DFC-0016 Application for Technical Assistance

Application for Technical Assistance (DFC-0016)

OMB No. XXXX-XXXX

Expiration Date: xx-xx-20xx

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 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 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 may meet eligibility and basic requirements to receive a technical assistance grant. Please click here to review the basic eligibility requirements. For a description of DFC’s Technical Assistance (TA) process and answers to frequently asked questions (FAQs), please click here. If a particular question on this form is unclear, please email FormsSupport@dfc.gov.

QUESTION 1: SPECIFY TYPE OF TECHNICAL ASSISTANCE REQUESTED

The DFC supports a wide variety of developmental transactions by providing direct loans, equity investments, political risk insurance and guaranties. The TA Division supports DFC with technical assistance for either pre-investment or post-investment technical assistance activities that support other potential or existing DFC transactions. Though each transaction may have unique structural aspects, all TA fits into one of two basic structural categories. Please read the definitions below and choose the structure that best fits the type of support that you are seeking.

r	Pre-Investment Technical Assistance: DFC grants to a stand-alone project or single-purpose entity. Click here for examples. *Note for pre-investment TA: DFC TA must be in support of, and accelerate or improve, a potential DFC project.
r	Post-Investment Technical Assistance: DFC grants to an entity with an existing DFC transaction. Click here for examples. Please select which type of DFC investment you have received: Debt Equity Political Risk Insurance Guarantee

QUESTION 2: IDENTIFY THE PROPOSED RECIPIENT OF TECHNICAL ASSISTANCE

For each DFC-supported TA, DFC enters into a grant relationship with a Borrower (in the case of Project Finance or Corporate Finance transactions) a Technical Assistance Facility (TAF) associated with a DFC Borrower, a recipient of DFC equity funding, a Guaranteed Party (in the case of Single or Multi-Borrower Guaranties), or recipient of political risk insurance. 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.

TECHNICAL ASSISTANCE APPLICANT

Name:

Address (incl. city, country and postal code¹):

U.S. Tax Identification Number: or N/A – Not a US Taxpayer

Are you registered on SAM.gov? Yes/No

SAM Unique Entity Identifier (UEI)²:

SAM Expiration Date:

Is the country listed in the address of the Technical Assistance applicant the location where the funds provided by DFC will be utilized? (Yes/No)

If “No,” please list the actual location (city, country):

QUESTION 3: IDENTIFY THE APPLICANT Representative

Please provide contact information for the individual who will be DFC’s primary point of contact regarding this application.

Name and Title of Representative:

Relationship to the Technical Assistance:

Name of Representative’s Company (if different from the Technical Assistance Applicant)

Address (if different from the address of the Borrower/Equity Recipient/Guaranteed or Insured Party):

Phone Number 1 (office): Phone Number 2 (mobile):

E-mail:

QUESTION 4: 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 underwriting process.

1. Please attach detailed chart(s)/schematic(s) showing the structure of the proposed technical assistance recipient. This may include ownership charts and/or organizational/management structures.

2. Please list and provide Each business entity/individual that owns 10% or more (either directly or indirectly) of the proposed technical assistance recipient.

Name
Type of Entity	Two choices: Individual or Business Entity
Country of Citizenship (for Individuals) or Incorporation (for Business Entities)
Primary Relationship to Borrower/Transaction	Choices – Owner/Shareholder, Lender, Manager/Director, Contractor
Minority Individual/Minority-Owned or Led Business3?	Y/N
Female Individual/Women-Owned or Led Business4?	Y/N
If Women-Owned or Led Business is “Yes,” there will be fields to provide: % owned by women, # of women on board of directors, and names and titles of women owners and/or executives.

QUESTION 5: DescriBE THE Technical Assistance Request

Please provide a brief description of the proposed TA, making sure to begin with a brief, clear statement of the project and/or the business, and the problem(s), challenge(s) or opportunity(ies) to be addressed via the activity (2-3 sentences). Please elaborate with a thorough description of the following information:

• Details of the TA request, including why TA is needed/what challenge will the TA help address.

• Description of key stakeholders (e.g. project sponsor, investors, government involvement, advisors/consultants, customers).

• If pre-investment TA, total size of the project and the estimated financing/equity/insurance request that would be requested from DFC.

• If pre-investment TA, description of how the TA funds provided would accelerate or improve project development.

• Description of DFC’s potential or existing investment use of proceeds.

