FY2007 DGF APPLICATION FORM

I. Key Information

Title of Proposed Activity
Sponsoring Network(s)/VPU
Department
Task Manager
Name of Grant Recipient/Executing Agency
Application Date

Is this an ongoing or new program/activity: Ongoing New Neither

Projected Need for DGF support:

----- Indicative Amounts -----
FY2007 / FY2008 / FY2009 / Total
(a) Program’s estimated budget during DGF support period
(b) DGF funding request
DGF burden sharing percentage

II.Endorsement (by Network and Sponsoring Unit)

Required signatures:

  • Signature of Sponsoring Unit (Country Director or Sector Director for multi-country grants) indicates agreement to incur Bank administration or supervision costs associated with this grant’s implementation.

III. Main Features of Proposal

1. Purpose of grant:

(a) brief description of objectives of program/activity and intended beneficiaries:

(b) brief description of project components, methodology and timeframe:

(c) brief description of recipient organization:

2. Proposed use of grant funds per FY (breakdown by project component, including consultants, travel, studies, equipment, etc.[1]). Please note that flat overhead rates or fees by executing agencies are contrary to the PCF Guidelines.

Table 1: Detailed Budget

*Note: Quantity times Unit Rate equals Total Cost (To add a component or a sub-component: first, "insert" appropriate number of rows; then "copy and paste" accordingly)

Components & Activities / Expenditure Category / Quantity / Unit / Unit Rate (US$) / Total Cost (US$)
1. NAME OF COMPONENT
1-A. Name of Activity
Goods / Type of goods / # of items
Services / Fees / # of months
Travel / # of trips
Subsistence / $$ stipend/day
Local Training / Training / # of participants
Small Civil Works / Type of Works / item
Subtotal Activity 1-A
1-B. Name of Activity
Goods / Type of goods / # of items
Services / Fees / # of months
Travel / # of trips
Subsistence / $$ stipend/day
Local Training / Training / # of participants
Small Civil Works / Type of Works / item
Subtotal Activity 1-B
SUBTOTAL COMPONENT 1
2. NAME OF COMPONENT
2-A. Name of Activity
Goods / Type of goods / # of items
Services / Fees / # of months
Travel / # of trips
Subsistence / $$ stipend/day
Local Training / Training / # of participants
Small Civil Works / Type of Works / item
Subtotal Activity 2-A
2-B. Name of Activity
Goods / Type of goods / # of items
Services / Fees / # of months
Travel / # of trips
Subsistence / $$ stipend/day
Local Training / Training / # of participants
Small Civil Works / Type of Works / item
Subtotal Activity 2-B
SUBTOTAL COMPONENT 2
3.Independent Grant Evaluation[2]
TOTAL PROPOSAL COST

Table 2: Summary by Component and Expenditure Category

Component 1 / Total Cost
Goods
Services
Training
Civil works
Other
Sum of Expenditures
Component 2
Goods
Services
Training
Civil works
Other
Sum of expenditures
Total for All Components
Goods
Services
Training
Civil works
Other
GRAND TOTAL:

3. Implementation arrangements (Role of Bank vis-à-vis recipient/executing agency and other partners, list of other donors and amount of their support, including in-kind contributions):

  1. Linkage to Bank’s work program (linkages to priorities in Watching Brief, TSS, CAS) and support for activity from other Bank sources (e.g. Institutional Development Fund, Small Grants Program, etc.)
  1. Indicate supervision costs and certify that funds will be provided by the grant-sponsoring unit from its own administrative budget.
  1. Indicate status of Financial Management Assessment [3]

Name of Financial Management Specialist: ______

  1. Indicate status of Procurement Assessment

Name of Procurement Specialist: ______

  1. Provide SAP Project Definition Code[4]

IV. Extent of Conformity with DGF Eligibility Criteria

1. Project contribution to furthering the Bank’s development objectives. (is the project innovative? Can the project be replicated in other countries?)

______

2. Exit strategy and potential future Bank activities as follow up to the project.

______

3.Provide rationale if Bank execution of project is sought.

V. Project Design Summary

Guidelines: The Project Design Summary (PDS) presents a summary of the proposal and should be used to monitor and evaluate the progress and achievements of the project. Performance indicators are measures of project outcomes, outputs and inputs that are monitored during implementation to assess progress toward project objectives.

Narrative Summary / Key Performance Indicators / Monitoring and Evaluation / Critical Assumptions
1. Project Development Objective / 1A
Outcome Indicators / 1B
Project reports/Process involved / 1C
(From Objective to Bank strategy (WB, TSS, CAS)
Provide a one-sentence statement of the overall objective that will have been achieved at the end of the project as a result of both the delivery of the project outputs and the involvement of beneficiary groups and/or institutions (stated under Outputs to Objective). The objective should express a single development purpose that is realistic, specific and measurable. / These indicators involve measurements that explain the degree of achievements towards objective. / Identify where the information for verifying each indicator will be found/methodology involved. / These assumptions often involve conditions, actions, risks, or responses outside the project.
2. Expected Outputs / 2A
Output indicators / 2B
Various project reports, supervision missions and evaluation reports / 2C
(From Outputs to Objective)
State here the end-of-project milestone to be achieved through the implementation of each component.
A correct statement of output milestones will be easy to measure (as reflected in the indicators to the right).
For simplicity and clarity of the logic, there should be one output statement for each corresponding project component.
Each output should correspond in number to its respective component.
3. Project Components/
Activities / 3A
Inputs (budget for each component) / 3B / 3C
(From Components to Outputs)
A component is a cluster of activities that contribute to a single project output. Link components to objectives.
List each project component as a main heading, followed by a list of major activities that are funded under it (use subheadings, or use a descriptive phrase that gives a flavor of the types of activities to be funded). / Inputs are generally monitored and evaluated via progress reports and disbursement reports.

VI. Summary of Annual Progress Report [5] - For Subsequent phase of ongoing grants only:

1. Brief description of past grant objectives and PCF previous contribution (total budget by FY):

2. Progress in achieving:

(a)development objectives (outcomes)

(b)proposed outputs

3. Brief description of any main changes in proposal since last submission (including any changes in status of other donor contributions) (Please provide a revised project design summary):

______

4. Most recent review(s) of project (Date of review(s) and period covered and by whom (i.e., sponsoring Bank unit, recipient organization, donors, independent third party):

Summary of findings:

(a)supervision reports/missions

(b)audits/financial report

(c)independent evaluation (if applicable)

1

[1]DGF funds may not be used to cover Bank staff costs which should be covered under the grant-sponsoring unit’s administrative budget. Grant funds are made to external grant recipients.

[2]Required by PCF/DGF for all grants larger than $250,000.

[3] Please note that Financial Management and Procurement assessments of the implementing organization are to be done during the design of the grant proposal; please contact the PCF Secretariat for more detailed information on the streamlined FM and PR Checklists that are available for TTLs’ use.

[4] As of January 1, 2007, SAP Codes are needed at the time the proposal is submitted to the Committee; please consult your RM Specialist if you need support in verifying the appropriate SAP Project Definition Code.

[5]The additional information requested in Section V is required for all ongoing programs and activities. This information will be reported to the Bank’s Board of Executive Directors in the DGF Annual Review report.