Application for DFC-DPA Loan Program

(DFC-014)
OMB No.

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 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.

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.

A0001
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. DFC-DPA Loans are limited to projects that support the national response
and recovery to the COVID-19 outbreak, or the resiliency of any relevant domestic supply
chain. Please click here to review the basic eligibility requirements and the DFC-DPA Loan
Program origination process. For general questions or eligibility questions, please email [email
address of new DFC domain to be added]. If a particular question on this form is unclear, please
email [email address of new DFC forms domain to be added].

If you are applying for a Funds transaction, please skip to Section 2.

Section 1: Project-Specific Transactions

QUESTION 1: SPECIFY FINANCING STRUCTURE

The DFC-DPA Loan Program (DDLP) supports a wide variety of transactions by providing direct
financing. Though each transaction may have unique structural aspects, all transactions fit 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.

✔ Project Finance/Investment: DFC provides financing to a stand-alone project or single

purpose entity.

Corporate Finance/Investment: DFC provides financing to a general corporate entity that

already has an operational track record.

QUESTION 2: IDENTIFY THE PROPOSED BORROWER/INVESTEE

In each DFC-supported transaction, DFC enters into a contractual relationship with a

Borrower/Investee (in the case of Project Finance or Corporate Finance transactions). 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.

Borrower/Investee
Name:
Address (incl. city and country):

website (if avail):

DUNS Number:
U.S. Tax Identification Number: or N/A – Not a US Taxpayer
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 Borrower/Investee/Guaranteed Party:
Name of Representative’s Company (if different from the Borrower/Investee/Guaranteed Party)
Address:
Phone Number 1 (office): (b) (6)
Phone Number 2 (mobile)
E-mail (b) (6)

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.

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

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

Name
Type of Entity Individual
Country of Citizenship (for
Individuals) or Incorporation (for
Business Entities)
Primary Relationship to
Borrower/Investee/Transaction
Owner/Shareholder
Veteran Owned or Led? Yes
Minority Owned or Led? Yes
Women Owned or Led? Yes
If yes, please provide:
 % owned by women
# of women on Board of Directors
names and titles of women owners
and executives:

QUESTION 5: DESCRIBE THE TRANSACTION

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

• What are the objectives 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
Financial Projections Model

Historical Financial Statements

QUESTION 6: DETAIL COSTS AND FUNDING

[If the Financing Structure chosen in Question 1 was Project Finance/Investment, then the online
form will show the following:]
For a Project Finance transaction, please provide a detailed list of the estimated project costs and
the types and amounts of funding that will be used to cover them. Remember to include both
hard/physical asset costs (e.g. buildings or equipment) and soft/implementation costs (e.g. legal
or consultant services, fees, contingency etc.) in the cost estimate. The total cost amount in
Column A must equal the total funding amount in Column B. For an example, please click [here].

Column A Column B
Cost Item USD % Funding Source USD %
(b) (4)
Debt:
(b) (4)
DFC loan (indicate proposed term)
Other term debt (indicate proposed term)
Supplier financing
0%
0% Subordinated Debt:
0% Third party subordinated debt
0% Shareholder subordinated loans
0% Equity:
0%
0% Cash
 0% In-kind contribution1 0%
0% Grants 0%
0% Other (please describe) 0%
Total Project Costs: 0 Total Project Funding 0

[If the Financing Structure chosen in Question 1 was Corporate Finance, then the online form will
show the following:]

For a Corporate Finance transaction, please provide a detailed list of how the DFC-supported
funding would be used and how the proposed transaction would affect the existing corporate
funding structure/leverage of the Borrower. For an example, please click [here].

Uses of the DFC-supported Funding

Cost Item USD %

0%
0%
Total Costs $0

Balance Sheet Comparison

Existing Balance USD % Proposed Future Balance USD %

Sheet Sheet
Total Assets 0% Total Assets 0%

DFC Debt 0%
Total Debt/Liabilities 0% Non-DFC Debt/Liabilities 0%
Net Worth $0
Non-DFC Net Worth 0

Would DFC debt be used to repay any existing debt?

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.

