Dfc004rl

PDF FOR REFERENCE ONLY

THIS FORM IS TO BE COMPLETED ON-LINE – PAPER SUBMISSIONS WILL NOT BE ACCEPTED

Investments Funds Application (DFC-004)

OMB No. 3015-0006

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 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 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 60 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 Finance 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.

Proposal Date	DEFAULT
GP Main Point of Contact (First Name)	TEXT BOX
GP Main Point of Contact (Last Name)	TEXT BOX
GP Main Point of Contact (Email)	TEXT BOX
GP Main Point of Contact (Phone Number)	TEXT BOX
Name of Firm	TEXT BOX
Address of Firm Headquarters	TEXT BOX
City of Firm Headquarters	TEXT BOX
Postal Code of Firm Headquarters1	TEXT BOX
Country of Firm Headquarters	TEXT BOX
Other Firm Locations (cities)	TEXT BOX
Year Firm Established	TEXT BOX
Website of Firm	TEXT BOX
SAM Registration Number (if available)	TEXT BOX (OPTIONAL)

FUND OVERVIEW
Fund Name	TEXT BOX
Fund Target Size in USD (including DFC amount)	TEXT BOX (numerical)
Max Fund Target Size in USD (including DFC amount)	TEXT BOX (numerical)
Min Fund Target Size in USD (including DFC amount)	TEXT BOX (numerical)
Proposed GP Commitment (%)	TEXT BOX (percentage)
Proposed DFC Commitment	TEXT BOX (numerical)
Fund Sectors	TEXT BOX (drop down menu)
If Other Sectors/Industries (please describe)	TEXT BOX
Fund Geography (region)	TEXT BOX (drop down menu)
Fund Geography (targeted countries)	TEXT BOX
Projected Fund Multiple and IRR returns (gross)	TEXT BOX (percentage)
Brief Description of the Fund and its Strategy (Please include how strategy aligns with DFC’s mandate)	TEXT BOX
Brief Description of the Fund for Public Disclosure After Approval (character range 40-149)	TEXT BOX (limit to 40-149 characters)

MANAGEMENT OVERVIEW
Fund Team Formation: Describe how the Fund Manager and the team were initially formed, and provide a brief history of how they have evolved to date. You may also refer to appropriate sections in the PPM or marketing presentation.	TEXT BOX
Number of Partners	TEXT BOX (numerical)
Total Number of Employees/Number of Senior Investment Professionals	TEXT BOX (numerical)
Please provide the current or projected number of female members of the GP’s or FM’s board of directors or other governing body, if applicable	GP _________# FM___________#
Firm’s Assets Under Management	TEXT BOX (numerical)
Number of Funds Previously Managed by this Firm	TEXT BOX (numerical)
SENIOR INVESTMENT TEAM (Please Attach CVs)

Name	Title	Year joined firm

{Include ability to upload multiple documents}

LP BASE

Total Capital Raised to Date in USD

TEXT BOX (numerical)

Total Capital Raised to Date (% of Target Fund Size)

TEXT BOX (percentage)

First Close Date (actual/anticipated) and Amount

TEXT BOX

(i) Explain why you are seeking DFC funding. (ii) What efforts have been taken to raise capital from private sector investors and what has been the outcome of those efforts? (iii) Is there a lack of available private sector support for the Fund, or for portfolio companies and if so for what reason?

TEXT BOX

List of Investors in prior funds and those who have Committed to this Fund and Amount

Name	Commitment to prior fund(s)	Commitment to this Fund	Location (country)

List of new Investors committed to this Fund

Name	Commitment	Location (country)

List any Development Finance Institutions (DFIs) with whom the Fund is engaged in discussions (include the stage of discussion/investment process and whether have provided soft or hard commitments)

Name	Stage of discussion	Commitment	Soft or hard

TRACK RECORD

Attach a summary of prior fund performance (see Track Record template)

FILE UPLOAD

INVESTMENT POLICY & ESG
Describe the developmental impact you believe the Fund will have in the host country/countries (e.g., job creation, infrastructure improvements, social policies/corporate social responsibility initiatives, technology and knowledge transfer).	TEXT BOX
Will the Fund target investments that are female-owned or serve female clients, clients located in rural areas, or other underserved populations? If so, what percentage will be dedicated to these populations?	Yes_____ No______ Women: _______% Rural: _______% Other: _____%
Is the General Partner or Investment Manger a women-owned enterprise or women-led enterprise?	Yes No
Number and percentage of female staff (GP, Fund Manager and Fund)		Number/Percentage of staff
	General Partner
	Fund Manager
	Fund
Please describe the Fund’s practices concerning provision of accountability and access to remedy for negative sub-project impacts on Individuals and communities.	TEXT BOX

OTHER - MISCELLANEOUS
(i) Describe any potential conflicts of interest of which you are aware. (ii) How do you plan to resolve potential conflicts of interest within the Fund, or with other investment vehicles managed by your organization or its affiliates?		TEXT BOX
Are there any substantive litigation, dispute resolutions, or regulatory actions brought against the manager, its principals or any portfolio companies?		TEXT BOX
If yes, please attach an explanation describing any litigation, community dispute, or complaint resolution processes that have occurred or are occurring involving the manager, its principals and/or its portfolio companies.		FILE UPLOAD
ATTACHMENTS
Attach the Fund's most recent marketing presentation		FILE UPLOAD
Attach the Fund's investment pipeline		FILE UPLOAD
Attach the Fund's PPM (if available)		FILE UPLOAD
Attach Fund’s ESG Policies		FILE UPLOAD
Attach Fund’s Know Your Customer Policies		FILE UPLOAD
Attach LPA (if available)		FILE UPLOAD
PROPOSAL DOCUMENTS
Document Name	Description		Document Date	File Name

DFC/US Government Questions
How did you hear 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 an 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: ______)
May DFC share the following information with other development finance institutions (DFIs) who may be interested in working with DFC on the type of project/transaction you are proposing? (a) The Fund Name and Location from Question 13 and questions 21 and 22; (b) The GP Point of Contact (Name and Email) from Questions 2-4; (c) The list of Fund Sectors (e.g. financial services, construction ) listed in Question 19.	Yes No
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 Funding2 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.	Checkbox “Certified”
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.	Checkbox “Certified”

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.