EUROPEAN COMMISSIONDIRECTORATE-GENERALHUMANITARIAN AID AND CIVIL PROTECTION

GRANT APPLICATION FORMS

2016 CALL FOR PROPOSALS

FOR UNION CIVIL PROTECTION MECHANISM

EXERCISES

FORMS A and TNOTE:

Financial Forms are in a separate file.

FORMS A:Summary and Administrative

Information

Form A1

EUROPEAN COMMISSIONDG ECHO

FOR COMMISSION USE ONLY

Proposal n°

PROJECT

Project title (max. 60 characters):

……………………………………………………………………………………….............................................

..............................................................................................................

Project acronym (max. 25 characters):

………………………………………………………………………………..

The project will be implemented in the following country(ies):

………………………………………………………………………………………………….

………………………………………………………………………………………………………………………

………….

Starting date: ...................... Ending date: .......................... Duration in months (max 24): ……………

COORDINATING BENEFICIARY AND ASSOCIATED BENEFICIARIES

Name of the coordinating beneficiary (CB): Insert the same name as in A4. ...............................................................................................................

Name of the associated beneficiary (AB1): Insert the same name as in A5.…………………………

Name of the associated beneficiary (AB2): Insert the same name as in A5.………………………….

Name of the associated beneficiary (AB3): Insert the same name as in A5.………………………….

(Continue as necessary)

PROJECT BUDGET AND REQUESTED EC FUNDING

Please indicate, in line with WP 2016, if the exercise project is under the external budget line or the internal budget line.

Internal budget item External budget item

Total project eligible cost: ……………. EUR

EC financial contribution requested: ……………. EUR ( = …….. % of total eligible costs)

Form A2

V. DECLARATION OF HONOUR BY THE APPLICANT

The undersigned [insert name of the signatory of this form]: in [his][her] own name [for a natural person]

or representing the following legal person: [only if the applicant is a legal person]full official name:official legal form:full official address:VAT registration number:

authorised to represent the consortium, hereby requests from the Commission a grant of EUR …….. with a view to implementing the exercise project on the terms laid down in this application.

I certify that the information contained in this application is correct and complete and that none of the applicants has received any other Union funding to carry out the exercise project that is the subject of this grant application.

I certify that the applicants are not in one of the situations which would exclude them from receiving Union grants and accordingly

declare that none of the applicants:

a) is bankrupt or being wound up, is having its affairs administered by the courts, has entered into an arrangement with creditors, has suspended business activities, is the subject of proceedings concerning those matters, or is in any analogous situation arising from a similar procedure provided for in national legislation or regulations;

b) has been convicted of an offence concerning professional conduct by a judgment of a competent authority of a Member State which has the force of res judicata;

c) has been guilty of grave professional misconduct proven by any means which the [Commission] [agency] can justify including by decisions of the European Investment Bank and international organisations;

d) is not in compliance with all its obligations relating to the payment of social security contributions and the payment of taxes in accordance with the legal provisions of the country in which it is established, with those of the country of the authorising officer responsible and those of the country where the [project] [work programme] is to be implemented;

e) has been the subject of a judgement which has the force of res judicata for fraud, corruption, involvement in a criminal organisation, money laundering or any other illegal activity, where such activity is detrimental to the Union's financial interests;

f) is subject to an administrative penalty.

[[Only for legal persons other than Member States and local authorities, otherwise delete] declare that the natural persons with power of representation, decision-making or control1

1 This covers the company directors, members of the management or supervisory bodies, and cases where one natural person holds a majority of shares.

over one of the applicants that are legal entities are not in the situations referred to in b) and e) above; ]

declares that the above mentioned legal person and the applicants:

g) have no conflict of interests in connection with the grant; a conflict of interests could arise in particular as a result of economic interests, political or national affinity, family, emotional life or any other shared interest;

h) will inform the Commission, without delay, of any situation considered a conflict of interests or which could give rise to a conflict of interests;

i) have not granted and will not grant, have not sought and will not seek, have not attempted and will not attempt to obtain, and have not accepted and will not accept any advantage, financial or in kind, to or from any party whatsoever, where such advantage constitutes an illegal practice or involves corruption, either directly or indirectly, inasmuch as it is an incentive or reward relating to the award of the grant;

j) provided accurate, sincere and complete information within the context of this grant award procedure.

