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(Form of Special Part (B) of the application for the project financing)

SPECIAL PART (B) OF THE APPLICATION FOR THE PROJECT FINANCING

(NB: completing Special Part (B) of the application for the project financing,

delete explanations and this comment!)

  1. INFORMATION ABOUT THE APPLICANT AND PARTNER(S)

1. Project title

Project title / (Indicate the project title).

2.Reimbursement of funds illegally disbursed to the applicant. The applicant has reimbursed all illegally disbursed and used funds of the European Union or other international assistance, or funds from the budget of the Republic of Lithuania, if any.

(Please, specify by signifying).

 Yes (the applicant repaid the funds, or there were no such funds) /  No (the applicant has not repaid the funds)

3. Reimbursement of funds illegally disbursed to the partner. The partner has reimbursed all illegally disbursed and used funds of the European Union or other international assistance, or funds from the budget of the Republic of Lithuania, if any.

(Please, specify by signifying. If more than one partner participates in the project, the information about each partner shall be provided separately, indicating the name of each partner in brackets).

 Yes (the applicant repaid the funds, or there were no such funds) /  No (the applicant has not repaid the funds)

4. Administrative capacity of the applicant and (or) partner(s)

(Please, enter the number of planned employees, the functions assigned to them, provide documents supporting their experience and competence: CVs, granting of qualifications, etc.).

Administrative capacity of the applicant and (or) partner(s)
Employees / Number / Assigned functions for the project implementation / Competence and experience of employees
Administrative staff of the project / (To specify the accompanying enclosures and page numbers of the application)
Estimated additional need for employees (if applicable) / (To specify the accompanying enclosures and page numbers of the application)
Staff assigned by the (1st) partner (if applicable) / (To specify the accompanying enclosures and page numbers of the application)
Staff assigned by the (2nd) partner (if applicable) / (To specify the accompanying enclosures and page numbers of the application)
Total number of employees

5. Justification of the choice of the project partner(s)

(Supplement the information provided in the general part (A) of the project application about the justification of the choice of the partner(s) specifying the experience of the partner(s) and its interrelation to the project activity/activities as well as the estimated added value from partnership. Specify if the project partnership is a continuation of the previous cooperation between the applicant and the partner(s). If yes, describe the previous cooperation. If the project provides for more than one partner, a separate table must be completed for each project partner. If the partner is from the Kingdom of Norway, the table must be completed in Lithuanian and English).

Justification of the choice of the project partner (please specify the partner)

6. Role and activities of the partner in the project

(This table contains a detailed description of partner's project activities and specifies how the partner's activities contribute to the achievement of project goals and objectives). If the project provides for more than one partner, a separate table must be completed for each project partner. If the partner is from the Kingdom of Norway, the table must be completed in Lithuanian and English).

Role and activities of the project partner (please specify the partner) in the project
Title of activity / Description of partner‘s role in implementing the activity
  1. LINKAGES OF THE PROJECT ACTIVITIES WITH OTHER PROJECTS

(NB. Information about linkages of the project activities with other projects has to be provided for the period of 5 years preceding application date. If activities envisaged to be implemented under the project are related to more than one project, information about each project shall be provided in a separate table).

Possible linkages of the activities envisaged to be implemented under the project with the activities of another project which was(is) financed from the state budget of the Republic of Lithuania, the Norwegian and European Economic Area Financial mechanisms, European Union and other international financial assistance (hereinafter – another project). / (Please, specify, whether the activities envisaged to be implemented under the project are related to other activities of the projects that were or are implemented by the applicant and (or) partner(s) financed from the Republic of Lithuania state budget, Norwegian and European Economic Area financial mechanisms, European Union and other international financial assistance.. If the answer is positive, proceed with completing further columns of the table.
Title of another project.
Source of financing of another project.
Value of another project.
Period of implementation of another project.
Linkage of the project activities to be financed with other project activities. / (Please, substantiate the separation of activities of the project to be financed from activities of another project.
Project activity is a particular action the implementation of which should facilitate the achievement of the set target of the project).

III. PROJECT COMPLIANCE WITH THE OBJECTIVES AND MONITORING INDICATORS OF THE NORWEGIAN FINANCIAL MECHANISM PROGRAMME

1. Project compliance with the objectives of the Norwegian Financial Mechanism, the Programme and the Measure.

(Describe and justify the compliance of project objective and targets with the objectives of the Norwegian Financial Mechanism, the Programme and the Measure).

Project compliance with the objectives of the Norwegian Financial Mechanism, Programme and Measure / Description of compliance
Project compliance with the general objective of the Norwegian Financial Mechanism “to reduce economic and social inequalities in the European Economic Area” / (Please, describe and substantiate the compliance of the project objectives and targets with the general objective of the Norwegian Financial Mechanism)
Project compliance with the general objective of the Norwegian Financial Mechanism Programme “to improve public health and reduce differences in the health status” / (Please, describe and substantiate the compliance of the project objectives and targets with the general objective of the Norwegian Financial Mechanism Programme)
Project compliance with the purpose of the Measure “to implement the Model in accordance with the needs of municipality” / (Please, describe and substantiate the compliance of the project objectives and targets with the purpose of the Measure)

2.Project compliance with the monitoring indicators.

