Third Schedule – Non-Depository Microfinance License Application Form

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Non-Depository Microfinance License Application Form THIRD SCHEDULE Non-Depository Microfinance License Application Form (CBS/LCR /REG/03 Article 5) Name of Applicant business/partnership/entity:
Reference
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Topic Information Entry Field 1 Legal or Company Name:
2 Business address of head office or location in Somalia Somali Business telephone number Business Somali e-mail address Somali website address Contact information Full name Position/title Address Telephone number E-mail address 12 Is the company a member of an industry association? If so, of which association? Yes: No:
Please enter the following information for the financial and Financing portfolio for two years. Financing portfolio As at 31st Dec 2023 As 31st Dec 2024 Description Individual Group Individual Group Outstanding Financing portfolio (US$) Portfolio at Risk (%) Total No. of Active Clients Female Active Client Male Active Client Number of Financings Disbursed

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Distribution by economic sector Description As at 31st Dec 2023 As at 31st Dec 2024 Trade (retail/wholesale/import) Consumer Financings (including health, education, funerals, e.g.) Housing improvements and related Financings Services Agricultural Financings Production Financings (other than Ag Financings) Transport/vehicles Machinery/Equipment Other Financial Data Assets at end of the quarter (Q1, 2025) B Equity and Liabilities at end of the quarter Total Assets: $ Total Liability/Equity $ Non-Current Asset $ Total liabilities: $ Current Asset $ Total Equity $ Total Revenue $ Total Expenses $ Net profit/loss $ Information on current activities with local, government, and/or international partners Partner’s name Financing (Amount in US) Description Capacity building (Amount in US) Partner Name Total amount of Financings disbursed (per year) Average amount disbursed Number of Financings/credit officers

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This application is required to be signed and stamped to be considered valid. Name of the authorized officer:
I, the undersigned certify that and declare that to the best of my knowledge and belief all the facts stated in this application are complete and correct