In case of award of grant, if applicable, the following evidence shall be provided upon request and within the time limit set by the Commission2: For situations described in (a), (b) and (e), production of a recent extract from the judicial

record is required or, failing that, a recent equivalent document issued by a judicial or administrative authority in the country of origin or provenance showing that those requirements are satisfied. Where the applicant is a legal person and the national legislation of the country in which the applicant is established does not allow the provision of such documents for legal persons, the documents should be provided for natural persons, such as the company directors or any person with powers of representation, decision making or control in relation to the applicant .

For the situation described in point (d) above, recent certificates or letters issued by the competent authorities of the State concerned are required. These documents must provide evidence covering all taxes and social security contributions for which the applicant is liable, including for example, VAT, income tax (natural persons only), company tax (legal persons only) and social security contributions.For any of the situations (a), (b), (d) or (e), where any document described in the two paragraphs above is not issued in the country concerned, it may be replaced by a sworn or, failing that, a solemn statement made by the interested party before a judicial or administrative authority, a notary or a qualified professional body in his country of origin or provenance.If the applicant is a legal person, information on the natural persons with power of representation, decision making or control over the legal person shall be provided only upon request by the Commission.

I declare that the applicants are fully eligible in accordance with the criteria set out in the specific call for proposals.

I certify that the applicants have the financial and operational capacity to carry out the proposed exercise proposal.

I acknowledge that according to Article 131 of the Financial Regulation of 25 October 2012 on the financial rules applicable to the general budget of the Union (Official Journal L 298 of 26.10.2012, p. 1) and Article 145 of its Rules of Application (Official Journal L 362, 31.12.2012, p.1) applicants found guilty of misrepresentation may be subject to administrative and financial penalties under certain conditions.

If selected to be awarded a grant, the applicants accept the general conditions as laid down in

2 In accordance with art.197 RAP, the RAO may, depending on a risk assessment, request that successful applicants provide the evidence of their complying with the exclusion criteria.

the grant [agreement] [decision publicly available].

Last name, first name:

Title or position in the consortium:

Signature [and official stamp] of the applicant:

Date:

Your reply to the grant application will involve the recording and processing of personal data (such as your name, address and CV), which will be processed pursuant to Regulation (EC) No 45/2001 on the protection of individuals with regard to the processing of personal data by the Community institutions and bodies and on the free movement of such data. Unless indicated otherwise, your replies to the questions in this form and any personal data requested are required to assess your grant application in accordance with the specifications of the call for proposals and will be processed solely for that purpose by the Commission. Details concerning the processing of your personal data are available on the privacy statement at the page: http://ec.europa.eu/dataprotectionofficer/privacystatement_publicprocurement_en.pdf.

Your personal data may be registered in the Early Warning System (EWS) only or both in the EWS and Central Exclusion Database (CED) by the Accounting Officer of the Commission, should you be in one of the situations mentioned in:- the Commission Decision 2008/969 of 16.12.2008 on the Early Warning System (for more information

see the Privacy Statement on http://ec.europa.eu/budget/contracts_grants/info_contracts/legal_entities/legal_entities_en.cfm), or

- the Commission Regulation 2008/1302 of 17.12.2008 on the Central Exclusion Database (for more information see the Privacy Statement onhttp://ec.europa.eu/budget/explained/management/protecting/protect_en.cfm#BDCE )

Form A3

PARTNERSHIP STATEMENT (To be signed by the Coordinating Beneficiary and each Associated Beneficiary)

A partnership is a relationship, involving shared responsibilities, between two or more entities for the purpose of implementing an Action funded by the European Union, represented by the European Commission. To ensure that the Project runs smoothly, the Commission thus requires the below outlined good partnership principles to be acknowledged and upheld.