• General timeline of the TA activity.

• If pre-investment TA, the timeline of the project development phase and where the TA support from DFC fits into that timeline.

• If pre-investment TA, explain any barriers to private sector investment the TA will address.

• Description of the procurement processes to retain service providers or identification of selected service providers. Please provide a detailed explanation for non-competitive appointments.

• If pre-investment TA is approved and a financial deal with DFC or another investor is subsequently closed, please confirm that the recipient could repay DFC’s portion of the total cost of the TA.

QUESTION 6: Describe THE DEVELopment impact

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

1. How and why the proposed TA activity is linked to any of the DFC’s impact theses and would enhance development impact.

2. Who the key beneficiaries of this activity are, how many there are and whether that number would change, whether they are underserved populations, whether new populations will be reached, and how the beneficiaries will benefit (i.e., enhanced capacity, training, new product or service, etc.). Explain the underlying assumptions that support these claims.

3. How the grant recipient anticipates monitoring results / change.

QUESTION 7: DescriBE Additionality

Please explain why it is beneficial to the project for DFC to share the cost of the TA work and be specific to the extent possible. (Would this activity or potential DFC investment have happened otherwise? Would the activity have happened at the same pace, direction, quality, or scale without this TA? Would business growth or development impact have happened at the same pace, direction, quality, or scale without this TA?)  

QUESTION 8: DescriBE Potential Risks

Please provide a realistic assessment of present and anticipated challenges or risks you may encounter during the TA grant and how you plan to address them.

QUESTION 9: DescriBE Experience

Please provide a brief overview of the recipient, including relevant past experience implementing similar activities related to the proposed technical assistance. For pre-investment technical assistance, please also describe relevant past experience implementing projects similar to the project that would be developed by the requested technical assistance (list past project titles, value, client, location, and dates). Please include whether you are partnering with any other entities or funders on this project and describe briefly what their relevant experience is.

QUESTION 10: Other funding sources

Please describe whether the proposed activity or a similar activity has been funded or is it being funded by other donors or funders. Please list who has funded or is proposed to fund the activity and briefly explain what was funded or will be funded.

QUESTION 11: Key outPuts/Deliverables

Please describe the key outputs or deliverables (e.g., technical report, workshop, training delivered) that will be derived from the proposed technical assistance activities

QUESTION 12: costs and budget

Please describe how much funding is requested of DFC and describe how the applicant will meet its cost share obligations. A recipient of DFC technical assistance support typically is obligated to cover one-half of the cost of the technical assistance activity (a description of DFC’s cost share requirements is linked here.

Concept Note Budget
Deliverable/Task	Total Cost	DFC Share	Client Share
One
Two
Three
Four
TOTAL

In most cases, DFC’s TA program will fund up to 50% of the cost of the TA activities, and the Grantee must cover the remaining costs as a cost share. DFC may provide a reduced amount of funding when other donors are also contributing a portion of the cost of TA activities.

DFC may fund a greater proportion of the cost of the TA activities, up to 75%, on a case-by-case basis. Examples of when DFC may cover up to 75% of TA support include, but are not limited to:

• TA for first-time fund managers; and

• TA supporting unfunded DFC investment guaranties.

QUESTION 13: HOW DID YOU LEARN ABOUT Technical Assistance at 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. USAID, State/Embassy, Commerce, Treasury, USTDA, DOD, USEXIM, etc. – there is a dropdown list)

____ 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 14: may we share your information with other dfi? (Yes/No)

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

• The Applicant 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 15: 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 Funding⁵

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

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]

1 For U.S. addresses, the zip code+4 is required for the postal code/zip code field in the address.

2 The UEI number is issued by the System for Award Management (SAM)

3 For U.S. entities, at least 51% of the owners or members of the board of directors are African Americans, Hispanic Americans, Native Americans, Asian Pacific Americans and Subcontinent Asian Americans. For non-U.S. entities, at least 51% of the owners or members of the board of directors are members of a demographic/social group considered to be a minority and/or economically disadvantaged in the country where the entity is incorporated/operates.

4 A women-owned enterprise is one in which women own at least fifty one percent (51%) of the company, or where the company was founded by a woman who continues to play an active role in running the company. A women-led enterprise is one in which the share of women in senior management is at least 30% or women comprise 30% or more of the board, investment committee or equivalent governing and/or investment decision-making bodies.

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