SCHEDULES
SCHEDULE 1
FORM 1 A
Regulation 3
THE TIER 4 MICROFINANCE INSTITUTIONS AND MONEY LENDERS ACT 2016
APPLICATION FOR A LICENCE (NON DEPOSIT)
(To be completed in Triplicate)
1. Name of Non-Deposit Taking Microfinance Institution
………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
2. Physical address of the head office: ……………………………………………..
…..................................................
3. Postal
address………………………................................................Email,…………………………………………………..
4. Telephone
number………….....…………………………………………………………………………………………………………….
5. Present administrative structure: ……………………………………………………………........................……………….
6. Date of incorporation or registration with NGO Bureau
……………………………………...………………………….
7. Certificate of incorporation or registration as the case may be (attach copy)
……………………………………
8. Names of places of business in Uganda and start date and the number of years each has been
established and has conducted or carried out business
S/N Place of Business Year No. Of Years
Established in
Operation
1
2
3
4
5
6
1
9. Details of Capital:
(a) Core
Capital…………………………………………………………………………………………………………………………………….
(b)Permanent and non-withdrawable capital.................
..........................................................................
(c)Redeemable capital........................................................................................................................
(d) Institutional capital……………………………………………………….............................................................
10. (a) Provide the following for each member of the Board of Directors
Name…………………………………………………………………………………………………………………………………………......
Designation………………………………………………………………………………….......................................................
Address………………………………………………………………………………………………………………………………………......
Other directorship……………………………………………………………………………………………………………………………
Date of appointment………………………………………………………………………………………………………………………..
(b) Provide the following for each of the senior management officers: -
Name......................................................................................................................................................
Designation.............................................................................................................................................
Nationality...............................................................................................................................................
Age..........................................................................................................................................................
Academic or Professional Qualifications & year obtained…………...........................................................
…………………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………….......................................................................
Details of previous employment:
Date of appointment…………………………………………………………………….........................................................
Position held &
responsibilities………………………………………........................................................................
11. Has any person responsible for the management of a company been convicted of an offence
relating to embezzlement or any other financial impropriety? If so, please provide the name of the
person and the related details.……………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………….....
………………………………………………………………………………………………………………………………………………………
12. Do you know whether any such application was rejected or withdrawn after it was made or any
authorization revoked? .......................... If so, give particulars…………….…………………………………………
……………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………..
13. Have you at any time been convicted of any criminal offence in any jurisdiction? …………………..
If so, give particulars of the court in which you were convicted, the offence, the penalty imposed
and the date of
2
conviction…………………………………………………………………………………………………………………………..
………………………………..…………………………………………………………………………………………………………………………
.
………………………………………………………………………………………………………………………………………………………….
14. Have you ever failed to satisfy any debt adjudged due and payable by you on an order of court,
or have you made any compromise arrangement with your creditors within the last 5
years?…………………………….
If so, give
particulars……………………………….............................................………………………………………………..
…………………………………………………………………………………………………………………………………………………………
….
15. Have you ever been declared bankrupt by a court or has a bankruptcy petition ever been served
on you? ..................................................
If so, give
particulars……………………………………………………………………………………………………………………………….
16. Have you ever been held liable by a court, for any fraud or other misconduct?................
If so, give
particulars………………………………………………..................................................................................
…………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
………..
17. BANKERS (if any):
S/N Name of Banker Address Details of
Banking
1
2
3
4
5
6
18. AUDITORS;
Provide details of the following Name of
auditors………………………………………………………………………………………………………………………………………………
…
3
Date of
appointment…………………………………………………………………………………………………………………………….
19. Has the Non-Deposit Taking Microfinance Institution been put under receivership in the past or
made any compromise or arrangement with its creditors in the past or otherwise failed to satisfy its
creditors in full?
Yes..............
No............... If yes please give details………………………………………………………………………………………………..
...............................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
...............................................................................................................................................................
20. Has the Non-Deposit Taking Microfinance Institution been the subject of an investigation, in any
country.................? If YES, give particulars…………………………………………………………...………………………….
…………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
……………………………………………………….…………………………………………………………………………………………………
21. Is the Non-Deposit Taking Microfinance Institution currently engaged or does it expect to be
involved in any litigation which may have a material effect on the resources of the institution?
Yes................ No................. If yes, give particulars……………………………………………………………………
22. Is the institution engaged or does it expect to be engaged in any business relationship with any
of its officers or significant shareholders? Yes................... No..................... If yes, give the
particulars……………………………………………………………………………………………………………………………………………
…
23. FINANCIAL SERVICES
(a) List and briefly describe current and envisaged financial products
S/N Financial Products and Services Description ( e.g. interest rates
or fees charged)
Financial Product and Services Description
(b) Describe the methodologies of delivering products and services
……………………………………………………………………………………………………………………………………………………………
4
……
……………………………………………………………………………………………………………………………………………………………
……
……………………………………………………………………………………………………………………………………………………………
……
……………………………………………………………………………………………………………………………………………………………
……
DECLARATION
We, the undersigned, being the Board of Directors of the institution, declare that to the best of our
knowledge and belief, the information contained herein is complete and accurate.
Chairperson…………………………………………………. (Name)
Signature…………............................................................................Date…………………………..………………….
Chief Executive Officer…………………………………………………. (Name)
Signature………………………………………………………………………………….Date…………………………………………………
Note: This form must be accompanied by all relevant documents and requirements prescribed in the
Act and these Regulations.
(a) Certificate of Incorporation
(b) Forms of particulars of directors and company Secretary
(c) Registered address
(d) National Identity Cards for all the directors and company secretary
(e) Certificates of good conduct for all the directors
(f) Proof of payment of fees for application of the licence.
(g) A copy of the interest rates according to the categories of loans products offered.
(h) Memorandum and articles of association.
(i)Copy of Loan Agreement.
(j)TIN Number
(k)Organisation Structure.