(Describe how Measure outcome and outputs indicators will be pursued, enter their numerical values and provide a justification of how they will be achieved)

Outcome and output indicators of the Measure / Numerical value of the indicator / Justification
Outcome indicator
Number of developed[1]and implemented Models in accordance with the needs of municipalities
Output indicator
Number of municipalities involved in the implementation of the developed Model

IV. VALIDATION OF THE NEED AND BENEFITS OF THE PROJECT

Validation of the need and benefits of the project
(Please, provide details and particular description and supplement information provided in table “Brief description (summary) of the project” in Part (A) of the application:
  • Project need: detailed description of problems and their causes, justification of the project need (indicating relevant statistical and other information about the status quo, etc.); specifying the obstacles, specific limitations faced by the target group of the project.
  • Planned outcomes and benefits of the project: description of qualitative changes, specifying how the implementation of the project will change the status quo, indicating positive impact on the settlement of problems of the target group(s). For the purposes of evaluation of compliance with the requirement laid down in paragraph 30 of the Guidelines, specify the percentage of young people (youth) aged between 14 and 29 in the total population of the applicant's municipality (provide data for 2014).
Maximum 2 pages.
The application may also be accompanied by additional documents and information supporting these answers.)

V. DESCRIPTION AND VALIDATION OF PROJECT ACTIVITIES

(Please, describe each project activity, indicating the number and title. Project activities shall correspond to the titles of activities indicated in table “Rationale of the project” in Part (A) of the application).

No / Target / Activity / Duration (beginning and end) / Description, validation and outcome of activity

VI. IMPLEMENTATION OF THE MODEL

(Describe the Model implementation process – the elements of Model implementation specified in paragraphs 1 to 5 of the table indicating which activities will be carried out during the implementation of each element of the Model (at least 200 words for each),activity implementation periods together with the indication of particular work by the applicant and/or partner(s) in implementing every element of the Model, if applicable, indicating other institutions involved in the implementation of Model elements and their expected contribution. Describe the organisation, management, funding, quality assurance and monitoring of the provision of youth-friendly health care services (YFHCS). Describe how the requirements and factors laid down in paragraphs 28 and 29 of the Guidelines will be taken into account during the Model implementation process).

Model implementation elements / Description
1. Preparatory Model implementation elements (actions taken before the submission of the project application (during the application preparation) which are important for the implementation of the Model (if applicable) / The description of activities must be accompanied by the copies of relevant documents (minutes of meetings, strategic documents of the municipality, draft technical specifications, etc.).
2. 2. Compulsory Model implementation elements:
2.1. The establishment of the YFHCS coordinating centre / introduction of and support to the YFHCS coordinating and case management function / In addition to the description of activities, it should be specified institution delegated by the municipality to act as the YFHCS coordinating centre (copies of documentary proof of delegation, draft job descriptions of the YFHCS coordinator(s) and other information and documents related to the introduction of and support to the YFHCS coordinating and case management function).
2.2. The administration of the Youth Health internet portal[2] at municipal level (preparation, publication, updating, adaptation, etc. of information)
2.3. The adaptation of the Algorithm(s) in priority area(s) of the YFHCS provision and application at municipal level / The description of activity must be accompanied by information about the relevance of the selected activity in the municipality
3. Optional Model implementation elements:
3.1. The implementation of recommended YFHCS good practice examples specified in paragraph 8 of Annex 9 to the Guidelines (if applicable, description of every good practice example selected for implementation in the municipality) / The description of activity must be accompanied by information about the relevance of the selected activity in the municipality.
3.2. other initiatives meeting the definition and criteria of the YFHCS provided in paragraph 6.3 of the Guidelines (if applicable, each selected initiative must be described) / In addition to the description of activities, should be provided information on how the selected initiative(s) meet the YFHCS definition and criteria, as well as justification of the relevance and necessity of the selected initiative(s) in the municipality.
4. Training of persons involved in the Model implementation and/or provision of the YFHCS / The description of institutions and organisations whose people are intended to be trained, planned training topics and training duration, organisation of and participation in training.
5. Equipping of the premises in which the YFHCS are to be provided / The description of where and how the premises will be equipped in which the YFHCS are to be provided and how the premises will meet the requirements of the YFHCS environment (safe, meeting the needs of the youth, attractive).

VII. PROJEC SUMMARY IN ENGLISH

Project summary in English
(Please, provide project summary in English language. Information provided in the summary shall correspond the information provided in column “Nature of the project“ table “Brief description (summary) in Part A of the application).