I, [LAST NAME, Name of the signatory of the statement], on behalf of

[Full official name of the entity]

[Official legal form of the entity]

[Full official address of the entity]

[VAT registration number of the entity]declare to have read and approved the content of the proposal entitled [ insert title of the proposal] submitted for funding to the Commission and I undertake to comply with the following principles of good partnership:

1. The Coordinating Beneficiary and the Associated Beneficiaries have read the Guide for Applicants and the Grant Application Forms and understand the purposes and expected results of the Call for proposals. Furthermore, the Coordinating Beneficiary and the Associated Beneficiaries understand their role in the Project before the submission of the application to the European Commission. They commit to comply with the relevant eligibility criteria, as defined in the Call for proposals.

2. The Coordinating Beneficiary and the Associated Beneficiaries have read the applicable Grant Agreement and understand their respective obligations under the Grant Agreement. The Associated Beneficiaries authorise the Coordinating Beneficiary to sign the Grant Agreement with the Commission on their behalf and to represent them in all dealings with the Commission in the context of the implementation of the Project.

3. The Coordinating Beneficiary consults other Associated Beneficiaries regularly concerning the different aspects of the implementation of the Project and keeps them fully informed.

4. The beneficiaries receive copies of reports - narrative and financial – prepared for and submitted to the Commission.

5. Any requests for amendments to the agreement (e.g. changes to the activities presented in Annex I to the Agreement, beneficiaries etc.) are agreed by the Coordinating Beneficiary and Associated Beneficiaries prior to submission to the Commission. Where no such agreement can be reached and the request is nonetheless submitted to the Commission the absence of agreement is to be mentioned in the request.

Name

Position

Date and place

Signature

Form A4 COORDINATING BENEFICIARY PROFILE

Coordinating beneficiary Profile InformationShort Name Participant ref. COLegal information on the Coordinating beneficiaryLegal Name Legal StatusVAT No Public

PrivateNatural person

Legal Registration NoRegistration Date

International organisation

Legal address of the CoordinatorStreet Name and No PO BoxPost Code Town/City

Country Code Country NameCoordinator contact person information (only if different to above)Title Function

Surname First NameDepartment / Service NameStreet Name and No PO BoxPost Code Town/CityCountryTelephone No Fax NoE-mail WebsiteCoordinator detailsNumber of employeesNumber of employees in department conducting projectIs the entity independent (Yes or No)If No, please indicate legal name(s) of owner(s) who own 25 % or moreBrief description of the structure and the activities of the Coordinating beneficiary

Form A5ASSOCIATED BENEFICIARY PROFILE (Complete for each Associated Beneficiary)

Beneficiary Profile InformationShort Name Participant ref. AB…Legal information on the BeneficiaryLegal Name Legal StatusVAT No Public

PrivateNatural person

Legal Registration NoRegistration Date

International organisation

Legal address of the BeneficiaryStreet Name and No PO BoxPost Code Town/City

Country Code Country NameBeneficiary contact person information (only if different to above)Title Function

Surname First NameDepartment / Service NameStreet Name and No PO BoxPost Code Town/CityCountryTelephone No Fax NoE-mail WebsiteBeneficiary details

Annual turnover Last Financial YearNumber of employeesNumber of employees in department conducting projectIs Your Organisation independent (Yes or No)If No, please indicate legal name(s) of owner(s) who own 25 % or moreBrief description of the structure and the activities of the Beneficiary

Form A6

CO-FINANCIER PROFILE AND COMMITMENT (Complete for each co-financier)

Legal Name and full address on the co-financier

Financial commitment

We will contribute the following amount to the project: ….. EUR

Status of the financial commitment

Stamp and signature of the authorised person

Name and status of the authorised person (obligatory):

Date of the signature(obligatory):

Signature (obligatory):

Form A7

OTHER PROPOSALS SUBMITTED FOR EUROPEAN UNION FUNDING

Please answer each of the following questions:

Have you (the coordinating beneficiary) or any of the associated beneficiaries already benefited from previous co-financing under any EU civil protection financial instruments or programmes? (Title, year, amount of the co-financing and duration)

Have you or any of the associated beneficiaries already benefited from previous European Union financing (grants, procurements or loans) for activities that may relate to the present proposal (e.g. an RTD project preceding the present proposal)? (title, year, amount of financing and duration)

Have you or any of the associated beneficiaries applied for European Union funding under any other financial instruments for actions which form part of or are directly related to this proposal? With what results? Please give full details!

