Public Private Partnership Facility

Model Forms

Public Private Partnership Facility

Facility for Sustainable Entrepreneurship

and Food Security (FDOV)

Tender 2012130625

Contents

Annex 3a:MODEL PROGRESS REPORT RESULT 1

Form to be used to report on progress onResult 1 ofthe project.

Annex 3b:MODEL ANNUAL PROGRESS REPORT

Form to be used to report on the annual progress of the project.

Annex 3c:MODEL FINAL REPORT

Form to be used to report on the achievement of the final result of the project.

Annex 3d:MODEL FINANCIAL REPORT

Form for financial report as part of the progress report on result 1, the Annual progress report and the Final report.

Annex 3e:SPECIFICATION PROJECT BUDGET ON RESULT AND SUB-RESULT LEVEL

Form to be used to provide budget specification as part of result 1.

Annex 3f:FORMAT ICSR RISK ANALYSIS

Form to be used to provide the ICSR Risk analysis as part of result 1

Annex 3g:REQUEST FOR MARKET CONFORMITY CHECK (RMCC)

Form to be sent to SGS Nederland BVto request for a check on Market Conformity for hardware purchases

Annex 3h:MODEL PROTOCOL OF RECEIPT

To be used for purchases done and owned by the partnership or one of the partners.

Annex 3i: F.I.E.T.S. CRITERIA

Annex 3j:CRITERIA AND GUIDELINE INDICATORS

All model forms will be digitally available at the website of FDOV:

Contents - page 1130625

Annex 3a:MODEL PROGRESS REPORT RESULT 1

FDOV project number: / FDOV…/…/…
Title of the project: / ……….
Name applicant: / ……….
Reporting period / ……….  ……….
Filing date progress report / ……….

Instructions:

This report presents a summary of the progress on Result 1 of the project as defined in Annex 1 of the Subsidy Ordinance (‘beschikking’).

-This report and attached documents must be in English.

-Send one (1) hard copy by postal mail toNL Agency, NL EVD International/PPP-facility FDOV(hereafter: NL Agency), and one (1) copy by e-mail to thePPP project officer.

-NL Agencyshould receive the Progress Reporton Result 1according to the date included in the Subsidy Ordinance.

-The Progress Report on Result 1 should be signed by the Applicant.

-Blue text can be deleted.

A. General

Contact information

-Were there changes in contact information of the applicant or project partners during the reporting period? Yes No
If there are any changes, please list them below, otherwise proceed with section B.:

Name of applicant/partner:

Correspondence address:

Visiting address:

Name contact person: Phone:

Email-address:

IBAN:BIC:
Other:

B. Progress of project and result(s) achieved

Summary

-Please summarise (Max 500 words) the progress of the project so far, including a description on the cooperation between the partners and qualitative project results.

Progress achieved under Result 1

-Is result 1 completed? Yes No
Please specify the sub-results, with reference and numbering in accordance to Annex 1 of the Subsidy Ordinance. E.g. if sub-result 3 of result 1 is completed, please specify so with reference to ‘R1.3’.

-Submit all corresponding Means of Verification (MoV's) for result 1. Number the MoV’s as defined in Annex 1 of the Subsidy Ordinance. E.g. R1.3.1

-Please describe the specific activities carried out in order to realise the result(s) and sub results; refer to the corresponding MoV's.

Bottlenecks and risks

-Please describe if there are any bottlenecks or risks identified or foreseen that could hinder the progress of the project. If relevant, describe what measures the partnership will take to mitigate the bottlenecks and risks.

-Please note that substantialchanges of the project in relation to the original project plan and Subsidy Ordinancehave to be approved by NL Agency. Substantial changes are defined as changes resulting in a different project results (output / outcome, reflected in MoV’s), partnership, planning or budget.Approval for these substantial changes can be done under section E ‘Project modifications’.

Sustainability and cross-cutting themes

ICSR

-Have the ICSR policies (according to OECD guidelines) been submitted by all the companies of the partnership? Yes No

-Is an EIA or more informal assessment of environment/climate/social impact required as part of result 1 (see Annex 1 of the Subsidy Ordinance)? Yes No
If required, integrate the relevant recommendations in the ICSR risk analysis of the project, including mitigation measures.