VIII. PROJECT RISKS AND METHOD OF THEIR REDUCTION

Risk / Probability (high, average, low) / Impact (high, average, low) / Risk reduction method
(Please, provide a brief description of possible risks related to the performance of project activities). / (Please, specify the probability of occurrence of such risk) / (Please, specify, the impact on the performance of project activities) / (Please, specify, in what ways and how quickly you can reduce the risk)

IX. PROJECT COMPLIANCE WITH THE PROVISIONS OF THE POLICY OF SUSTAINABLE DEVELOPMENT, EFFECTIVE MANAGEMENT, GENDER EQUALITY AND EQUAL OPPORTUNITIES

(Please, supplement the information provided in the General Part (A) of the project application describing the compliance of the project with the provisions of the policy of sustainable development, effective management, gender equality and equal opportunities and specify concreate measures to ensure contribution of the project to the implementation of these provisions.

Compliance of the project with the provisions of the policy of sustainable development, effective management, gender equality and equal opportunities

X. ELIGIBLE EXPENDITURES OF THE PROJECT BUDGET

(Expenditures of the project budget shall be justified in a separate table according to the Table of justification of the project budget expenditures and its filling instruction provided on the website of the CPMA ())

XI. LIST OF ACCOMPANYING DOCUMENTS

The applicant shall provide the following documents together with the application for the financing of the project:

  1. A document proving the powers of the person who has signed the application (if signed by a person other than the director of the applicant's institution).
  2. Copies, if any, of the regulations (operational rules and/or statutes) of the partner(s) (if the enclosed documents are in Norwegian, their translation into the Lithuanian or English language must also be provided);
  3. A copy of the contract on the provision of public health care services and (YFHCS) in the applicant's municipality. Applicable if the partner is the public health bureau of the municipality other than the applicant's one.
  4. A certificate(s) that each partner(s) registered in the Republic of Lithuania has/have no amounts due to the national and municipal budgets and public funds issued by a regional office of the State Tax Inspectorate (original or copy) or a document issued by the state enterprise Centre of Registers confirming joint data managed by competent authorities (original or copy). A certificate(s) or the above-mentioned document(s) must be issued no more than 2 months prior to the submission of the application. Documents (originals or copies) confirming the deferral of taxes in cases when the payment of the tax has been deferred under the agreement with a tax administration authority. The requirements of this paragraph shall not apply if the partner(s) is/are a budgetary institution(s).
  5. Documents of the partner(s) registered in the Kingdom of Norway meeting the legal acts of the Kingdom of Norway and proving that the partner(s) has fulfilled the liabilities related to the payment of taxes and contributions (if the enclosed documents are in Norwegian, their translation into the Lithuanian or English language must also be provided). Not applicable to partner(s) that is/are a budgetary institution(s).
  6. Curriculum vitae (CV) of employees of the applicant and partners who will be directly involved in the implementation and administration of the project (if the enclosed documents are in Norwegian, their translation into the Lithuanian or English language must also be provided).
  7. A copy of the joint activity (partnership) agreement in Lithuanian (if the partner(s) is/are registered in the Register of Legal Entities of the Republic of Lithuania) or in English (if at least one partner is registered in the Kingdom of Norway under the legal acts of the Kingdom of Norway) (applicable if the application is submitted with a partner(s)).
  8. A protocol of intent or similar document in free form signed by the applicant and partner(s) (if applicable) with the commitment for the period from entry of force of the project contract and at least for 1 year after completion of the project not to change the nature or implementation conditions of the activity which has received the funding and ensure support to the functioning of the implemented Model in the municipality for at least 1 year after the project completion.
  9. A declaration(s) on the compliance with the requirement laid down in paragraph 33 of the Guidelines in a free form signed by the applicant and/or partner(s).
  10. A completed table of justification of project budget expenditure: () and documents justifying project budget.
  11. Project publicity plan (Annex 8 to the Guidelines).
  12. A commitment of the applicant and/or partner(s) to cover unforeseen or ineligible expenditure which is necessary for the project implementation from its own resources (if the enclosed documents are in Norwegian, their translation into the Lithuanian or English language must also be provided).
  13. If applicable, a copy of the certificate of registration or an equivalent document of each partner registered in the Kingdom of Norway (if the enclosed documents are in Norwegian, their translation into the Lithuanian or English language must also be provided).
  14. During the assessment of the application the PI Central Project Management Agency shall have the right to request additional information for the assessment of eligibility of expenditures. The application for the financing of the project may be accompanied by other documents supporting the information provided in the application for the financing of the project.

XII. THE APPLICANT’S CONFIRMATION

I hereby confirm that information provided in the Form of the Special Part (B) of the application for the financing of the project is accurate and correct.

(Position of responsible person of the applicant) (Signature) (Forename, surname)

Place of seal

[1]Model is developed by implementing the project “Development of a Model for the Provision of Youth-Friendly Health Care Services” therefore outcome indicator is applied only to implementation of the Model.

[2] Instead of the development of a new portal, integration into the existing system will only be needed, i.e. registration and creation of an account / user for the Youth Health internet portal at national level and its administration at municipal level.