) who may be interested in working with DFC on the in the type of project/transaction you are proposing?

• The Investee Name and Location from Question 2;

• The Representative Name, Title, and E-mail address from Question 3;

• The DFC-designated sectoral category (i.e. financial services, power generation) that corresponds with the nature of your project/transaction.

Please note that this is not a guarantee that DFC will share the information nor a guarantee that recipients of the information will provide additional support to the transaction.

QUESTION 11: ANTI-LOBBYING CERTIFICATION

Anti-Lobbying Certification

Per 31 USC § 1352, DFC is required to obtain certifications with regard to funds paid to lobbyists. Pursuant to that requirement, please complete the certifications below.

U.S. Government Appropriated Funding ²

The applicant certifies, to the best of the applicant’s knowledge, that no party involved with the proposed transaction has used or will use funds appropriated by the U.S. government (through contracts, grants, loans, or cooperative agreements) to pay any person for influencing or attempting to influence an officer or employee of any U.S. government agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with any federal contract, grant, loan or cooperative agreement.

Private Funding

The applicant certifies, to the best of the applicant’s knowledge, that if any party involved with the proposed transaction has used or intends to use funds other than funds appropriated by the U.S. government to pay any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this proposed Federal contract, grant, loan, or cooperative agreement, such party has completed or shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.

 

SUBMISSION/SIGNATURE Page

Select DFC Origination Officer

Please select a recipient to receive your application materials. If you are already working with a DFC origination officer, please select their name from the menu below. If not, please select “Officer not assigned” and your application will be forwarded to a DFC officer who reviews incoming applications.

Officer Name: (drop-down list)

I certify that the statements and information provided herein are true to and correct to the best of my knowledge and belief.

Name:

Title/Role in Transaction: Email Address:

[SIGN and SUBMIT BUTTON]

Note: Some of the questions in the form require the attachment of specific documents. In addition, at the bottom of every page of the electronic form, there is a link that will allow the applicant to attach additional supporting documentation as necessary. A list of the essential supporting documentation requested by DFC is as follows:

1 For U.S. Addresses, the zip code + 4 is required

2 The use of funds appropriated by the U.S. Government to pay lobbyists is prohibited by law.