-Is one of the first essential suppliers or one of the project partners possibly using child labour or forced labour? Yes No
If yes, please identify the partner and elaborate on the situation.

-Please indicatethe most essential raw material(s) and/or semi-finished product(s) necessary for the manufacturing or development of the main final products or results(s) of the project. Identify in Table 1 below for each essential raw material / semi finished product indicated what company is the first essential supplier.

Table 1 Supply chains of the mainproject products or results

Essential raw material(s) / semi-finished product(s) of the project / First essential supplier (s)
1. [ please indicate the essential raw material / or semi-finished product here] / [Name essential supplier #1, contact details supplier #1]]
2.Etc. / [Name essential supplier #2, contact details supplier #2]]
Etc. / Etc.

With regard to the implementation of the project according to ILO Conventions 138 and 182 against child labour and ILO Conventions 29 and 105 against forced labour, you must establish that no use is made of child labour or forced labour at the partners involved in the partnership, or at the first essential supplier to the project. You are legally bound to provide NL EVD International with any information you may have about the possible use of child labour or forced labour by such partners or suppliers. If one of the aforementioned partners or suppliers is found to be using child labour or forced labour, or if you fail to pass oninformation you have received on this subject to NL EVD International, the subsidy may be withdrawn.

-Please provide a copy of the ICSR risk analysis in accordance with Annex 3f and report theactivities have been implemented during result 1 and the status of the mitigation measure(s) and ICSR risk(s).

F.I.E.T.S.

-Please identify what specific activities will be implemented as part of the project on sustainability (F.I.E.T.S: Financial, Institutional, Ecological, Technical, Social). Please refer to the Subsidy Ordinance and paragraph 2.4.Sustainability/ICSR and crosscuttingthemes of the project plan submitted under FDOV phase II of the FDOV call 2012. Refer to the relevant F.I.E.T.S. elements provided in Annex 3i when filling out table 2. If necessary it is allowed to introduce new indicators.

Table 2 F.I.E.T.S related activities of the project

F.I.E.T.S. related activities of the project
1 Financial / Relevant element(s) mentioned in Annex 3i / Relevant sustainability indicator
1.1[Please describe the relevant activity] / [Please identify relevant element(s) mentioned in Annex 3i. Please choose one or more of the following options:
a. substantial local contribution, especially from private parties;
b. Dutch and local SME's play a significant role in the project;
c. products/services are delivered after the project period based on local revenues through taxes or pricing of products/services;
d. the price for a service/product includes costs of management, maintenance and depreciation.] / [Please identify the relevant sustainability indicator ]
1.2 / … / …
1.3 Etc. / Etc. / Etc.
2 Institutional / Relevant element(s) mentioned in Annex 3i / Relevant sustainability indicator
2.1Please describe the relevant activity] / [Please identify relevant element(s) mentioned in Annex 3i. Please choose one or more of the following options:
a. Local party is made responsible for the sustained delivery of the services or products after the project period.[…].
b. Solid stakeholder assessment is provided
c. Project is in line with national legislation and directives
d. Partners report in a transparent way on planning, main decisions, budgetary issues and the results of the project.
e. Capacity building of e.g. local private sector to ensure sustainable delivery of services and products] / [Please identify the relevant sustainability indicator]
2.2
2.3 Etc / Etc / Etc
3 Ecological (environment and climate) / Relevant element(s) mentioned in Annex 3i / Relevant sustainability indicator
3.1 [Please describe the relevant activity] / [Please identify relevant element(s) mentioned in Annex 3i. Please choose one or more of the following options:
a. assessment of the impact of the project on the environment […] and the living conditions of the target group;
b. proposed technologies are suitable:
- avoidance of pollution of water, soil, air
- recycle waste] / [Please identify the relevant sustainability indicator]
3.2 / Etc
3.3 Etc. / Etc / Etc
4 Technical / Relevant element(s) mentioned in Annex 3i / Relevant sustainability indicator
4.1 [Please describe the relevant activity] / [Please identify relevant element(s) mentioned in Annex 3i. Please choose one or more of the following options:
a. installed infrastructure will remain operational beyond the project period […];
b. technology is easily bought or (partially) produced locally and managed by the local […] private sector;
c. capacity building to ensure the management and maintenance of the infrastructure/products;
d. technology is affordable for local users […];
e. choice for technology is based on a comparison between different options taking into account environmental and social (e.g. gender) issues, preferably through participatory process.] / [Please identify the relevant sustainability indicator]
4.2.
4.3 Etc / Etc / Etc
5. Social / Relevant element(s) mentioned in Annex 3i / Relevant sustainability indicator
5.1.[Please describe the relevant activity] / [Please identify relevant element(s) mentioned in Annex 3i. Please choose one or more of the following options:
a. project is demand driven and focuses on basic needs, contributes to empowerment and self-reliance;
c. project takes into account specific needs of vulnerable groups and poorest in society;
d. gender inclusiveness;
e. good working environment in the broadest sense, taking into account ICSR or
f. social-cultural values of society are taken into account.] / [Please identify the relevant sustainability indicator]
5.2
5.3 etc / Etc / Etc

