For Investment Enterprises Only

List of forms

# / Name / Page
003 / Financing Application Form (for Investment Enterprises only) / 2-5
003A / Financing Application Form (for Financial Intermediaries requesting a long term refinancing or co-financing) / 6-10
003B / Short Term Loan Rediscount Application Form / 11-12]
003AT / Technical Assistance Application Form / 13-15

FDI-003

FINANCING APPLICATION FORM

For Investment enterprises only

(Financing long term assets)

A. THE SOLLICITANT ENTERPRISE

1. / Name
2. / Date of creation
3. / Location
4 / Primary Activity
5. / Top Manager
6. / Legal representative
7. / Type of enterprise (Haitian, Joint venture, Haitian with foreign technical assistance?)
8. / Legal status (Partnership, Anonymous society, Sole proprietorship, or others?)
9. / Main shareholders or senior partners / # Shares / Percentage
10. PRESENT FINANCIAL POSITION AND PERFORMANCE
Total assets
Current assets
Net fixed assets
Other long term assets
Current liabilities
Medium et long term debts
Equity
Annual sales
Net margin

B. THE SOLLICITANT ENTERPRISE (CONTINUED)

Creditors

Name of the creditor / Debt balance
1
2
3
4
5
6
7
8
11. CURRENT COMPETITIVE POSITION
Market size
In terms of quantity
In terms $/G sales
Market share as a percentage of the market size
Rank based on the relative market share

C. THE PROJECT

1. / Brief Description
2. / Nature (Creation, Modernization, Expansion, Working capital reinforcement or other?)
3. / Objectives
4. / Total Cost (Specify the currency)
5 / Financial impact / Before project / Projections without project / Projections with project
-- / Annual Sales (average)
-- / Net margin
-- / Cash flows before debt service
-- / Debt service
-- / Debt/Equity Ratio

THE PROJECT (Continued)

6 / Economic Impact / Before project / Projections without project / Projections with project
-- / Value of the annual production
-- / Export Sales as a percentage of the value of the annual production
-- / Production cost
-- / Cost of imported inputs as a % of the total production cost
-- / Number of jobs
Other economic impact
7. /

Financing plan

/ Land and building / Equipments / Others
-- / FDI
-- / Other local banks
-- / International Institutions
-- / Equipment suppliers
-- / Others (to be specified)
-- / Equity
8. / Name of the creditors besides FDI
a) Other local banks
b) International Institutions
b) Equipment suppliers
d) Other creditors
7. / Collateral
Type of collateral / Underlying asset / Expertise or market value / Beneficiary

D. FINANCING REQUESTED FROM FDI

1. / Instrument preference / Amount / % of the FI’s loan / % of the project cost
Rediscount
Guarantee
Co-financing
Venture loan
Subordinated loan
Venture capital
Institutional Micro-credit

Message

Date / Authorized Signature

Section reserved for FDI’s Credit Department

FDI-003A

FINANCING APPLICATION FORM

For Financial Intermediaries only

(Financing long term assets)

E. THE FINANCIAL INTERMEDIARY

1. / Name
2. / Address
3. / Officer in charge of the dossier
E-mail address
Phone

F. THE FINAL BENEFICIARY

B. THE FINAL BENEFICIARY (CONTINUED)

10. PRESENT FINANCIAL POSITION AND PERFORMANCE
Total assets
Current assets
Net fixed assets
Other long term assets
Current liabilities
Medium et long term debts
Equity
Annual sales
Net margin

Creditors

Name of the creditor / Debt balance
1
2
3
11. CURRENT COMPETITIVE POSITION
Market size
In terms of quantity
In terms $/G sales
Market share as a percentage of the market size
Rank based on the relative market share

C. THE PROJECT

THE PROJECT (Continued)

Financing plan

/ Land and building / Equipments / Others
-- / FDI+ Its financial intermediary in the operation
-- / Other local banks
-- / International Institutions
-- / Equipment suppliers
-- / Others (to be specified)
-- / Equity
8. / Name of the creditors besides FDI and its financial intermediary
a) Other local banks
b) International Institutions
b) Equipment suppliers
d) Other creditors

D. THE FINANCIAL INTERMEDIARY LOAN

1. / Amount Requested by the final beneficiary
2. / Amount approved by the financial beneficiary
3. / Approval date
4 / Interest rate
5. / Maturity
6. / Date of the first disbursement by the financial intermediary
7. / Collateral
Type of collateral / Underlying asset / Expertise or market value / Accepted value

E. FINANCING REQUESTED FROM FDI

1. / Instrument preference / Amount / % of the FI’s loan / % of the project cost
Rediscount
Guarantee
Co-financing
Venture loan
Subordinated loan
Venture capital
Institutional Micro-credit

Message

Date / Authorized Signature

Section reserved for FDI’s Credit Department

FDI-003B

SHORT TERM LOAN REDISCOUNT APPLCATION FORM

(Financing working capital needs)

F. THE FINANCIAL INTERMEDIARY

1. / Name
2. / Address
3. / Officer in charge of the dossier
E-mail address
Phone

G. THE FINAL BENEFICIARY

H. THE FINAL BENEFICIARY (CONTINUED)

10. . PRESENT FINANCIAL POSITION AND PERFORMANCE
Total asset
Net worth
Sales (annual)
Net margin

I. THE FINANCIALINTERMEDIARY LOAN

J. FINANCING REQUESTED FROM FDI

1. / Instrument preference / Amount / % of the Financial intermediary loan
Rediscount
Institutional Micro-credit

Message

Date / Authorized Signature

Section reserved for FDI’s Credit Department

FDI-003AT

TECHNICAL ASSISTANCE APPLICATION FORM

A. THE COMPANY

1. / Company Name
2. / Date of creation
3. / Location
4 / Main activity
5. / Top Management
6. / Legal Representative
7. / Type of enterprise (Haitian, Joint venture, Haitian with foreign technical assistance?)
8. / Legal Status (anonymous society, Partnership, Sole proprietorship, other)
9. / Main shareholders or Senior partners / # Shares / Percentage
10. CURRENT FINANCIAL POSITION AND PERFORMANCE
Total asset
Long term asset
Net fixed asset
Other long term asset
Current liabilities
Medium and long term debts
Net worth
Sales
Net margin

Market share

Rank in terms of market share

B. THE PROJECT

1. / Brief presentation
3. / Objectives
4. / Estimated Total Cost (Specify the currency)
5. / Financing to be solicited from FDI / %

C. TECHNICAL ASSISTANCE SOLICITED FROM FDI

1. / Nature of the intervention solicited from FDI
Diagnosis / Type?
Feasibility study / Type?
Preparation of Business Plans
Preparation of terms of reference / Subject
Recruiting and selecting consultants / Framework?
Preparation of strategic plan / Horizon?
Implementing strategies
Preparing and implementing financial restructuring plan
Financing feasibility and other studies / Estimated cost
Other

Other information

We acknowledge that costs incurred by FDI in response to this application constitute a debt on our part to FDI. We commit ourselves to reimburse on presentation of an invoice by FDI. Concerning disbursements made by FDI to finance feasibility studies of investment project, our reimbursement is conditioned the demonstration by the consultants of the feasibility of the project and its implementation.

Date / Signature authorized

Section reserved to FDI