1An 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 7: DESCRIBE COLLATERAL AND/OR CREDIT ENHANCEMENTS (IF
APPLICABLE)

DFC usually requires a collateral/credit enhancement package tailored to the specific risks of a
given transaction. Following are indicative categories of collateral/credit enhancement that DFC
may require. Please indicate below those categories that may be available (check all that apply):

✔ Pledge of shares of the Borrower

✔ Liens/Mortgages on Borrower assets (Specify types/locations: ___________)

Liens/Mortgages on other assets (Specify types/locations: _____________)

Guaranties from creditworthy individuals or companies (Specify name(s) of guarantor(s):)

Irrevocable standby letter(s) of credit

Debt Service Reserve Account

“Key Man” Life Insurance

Other (describe:____________________________)

QUESTION 8: 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:
 Question 9: 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 DDLP financing because private financing is not available on reasonable terms sufficient
to make the investment viable.

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., unworkable tenor
and/or pricing).
SUBMISSION/SIGNATURE Page
I certify that:

✔ the Applicant or any owner of the applicant is not presently suspended, debarred, proposed
for debarment, declared ineligible, voluntarily excluded from participation in this transaction
by any Federal department or agency, or presently involved in any bankruptcy.

✔ the Applicant, any owner of the applicant, or any business owned or controlled by any of
them, has not ever obtained a direct or guaranteed loan from any Federal agency that is
currently delinquent or has defaulted in the last 7 years and caused a loss to the
government.

✔ the Applicant (if an individual) or any individual owning 20% or more of the equity of the
Applicant is not subject to an indictment, criminal information, arraignment, or other means
by which formal criminal charges are brought in any question, or presently incarcerated, or
on probation or parole.

✔ Within the last five years, for any felony, the Applicant (if an individual) or any individual
owning 20% or more of the equity of the Applicant has not: (1) been convicted; (2) pleaded
guilty; (3) pleaded nolo contendere; (4) been placed on pretrial diversion; or (5) been placed
on any form of parole or probation (including probation before judgment).

✔ all loans will be used for eligible projects within the United States.

✔ I certify that the statements and information provided herein are true to and correct to the
best of my knowledge and belief. I understand that knowingly making a false statement to
obtain this loan is punishable under the law, including under 18 U.S.C. 1001 and
3571 by imprisonment of not more than five years and/or a fine of up to $250,000 or twice
the gross pecuniary gain from the offense or twice the gross pecuniary loss to another
person; and, if submitted to a federally insured institution, under 18 U.S.C. 1014 by
imprisonment of not more than 30 years and/or a fine of not more than $1,000,000.”

Name:
Title/Role in Transaction:
Email Address: (b) (6)

Submit
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:

SUPPORTING DOCUMENTATION
1. COMPLETE BUSINESS PLAN/PRELIMINARY INFORMATION MEMORANDUM

Since DFC supports a variety of transaction structures in many different sectors/industries, it is

not possible to provide a standard business plan template. The following checklist details the
items that applicants should consider as they prepare their business plans. Please provide as
complete a business plan as possible.

Investment/Transaction Summary
• Investment/Transaction Description/Status Describe the purpose for which the DDLP is to
be used and investment made to date, market or feasibility studies performed, status of
documentation/permits/government consents, environmental studies, past and ongoing
consultations with project-affected communities (including disadvantaged and vulnerable
groups), etc.
• Financial Plan and Credit Support Describe the proposed DFC and other lender debt --
loan amount, tenor, grace period -- and source, timing and amount of equity contributions,
grants or other funding; describe any proposed collateral and other credit support

Key Parties
• Owners/Shareholders, Guarantors, Management, Contractors, Regulators -- Provide
detailed information on the key parties associated with the transaction, fully explain their
role(s), and explain the relationships among them. If certain characteristics (e.g. a strong
credit rating) or capabilities/experience (e.g. a strong track record in a given market or
industry) are important to that party being considered a good candidate to fulfill their role in
the transaction, please highlight that information.