Form A8

INVOLVEMENT OF THE COMPETENT NATIONAL CIVIL PROTECTION AUTHORITY/MARINE POLLUTION AUTHORITY

(for all beneficiaries and (the countries participating in the exercise) by deploying intervention resources on the field)

Name: [name of the competent national civil protection authority/marine pollution authority][name of the department within the competent national civil protection authority/marine pollution authority]

Contact person: [name of the contact person in the competent national civil protection authority/marine pollution authority][position/rank in the competent national civil protection authority/marine pollution authority]

Full address: [street/P.O. Box][town][country][phone][Fax][E-mail]

Confirms that it has been informed about the following project proposal and its content:

[Project title:]

Lead by: [name of Coordinator’s organisation]

And declares that the competent national civil protection authority/marine pollution authority (please circle the answer that applies):

1) Supports the application of the above mentioned project YES / NO

2) Confirms it is consistent with national policies, plans and procedures YES / NO

3) Will participate in the project (please circle all that apply)

a) as coordinating beneficiary YES / NO

b) as associated beneficiary YES / NO

4) Will participate as exercise player as required by the legal basis governing the national participation in the Community Civil Protection Mechanism (i.e. ensuring at minimum the participation of the declared 24/7 national operational contact point, etc) YES / NO

Person entitled to enter into commitments on behalf of the competent national civil protection authority/marine pollution authority

Name:

Status/title:

Signature

Date

Place

Form A9

Template of Legal Entities Form

The Legal Entity form specifically adapted to the legal status of the Beneficiaries (public entity or private company) as well as to the country/ language is available on

http://ec.europa.eu/budget/contracts_grants/ info_contracts/legal_entities/legal_entities_en.cfm

ATTENTION/ The document below is only an example. Please use the appropriate document available from the above link.

Form A10

Template of Financial Identification Form

The financial identification form specifically adapted to the country/ language of the bank account is available onhttp://ec.europa.eu/budget/contracts_grants/info_contracts/financial_id/financial_id_en.cfm

Form A11

EUROPEAN COMMISSIONDIRECTORATE-GENERAL HUMANITARIAN AID AND CIVIL PROTECTION - ECHO

ECHO B – Humanitarian and Civil Protection OperationsB/1 – Emergency Response

Brussels, DG ECHO, Unit B1

Name of Coordinating beneficiary:

Contact person1:

Postal Address:

E-mail1:

ACKNOWLEDGEMENT OF RECEIPT

Title of the project1: ........Correspondence No. of the project:

Sir, Madam

I acknowledge receipt of your proposal for which I thank you.

Your proposal will be examined by our services, with respect to its eligibility. Those projects declared eligible will then undergo an evaluation procedure by the Commission.

I will let you know the final decision, as soon as it has been taken.

Yours faithfully,

Signature ECHO: .......................................................Form A12

1

1 1 To be completed by the Coordinator1

VAT DECLARATION APPLICABLE TO PUBLIC ENTITIES ESTABLISHED WITHIN THE EUROPEAN UNION

(If they are public entities established within the EU, both the Coordinating Beneficiary and the Associated Beneficiaries need to complete this form.)

The undersigned [LAST NAME, Name of the signatory of the declaration], on behalf of[Full official name of the entity][Official legal form of the entity][Full official address of the entity][VAT registration number of the entity]

declare that

the activities3 implemented in the frame of this project by this public law body are activities or transactions that the public law body carries out as a public authority under national law (VAT is not eligible4), or

the activities implemented in the frame of this project by this public law body are not activities or transactions that the public law body carries out as a public authority under national law (VAT is eligible)., or

some of the activities implemented in the frame of this project by this public law body are activities or transactions that the public law body carries out as a public authority under national law (VAT is not eligible) and some of the activities implemented in the frame of this project by this public law body are not activities or transactions that the public law body carries out as a public authority under national law (VAT is eligible).5

Please note that your answer shall be based on national legislation. You may be asked to substantiate your answer by providing an extract from the relevant national legislation at liquidation stage.