C. Output, Outcome and Impact

-Please provide the baseline situation on relevant indicators of the project at output, outcome and,where possible,impact level. As a minimum requirementinclude the indicators mentioned in Annex 1, Result 1 of the Subsidy Ordinance, indicators defined in Table 2 (FIETS) of this report and pay attention to gender. Additional indicators can be added, using the indicators in Annex 3j as guideline. These are set up in a general manner and can be modified and specified. Please use the indicated units if possible. Non-relevant indicators can be deleted from the table, whereasmissing indicators, relevant and feasible for the scope and context,can be added manually.
Please provide a brief explanation below the table on background of the presented data. For example, what geographic region, time period and targeted population are included?

D. Financial report

-Please report on the financial and labour realisation as well as the realisation on hardware purchases. Please use the mandatory Annex 3d for this.
If relevant, a textual clarification on the financial report can be given here. Modifications in budget or foreseen liquidity requirements must be requested under section ‘D Project modifications’of this report.

-Specified project budget
As part of result 1, please provide a specification of the project budget at the level of result and sub-result using the mandatory format in Annex 3e. If relevant, a clarification on the budget specification can be given here.

-Revolving fund

The continuity of the revolving fund has to be secured. If financial means flow back to the partnership or a partner this should be reinvested. The continuity should be based on a adequate arrangement.If relevant, a clarification,by means of long term prognostications, can be given here.

E. Project modifications

Substantial changes in the project in relation to the Subsidy Ordinance and original project plan have to be approved by NL Agency. Substantial changes are defined as changes resulting in a different project results (output/outcome, reflected in MoV’s), changes in partnership, planning, changes in staff at project management and senior level and changes in budget allocation >10% of result budget. Please, keep in mind that reallocation of budget between Technical Assistance and Hardware is not allowed.

Update work plan

-Please indicate whether the project work plan needs to be adjusted and its effect on reaching the project results (and MoV’s). In case of an adjustment, please give a detailed description and motivation. In case of a substantial change approval of NL Agency is needed. If there are changes in project managementorsenior staff this can be indicated here.

Project duration and planning

-Please indicate if the project planning and/or completion date has to be changed. In case of a request for a change, please give a detailed motivation. For extension of the project period, approval of NL Agencyis needed.

Project budget

-Please indicate changes in the liquidity requirement foreseen for the remaining project results. Please indicate whether a change in project budget allocation more than 10% of the project budget is needed or a different liquidity forecast is foreseen. If so, please give a detailed motivation. In case of a budget change >10% approval of NL Agency is needed.

-Please indicate all possible changes in hardware, as compared to the originally approved budget, in Table 4 below. Changes in hardware already reported to NL Agency in earlier progress reports or through a Request for Market Conformity Check (RMCC) can be excluded from this progress report. Changes in hardware have to be approved by NL Agency.

Table 5 Changes in hardware items compared to the hardware list provided with the progress report on result 1 (Annex 3d). Please, only include hardware that will be modified.

Item[1] / Description and Motivation of proposed change[2] / Quantity / Price in € / New/ adjusted amount in € / Original approved amount in €
Add more lines manually
TOTAL

F. List of annexes

Please make sure all Annexes mentioned below are adhered to this report

Annex 3d, Financial report

Annex 3e, Specification project budget on result and sub-result level

Annex 3f, format ICSR RISK ANALYSES

Means of verification (MoV’s)

-As specified under section B, ‘Progress of project and result(s) achieved. Please mark the MoV’s with the corresponding number (e.g. R1.3.4)

Other annexes

-Other relevant annexes provided, please specify here.