Sector/Target Market/Economics
• Sector/Industry Describe the competitive environment in which the investment is being
made and any recent or emerging trends that may affect its success.
• Product/Services Describe the ultimate products or services that this investment will
produce, and in what quantity.
• Economic/Technical Specifications If relevant, provide economic assumptions, technical
parameters, construction plans/schedule, equipment/land to be procured, off-take
arrangements, etc.
• Agreements List any key contractual arrangements necessary to the success of the
investment such as concession or franchise/royalty agreement(s), construction contract(s),
offtake agreement(s), environmental impact studies, feasibility studies, marketing studies,
technical assistance agreement(s), management services agreement(s), lease(s), etc. (and
attach electronically if available)

Legal, Economic, Political Environment and Government Participation

• Licenses/Permits List all licenses, permits, consents, approvals, environmental
requirements etc. required by the country/local government and the status of such
documentation.
• Legal Regime List local laws, regulations or pending reforms that will impact the investment
or the sector.
• Government/Multilateral Participation Describe any government or multilateral involvement
in the investment or the sector and any government incentives such as tax holidays.
• Litigation or Dispute Resolution Describe any litigation or community dispute or complaint
resolution processes that have occurred or are occurring involving any of the key parties that
could affect this investment.

Transaction Strengths/Risks and Risk Mitigation

• Strengths Describe those factors that contribute to the long-term viability of the
investment/transaction.
• Risks Describe risks such as credit risks, sector/market risks and competition, operational
and management risks, economic risks, legal/regulatory risks and environmental, and what
steps the Borrower/Investee/Guaranteed Party will take to mitigate such risks and provide
access to accountability and remedy for negative project impacts on individuals and
communities.
2. Financial Projections Model
The financial projections model should cover at least the entire proposed term of the DDLP
financing. It should include detailed, financially-justifiable assumptions on all key drivers of the
proposed transaction and should clearly demonstrate how funds provided under the DDLP will
be repaid or recouped successfully. The model should also include financial statements (i.e.,
balance sheet, income statement, cash flow statement) and ratios or other financial
measurements relevant to the industry/transaction type being modeled. In addition, the model
should be structured in such a way as to make it simple to adjust key assumptions and thereby
analyze potential financial performance under adverse conditions.

If the applicant does not already have a financial projections model that meets these criteria,
DFC has provided a template (link to model template and user guides) that may assist some
applicants in creating a model. Please note that this template is not designed to model financial
institutions or other entities with lending or leasing portfolios.
3. Historical Financial Statements
Evaluating the financial strength of parties upon which the transaction will depend (primary
investors, guarantors, key contractors or off-takers) is an important part of DFC’s evaluation. For
each such party, please provide financial statements, preferably prepared in accordance with U.S.
Generally Accepted Accounting Principles (“U.S. GAAP”) or International Financial Reporting
Standards (“IFRS”). Financial Statements must be prepared in English or accompanied by a
certified English translation. Listed below are the types of financial statements that should be
submitted for each type of entity:

For a public corporation: - 10K or equivalent (most recent 3 years)

- 10Q or equivalent (most recent quarter)
For a private corporation: - Annual Financial Statement (preferably audited; most recent 3
years)
- Quarterly Financial Statement (most recent quarter)
- Tax Return (most recent 3 years)
For a partnership: - Annual Financial Statement (preferably audited; most recent 3
years)
- General Partner information, including (i) current signed Statement
of Net Worth (assets, liabilities, net worth) and (ii) ownership

For an individual: - Current Signed Personal Financial Statement (assets, liabilities, net
worth) – provide link to DFC-005 (fillable PDF)
- Tax Return (most recent 3 years)
 Section 2: Investment Funds Transactions

Proposal Date

GP Main Point of Contact (First Name)

GP Main Point of Contact (Last Name)

GP Main Point of Contact (Email)

GP Main Point of Contact (Phone Number)

Name of Firm

Address of Firm Headquarters

City of Firm Headquarters

Country of Firm Headquarters

Other Firm Locations (cities)

Year Firm Established

Website of Firm
 FUND OVERVIEW

Fund Name

Fund Target Size in USD (including DFC amount)

Max Fund Target Size in USD (including DFC amount)

Min Fund Target Size in USD (including DFC amount)

