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OMB Control No: 3420-0035	ICR Reference No: 201411-3420-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: OPIC	Agency Tracking No: OPIC-254
Title: Personal Financial Statement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/09/2015
	Date Received in OIRA: 11/13/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved
Responses	75	0	0
Time Burden (Hours)	75	0	0
Cost Burden (Dollars)	5,625	0	0

Abstract: Individual sponsors of OPIC-supported projects would use this form to provide a detailed breakdown of their current personal balance sheet (assets, liabilities and net worth), any contingent liabilities and their income stream. OPIC personnel would utilize this information to evaluate the individual sponsor's ability to meet their financial obligations (such as guaranty of completion) with regard to the OPIC-supported project.

Authorizing Statute(s): US Code: 22 USC 234(d) Name of Law: Foreign Assitance Act of 1961

Citations for New Statutory Requirements: US Code: 22 USC Section 234 (d) Name of Law: Foreign Assistance Act if 1961

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 51377	08/28/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 67208	11/12/2014
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Personal Financial Statement	OPIC-254

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	75	75
Annual Time Burden (Hours)	75	75
Annual Cost Burden (Dollars)	5,625	5,625

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The personal financial statement is considered supporting documentation to the OPIC application for financing, but it is only requested if a sponsor of the project being financed is an individual (rather than a corporate entity) and that individual is providing equity investment in or other credit support to the project. OPIC officers generally do not request that individual project sponsors provide personal financial statement information until the officers have already reviewed the application for financing and determined that the application has a high probability of advancing to the underwriting phase. So, though OPIC currently receives approximately 200 applications for financing on an annual basis, approximately 120 of them will make it to the underwriting phase, and half of those applications will not involve any individual sponsors. Therefore, assuming that 60 active applications have individual sponsors and that some will have more than one individual sponsor from whom the OPIC officer requires personal financial information in order to complete the underwriting, OPIC can conservatively estimate that it may elicit up to 75 personal financial statement forms per year.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Kristen Meehan 202 336-8598 kristen.meehan@opic.gov

View ICR - OIRA Conclusion