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USAID Advancing Kosovo Together Program

Annual Program Statement (APS) No.1


Issuance Date: September 24, 2014
Dear Applicant:
The USAID Advancing Kosovo Together (AKT) program is seeking grant applications 1 from qualified
locally registered Kosovo non-government organizations 2 to implement activities that support increased
interaction between Kosovo Serbians and Kosovo Albanians to help further Kosovos social, economic,
and political development in 16 targeted municipalities3.
The program seeks to address limited interaction between Kosovos communities which reduces the
potential for strong municipal development that meets the needs of all citizens, provides greater markets
for Kosovo non-majority businesses, promotes job creation, and encourages citizen engagement
municipal administrations to provide quality municipal services to all its citizens. Kosovos NGOs can
help accelerate the achievement of the programs four objectives through demand-driven, communitybased activities that best help foster positive and constructive inter-ethnic communication and can reach a
broad range of people who have never engaged with the other, centered on common problems, needs, and
solutions. Applications from local organizations can include a broad range of activities, from grassroots
community exchanges, events that help better integrate non-majority and majority markets, to advocacy
efforts to improve the responsiveness of local administrations to service non-majority communities.
An APS Briefing Session will be held on October 6, 2014 at the Advancing Kosovo Together office
located at Nazim Gafurri 34, 10000 Pristina, Kosovo from 10:00 to 12:00 and on October 7, 2014 at the
Advancing Kosovo Together RCRC office located at Cika Jovina No.13, North Mitrovica, Kosovo from
10:00 to 12:00. These workshops will allow eligible and interested applicants the chance to ask questions
about the APS and receive guidance on how to complete the application form. Interested applicants that
meet the eligibility requirements defined in Section III below and would like to attend this workshop must
confirm their attendance by sending the participants name and the organizations name to:
grants@usaidakt.org. Only one person may attend from each organization. The USAID/AKT program
will not cover any costs related to participation in this meeting.
Grants under this annual program statement will be awarded and implemented in accordance with USAID
and US Government regulations governing grants under contracts and Advancing Kosovo Togethers
internal grant management policies.
Program and Chemonics International Inc. employees may not ask for, and applicants are prohibited from
offering, any money, fee, commission, credit, gift, gratuity, thing of value, or compensation to obtain or
reward improper favorable treatment regarding this solicitation. Any improper request from a program
employee should be reported to the chief of party or BusinessConduct@chemonics.com.
The following Annexes are included with this APS:

1 It is estimated that awards as a result of this solicitation will range in value from approximately EUR 3,000
to EUR 15,000 for less than a year period.

2.For the purposes of this APS, the term CSO includes non-governmental organizations (NGOs), educational institutions, private
businesses, professional associations, and other community based organizations

3 The 16 partner municipalities include Graanica/Graanic, Klokot/Kllokot, Novo Brdo/Novobrd, Parte/Partesh,


Ranilug/Ranillug, trpce/Shtrpc; Gjilan/Gnjilane, Istog/Istok, Klin/Klina/, Obiliq/Obili/, Pej/Pe, Vushtrri/Vuitrn/, North
Mitrovica/Mitrovica e Veriut, Leposavi/Leposaviq, Zubin Potok/Zubin Potok, and Zvean/Zvean.

- Annex A Grant Application Form


- Annex B Grant Application Budget Form
- Annex C Implementation Timeline
- Annex D Applicant Self-Assessment Form
- Annex E Required Certifications
-Annex F -- Survey on Ensuring Equal Opportunity
SECTION I. PROGRAM DESCRIPTION
IA. BACKGROUND AND PROGRAM OBJECTIVE
Advancing Kosovo Together is a three-year program financed by USAID and implemented by Chemonics
International. The goal of the program is to is to foster positive and constructive inter-ethnic cooperation
between the Kosovo Serb non-majority and Kosovo Albanian majority communities in addressing
common problems of unemployment, social needs, and municipal services in 16 targeted municipalities
throughout Kosovo
As a result of this solicitation, Advancing Kosovo Together will award grants to: Kosovo Civil Society
Organisations (CSOs) for a variety of creative activities that support the following programmatic
objectives.
1
2
3
4

Improve autonomous, horizontal communications between: (a) Kosovo Albanian and nonmajority communities; and (b) the Government of Kosovo and non-majority communities;
Improve economic opportunities in target municipalities; and
Increase the efficiency and capacity of targeted municipal administrations to respond to the
needs of all the citizens.
Build capacity of host-country organizations to leverage cross-ethnic leadership to achieve
program objectives and implement USAID Kosovo funded activities

For the purpose of this APS, the term CSO includes non-governmental organizations (NGOs), educational institutions, private
businesses, professional associations, and other community based organizations.