Name:Status/Title:

Signature

Date

Place

Form A13

3 The term 'activities' is to be understood at the level of tasks of the project which will be considered in the light of the objective(s) of the project.4 VAT paid in relation to activities falling within the public mandate of the public law body may be eligible, if the activities are exempt activities listed in Article 13(2) of the Council Directive 2006/112/EC of 28 November 2006 on the common system of value added tax (OJ L 347/1, 11.12.2006). In such a case, please submit a separate statement together with this form, listing such activities.5 Please attach to this form a list of activities which you implement as a public authority (VAT is not

eligible).

FOR INTERNATIONAL ORGANISATIONS ONLY (IOs) – SPECIAL PROVISIONS6

Legal Name

Please mark with an X the appropriate answer:

1.Does the IO accept the provisions of the General Conditions regarding settlement

of disputes7?Yes……

No…..

1.1.If you have answered NO to question 1,

please select one dispute settlement procedure8 which the IO accepts:

Permanent Court of Arbitration

……

Arbitration committee

……..

2.Does the IO accept that the Certificates

on the financial statements9 are established by an external auditor?

Yes……

No…..

3.Does the IO accept the provisions of the

General Conditions regarding checks, audits and evaluations10?

Yes……

No…..

3.1 If you have answered NO to question 3, please indicate whether there has been a

framework agreement signed between the IO and the Commission containing a verification

annex?

Yes……

No…..

4. Does the IO accept the provisions of the General Conditions regarding applicable

law11?

Yes……

No…..

4.1 If you have answered NO to question 4, does the IO accept Union Law as applicable law?

Yes……

No…..

4.1.1If you have answered YES to question 4.1,

does the IO accept Belgian law as subsidiary applicable law?

Yes……

No…..

If you have answered NO, which law do you accept as subsidiary law (insert law of a

Member State or an EFTA country)? ………………………………….

Stamp and signature of the authorised person

Name and status of the authorised person (obligatory):

Date of the signature(obligatory):

Signature(obligatory):

6 This form is to be filled in by beneficiaries which are IOs.7 Article II.18 of the General Conditions (Annex II of the Grant Agreement Template).8 The dispute settlement procedures (Permanent Court of Arbitration and Arbitration Committee) are described in the specific clauses applicable to IOs in

the Special Conditions of the Grant Agreement Template.9 Articles I.4.3 and I.4.4 of the Special Conditions of the Grant Agreement Template.10 Article II.27 of the General Conditions (Annex II of the Grant Agreement Template).11 Article II.18 of the General Conditions (Annex II of the Grant Agreement Template).

SECTION T:

Objective, actions and expected

resultsProject planning

and structure

Form T1

SUMMARY OF THE PROJECT (Maximum 5-6 pages)

The issues covered in all of the boxes must be explained concisely. Please make sure to use the correct box (Example: Objectives should be described under objectives and not under expected results and vice versa.).

Background

Scenario

Objectives

Expected results

Actions and means involved

Methodology (exercise control, distaff, planning group etc.)

Evaluation and dissemination

Subcontracting12

12 Please provide a list of all the tasks that will be subcontracted, including the information on the relevant provider and procedure. Having regard to the nature of the action and what is necessary for its implementation, explain the added-value of the subcontracting (information to be in line with the information provided in form F5).

Form T2

Project AcronymTask ID Task Title Start Date End Date Activity Deliverables

(Maximum number of tasks – 10)

Form T3a

Project Acronym T3a - Task Form

Task ID Task Title

Objectives

DESCRIPTION

Activity A.1Name of the activity:Description (what, how and where):Expected results:Constraints and assumptions:Responsible for implementing it:Action will be subcontracted: Yes/No/Partially

Activity A.2Name of the activity:Description (what, how and where):Expected results:Constraints and assumptions:Responsible for implementing it:Action will be subcontracted: Yes/No/Partially

Etc.

Form T3b

Project AcronymT3b- Task Form Page 1 of

maximum 10 (1 task per page)

Task ID Task Title

Start Date End Date Duration

Deliverable Date Deliverable Description

Form T4

CONTINUATION

Continuation after the project ends:

What still needs to be done (which actions will have to be continued or maintained)

How will this be achieved, which resources will be necessary to continue the actions?

How will the equipment acquired be used?

Which personnel will continue to work on the project?