FPI 2013 CONFIDENTIAL 12
Table 1.7: Total Turnover for the year ended 2013
Please enter the total turnover of your entity for the year 2013
31st December 2013 Total Turnover including Other Income
Table 1.8: Gains/Loss from Foreign Exchange and sales of Fixed Assets during the year 2013 in Rwf. Item 2013 Gain/Loss in Foreign Exchange
Gain/Loss on the sale of Fixed Assets
Total
1.9 Assets at 31st December 2013 in RWF Please enter the net Book Values (in RWF) of assets under each type of investment. Table 1.9: Actual assets as at 31st December, 2013 in RWF Type of Assets 31st December 2013 Land
Building and Civil Works
Plant and Machinery
Vehicles
Computers and accessories
Furniture and Fittings
Pre-Start-up Expenses
Work in progress
Working Capital
Inventories
Other (specify)
Total
FPI 2013 CONFIDENTIAL 13
1.10. Corporate Social Responsibility during 2013 Please enter the values (in Rwf.) of your entity’s Corporate Social Responsibility. Table 1.10: Please enter the value of the activities you performed (where applicable) No. Item Amount Spent (RWF) 2013 1 Education
2 Health and welfare
3 Safety and Security
4 Arts and Culture
5 Sports Development
6 Environment
7 Water
8 Road
9 Religious
10 Donations to vulnerable groups
11 Donation to other charity org.
12 Other (Specify)
Total
FPI 2013 CONFIDENTIAL 14
1.11. Please, indicate which parts (2 or 3) of this questionnaire are relevant to you by Answering the five questions below? The table below provides filtering questions that will help you decide the parts to answer, please tick in the appropriate box.
Table 1.11: Filtering Questions (FQ)
Filtering Questions (FQ) Yes No FQ1 Do non-resident entities, governments or individuals hold shares (equity or other equity) in your entity? If yes, please complete Tables 2.2 and 2.3
FQ2 Does your entity borrow from non-resident entities/individuals or have outstanding loan commitments? If yes, please complete Table2.4.
FQ3 Do non-resident entities, governments or individuals hedge for risk for your financial instruments (financial derivatives) If yes, please complete Table 2.5
FQ4 Does your entity own shares (equity or other equity) in non-resident entities? If yes, please complete Tables 3.1 and 3.2.
FQ5 Has your entity lent money to non-resident entities or individuals or has unpaid amounts outstanding? If yes, please complete Tables 3.3.
FQ6 Does your entity hedge risks for other financial instruments (financial derivatives) in non-resident entities, governments or individuals If yes, please complete Table 3.4
NB: If you ticked ‘no’ for every question, do not go further. Thank you.
FPI 2013 CONFIDENTIAL 15
PART 2
Foreign Investment in your Enterprise (Liabilities)
Section1. Foreign Equity Liabilities
Table 2.1 Investment Relationships
Relationships Symbol Direct Investor DI Direct Investment Enterprise DIE Fellow Enterprise FE Foreign Portfolio Investor FPI Other Equity Investor Other Investment Fund Shareholder IFS
1
Table2.2. Equity and Investment Fund Shares in Your enterprise by Non-resident Investors
Equity Type Source Country (Continue on separate sheet if necessary) Percentage Shareholding Relationship: DI , DIE, or FE, FPEI, Other and IFS
A Closing Balance 31 Dec 2012 B Purchase/ Increase in 2013 C Sales/ Decrease in 2013 D Changes due to ‘Other’ changes D=E-(A+B-C) E Closing Balance 31st Dec 2013
Paid-up Share Capital 1.
Share Premium 1.
Reserves ( include Capital, Statutory, revaluation, & Other) 1.
2
Other Equity (e.g. Equity Debt Swaps, Shareholders Deposits) 1.
2
Accumulated Retained Earnings/Loss 1.
2
2
Table2.3. Dividends, Profits Remitted and Retained Earnings
A Net Profit (or Loss) After Tax in 2013
B Source country C (%) shareholding D Relationship: DI , DIE, or FE, FPEI, Other and IFS E Net Profit (or Loss) After Tax in 2013attributable to=A*C F Dividends Declared
G Dividends Paid/Profits Remitted H Official Use Only Retained Earnings = (E-F)
TOTAL
3
Section2. Foreign Non-Equity Investment
Table 2.4 Non-Equity liabilities from Non-resident Investors
Types of non-equity liabilities Source Country (Continue on separate sheet if necessary) Relationships
DI , DIE, or FE, Other Original Maturity LT-12months or more ST-Less than 12 months (Indicate LT or ST) A Closing Balance 31 Dec 2012
B Disbursements received during 2013
C Principal Repayment during 2013 D Changes due to ‘Other’ changes D=E-(A+B- C) E Closing Balance 31 Dec 2013 (Including Accrued interest Not Paid) G Interest Paid (in 2013) Loans (Including Financial Leases, Repos)
2
Debt securities (Including Money Market Instruments, Bonds). 1.
2
Trade Credits & Advances
2
If any question about type of investment above please refer to definition 10.
4
Once again we wish to assure you that the information you have provided will be treated with strict confidentiality.
Kindly certify this information.
Name: _________________________________________________________ _______________________________
Address: ______________________________________________________________________________________
Signature: ________________________ Date: __________________ Stamp: ______________________________
THANK YOU FOR YOUR COOPERATION AND FOR PROVIDING YOUR FINANCIAL STATEMENTS.
FOR OFFICIAL USE
Name of Interviewer: _______________________ Signature: ___________________ Date: __________________
General remarks / comments
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