Proposed GP Commitment (%) 0.00%

Proposed DFC Commitment

Fund Sectors
Healthcare
If Other Sectors/Industries (please describe)

Projected Fund Multiple and IRR returns (gross) 0.00%

Brief Description of the Fund and its Strategy

Brief Description of the Fund for Public Disclosure After

Approval (character range 40-149)
 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.
Number of Partners

Total Number of Employees/Number of Senior

Investment Professionals
Is the General Partner or Investment Manger a women-
owned enterprise or women-led enterprise? Yes

Please provide the current or projected number of GP _________#

female members of the GP’s or FM’s board of directors FM___________#
or other governing body, if applicable

Firm’s Assets Under Management

Number of Funds Previously Managed by this Firm

SENIOR INVESTMENT TEAM BACKGROUND

Name Title Year Location (city, Focus (industry, Prior work experience Education
joined firm country) function, if any) (include firm, position
number of years)
 LP BASE

Total Capital Raised to Date in USD

Total Capital Raised to Date (% of Target Fund Size) 0%

First Close Date (actual/anticipated) and Amount

(i) Explain why you are seeking DDLP 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?

List of Investors in prior funds and those who have Name Commitment to prior Commitment to this Location (country)
Committed to this Fund and Amount fund(s) Fund

List of new Investors committed to this Fund Name Commitment Location (country)

TRACK RECORD

Attach a summary of prior fund performance (see

Track Record template)
 INVESTMENT POLICY & ESG

Describe the impact you believe the Fund will have

(e.g., job creation, development of critical supply
chains, number/value of product produced or
supplied ,).

Will the Fund target investments that are female-

owned or serve female clients, clients located in Yes
rural areas, or other underserved populations?
Women:_______%
Rural:_______%
If so, what percentage will be dedicated to these Other: _____%
populations?
Number/Percentage of staff
Number and percentage of female staff (GP, Fund General Partner
Manager and Fund)
Fund Manager

Fund

Please describe the Fund’s practices concerning

provision of accountability and access to remedy

communities.
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?
Are there any substantive litigation, dispute
resolutions, or regulatory actions brought
against the manager, its principals or any
portfolio companies?

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.

ATTACHMENTS
Attach the Fund's most recent
marketing presentation
Attach the Fund's investment pipeline

Attach the Fund's PPM (if available)

Attach Fund’s ESG Policies

Attach Fund’s Know Your Customer Policies

Attach LPA (if available)

PROPOSAL DOCUMENTS
Document Name Description Document Date File Name
SUBMISSION/SIGNATURE Page
I certify that:
the Applicant or any owner of the applicant is not presently suspended, debarred, proposed
for debarment, declared ineligible, voluntarily excluded from participation in this transaction
by any Federal department or agency, or presently involved in any bankruptcy.
the Applicant, any owner of the applicant, or any business owned or controlled by any of
them, has not ever obtained a direct or guaranteed loan from any Federal agency that is
currently delinquent or has defaulted in the last 7 years and caused a loss to the
government.
the Applicant (if an individual) or any individual owning 20% or more of the equity of the
Applicant is not subject to an indictment, criminal information, arraignment, or other means
by which formal criminal charges are brought in any question, or presently incarcerated, or
on probation or parole.
Within the last five years, for any felony, the Applicant (if an individual) or any individual
owning 20% or more of the equity of the Applicant has not: (1) been convicted; (2) pleaded
guilty; (3) pleaded nolo contendere; (4) been placed on pretrial diversion; or (5) been placed
on any form of parole or probation (including probation before judgment).
all loans will be used for eligible projects within the United States.

I certify that the statements and information provided herein are true to and correct to the
best of my knowledge and belief. I understand that knowingly making a false statement to
obtain this loan is punishable under the law, including under 18 U.S.C. 1001 and
3571 by imprisonment of not more than five years and/or a fine of up to $250,000 or twice
the gross pecuniary gain from the offense or twice the gross pecuniary loss to another
person; and, if submitted to a federally insured institution, under 18 U.S.C. 1014 by
imprisonment of not more than 30 years and/or a fine of not more than $1,000,000.”

Name:
Title/Role in Transaction:
Email Address:

Submit