G. Declaration and signature

-As Result 1 has been finalised according to the Subsidy Ordinance, project partners request the written permission of NL Agency to continue with the further implementation of the project.

Applicant
Organisation:
Name:
Position:
Date:
Signature:

Annex 3a - page 1

Annex 3b:MODEL ANNUAL PROGRESS REPORT

FDOV project number: / FDOV…/…/…
Title of the project: / ……….
Name applicant: / ……….
Reporting period / ……….  ……….
Filing date progress report / ……….

Instructions:

-This annual progress report presents a summary of the progress of the project and the result(s) achieved so far, and may concern multiple project results as defined in Annex1 of the Subsidy Ordinance (‘beschikking’).

-This report and attached documents must be in English.

-Send one (1) hard copy by postal mail to NL Agency, NL EVD International/PPP-FacilityFDOV(hereafter: NL Agency), and one (1) copy by e-mail to the PPP project officer.

-NL Agency should receive the Annual Progress Report according to the dates included in the Subsidy Ordinance.

-The Annual Progress Report has to be signed by the Applicant.

-Please focus on the news and events that occurred in this reporting period.

-Blue text can be deleted.

A. General

Contact information

-Were there changes in contact information of the applicant or project partners during the reporting period? Yes No
If there are any changes, please list them below, otherwise proceed with section B.

Name of applicant/partner:

Correspondence address:

Visiting address:

Name contact person: Phone:

Email-address:

IBAN:BIC:
Other:

B. Progress of project and result(s) achieved

Summary

-Please summarise (max 500 words) the progress of the project so far, including a description on the cooperation between the partners and qualitative project results.

Progress achieved under Result 2

-Are activities for result 2 carried out in the reporting period? Yes No
If yes, please describe the specific activities carried out.

-Are sub results of result 2 completed? Yes No
If yes, please specify the sub-results, with reference and numbering in accordance to Annex 1 of the Subsidy Ordinance. E.g. if sub-result 3 of result 2 is completed, please specify so with reference to ‘R2.3’.
Submit the correspondingMeans of Verification (MoV's) for the sub-result(s). Number the MoV’s as defined in Annex 1 of the Subsidy Ordinance. E.g. 2.3.1

-Is result 2 completed? Yes No.
All MoV’s have been provided together with this, or earlier progress reports.

Progress achieved under Result 3

-Are activities for result 3 carried out in the reporting period? Yes No
If yes, please describe the specific activities carried out.

-Are sub results of result 2 completed? Yes No
If yes, please specify the sub-results, with reference and numbering in accordance to Annex 1 of the Subsidy Ordinance. E.g. if sub-result 3 of result 3 is completed, please specify so with reference to ‘R3.3’.
Submit the corresponding Means of Verification (MoV's) for the sub-result(s). Number the MoV’s as defined in Annex 1 of the Subsidy Ordinance. E.g. R3.3.1

-Is result 3 completed? Yes No.
All MoV’s have been provided together with this, or earlier progress reports.

Progress achieved under Result 4

-Are activities for result 4 carried out in the reporting period? Yes No
If yes, please describe the specific activities carried out.

-Are sub results of result 4 completed? Yes No
If yes, please specify the sub-results, with reference and numbering in accordance to Annex 1 of the Subsidy Ordinance. E.g. if sub-result 3 of result 4 is completed, please specify so with reference to ‘R4.3’.
Submit the corresponding Means of Verification (MoV's) for the sub-result(s). Number the MoV’s as defined in Annex 1 of the Subsidy Ordinance. E.g. R4.3.1

-Is result 4 completed? Yes No.
All MoV’s have been provided together with this, or earlier progress reports.

Progress achieved under Result 5

-Are activities for result 5 carried out in the reporting period? Yes No
If yes, please describe the specific activities carried out.

-Are sub results of result 5 completed? Yes No
If yes, please specify the sub-results, with reference and numbering in accordance to Annex 1 of the Subsidy Ordinance. E.g. if sub-result 3 of result 5 is completed, please specify so with reference to ‘R5.4’.
Submit the corresponding Means of Verification (MoV's) for the sub-result(s). Number the MoV’s as defined in Annex 1 of the Subsidy Ordinance. E.g. R5.3.1