Annex A

Grant Idea Snapshot Form

(to be completed and submitted by all applicants)

Please answer the following questions. Responses must not exceed 2 pages total and must be in 12-point font.

  1. Organization name and description:
  1. Contact information:

Organization address:
Organization phone:
Organization website:

The contact person (agent) is responsible for communications between YLA and the Applicant. This applies to all aspects of the grant application, from initial ideasnapshot through negotiation and award. The agent must have full authority and responsibility to act on behalf of the Applicant. The agent should be someone who will be directly involved with the grant activity and has a proven, established relationship with the Applicant.

Name of agent:
Title of agent:
Phone:
Email:
  1. Is the organization legally registered under the laws of the Government of Uganda (GOU) and in good-standing with the local government?
  1. Describe the proposed concept. What is the issue/problem that the concept will address? How will the issue/problem be addressed? Who are the beneficiaries of this opportunity? What are the expected results of this opportunity? How does the opportunity relateto the YLA objectives (as described in Section 1B of the APS) and the program description (as described in Section IC)?
  1. Describethe organization’s relevant past performance in the proposed geographical area and/or the proposed technical area. If the organization does not have relevant past performance, describe the organization’s potential and relevant capability and performance related to YLA’s priority areas.
  1. Estimatethe approximate cost of the proposed concept, using the format below.An exact detailed budget is not necessary at this point, only a plausible estimated calculation, which should be realistic and within 15 percent (+/-) of the final approved budget. Note that the budget must be provided in UGX.
  2. How much funding is requested from YLA and for what items/activities?
  3. What contribution (cash or monetized in-kind services or equipment) could you provide as the grantee?
  4. Will any funding come from other sources? If so, what other sources and how much?

Budget Category / Applicant Resources
(in UGX) / Third Party Resources (identify source)
(in UGX) / Total Resources Needed from YLA
(in UGX)
Salaries:
Other Direct Costs:
Training:
Travel and Transportation:
Goods and Materials:
[Add more rows as needed.]
Total Estimated Costs (in UGX)
  1. Describe how the results of the proposed activity are sustainable.
  1. Signature:

By affixing my signature below, I certify that to the best of my knowledge, the information provided in this application is accurate and correct:

Submitted by (name and title): ______

Signature: ______Date: ______

FOR PROJECT USE ONLY
Date received ______Grant Reference No. ______
The undersigned hereby certifies that: (a) the prospective grantee has received an official delivery receipt for its Grant Idea Snapshot Form, (b) a copy of that receipt has been filed, (c) a reference number has been assigned, and (d) a grant application file has been opened. In addition, the prospective grantee has been advised as to the review and appraisal process, and its primary project point of contact.
YLA Grants Manager Name ______Date ______