IC.

APS PROGRAM DESCRIPTION

The focus on the grants activity is to help support AKT four program objectives as defined in Section 1A.
Youth initiatives, activities targeted at women and children, media initiatives, such as theatre, reality TV,
comedy TV, art and film will be highly encouraged. Business training activities, activities targeted at
employability of women and youth, access to finance initiatives, income generation activities for
returnees and activities that increase income and sales for SMEs.Citizen initiatives targeted at
strengthening municipal transparency , such as monitoring of municipal plans, budgeting and own source
revenue collection.
The grants should support activities and programs that help achieve the programs results, for example:

Raising awareness of legislation related to non-majority communities, e.g. the Law on


Languages, Law on the Protection and Rights of Communities, and laws on minority and women
employment in the public sector
Promoting inter-ethnic understanding and increased participation through arts programs, media,
theatre, or other inter-personal communication mechanisms;
Creating economic opportunities for non-majority youth and women;
Expanding business development and access to finance opportunities for non-majority businesses,
youth entrepreneurship, women-owned enterprises, and livelihood development for returnees;
Improvement of collaboration of business associations in partner municipalities;
Business activities that support job skills training for non-majority women and youth
Increase management and financial capacity to women producers and/or women associations
Activities that promote transparency and community engagement in municipal level
Activities that strengthens communication between municipality and citizens in obtaining
input from citizens in the municipal decision making process.
Activities that promote monitoring mechanics for assembly meetings, municipal plans,
municipal budgeting and own source revenue collection.
Promote formation of citizen groups to participate in monitoring and observation of projects
during and after their completion, in particular projects of municipal public service delivery
Activities that promote good governance practices and tools at the municipal level of
governance.
Activities that promote and strengthen information-sharing among Kosovo Serb and Kosovo
Albanian CSOs through forums and networking.

All grants must have a period of performance within the Advancing Kosovo Together APS program
period (September 2014 September 2015) and should be for a duration of no more than 12 months.
Advancing Kosovo Together recognizes that some grantees may need technical assistance to more
effectively carry out the activity. Consequently, applicants are encouraged to specify their needs for
technical assistance and/or training in their application.
ID.
AUTHORITY/GOVERNING REGULATIONS
Advancing Kosovo Together grant awards are made under the authority of the U.S. Foreign Affairs Act
and USAIDs Automated Directive System (ADS) 302.3.5.6, Grants Under Contracts. Awards made to
non-U.S. organizations will adhere to guidance provided under ADS Chapter 303, Grants and
Cooperative Agreements to Non-Governmental Organizations and will be within the terms of the

USAID Standard Provisions for Non-U.S. Non-Governmental Recipients, as well as the Advancing
Kosovo Together grants procedures.
ADS 303 references three additional regulatory documents issued by the U.S. Governments Office of
Management and Budget (OMB) and the U.S. Agency for International Development:
- 22 CFR 226: Administration of Assistance Awards to U.S. Non-Governmental Organizations
- OMB Circular A-122: Cost Principles for Nonprofit Organizations
- OMB Circular A-133: Audits of States, Local Governments, and Nonprofit Organizations
Full text of the OMB circulars can be found at http://www.whitehouse.gov/omb/circulars/. Advancing
Kosovo Together is required to ensure that all organizations receiving USAID grant funds comply with
the guidance found in these circulars, as applicable to the respective terms and conditions of their grant
awards.
Under the Advancing Kosovo Together grant program, USAID retains the right at all times to terminate,
in whole or in part, Advancing Kosovo Together grant-making authorities.
SECTION II. AWARD INFORMATION
Advancing Kosovo Together anticipates awarding up to 455,000 EURO through approximately 20 to 25
grant awards. Each grant award is expected to range from between 3,000 to 15,000 EURO however will
be negotiated based on the scope of the activity proposed by the grantee. The duration of any grant award
under this solicitation is expected to be no more than 12 months. The type of grant to be awarded will be
determined during the negotiation process.
SECTION III. ELIGIBILITY
IIIA.

ELIGIBLE RECIPIENTS

Applicants must be a registered CSO in Kosovo, all CSOs should be formally constituted,
recognized by and in good standing with appropriate Kosovo authorities, have its principle place
of business in the recipient country, be majority owned by individuals who are citizens or lawful
permanent residents of Kosovo, and compliant with all applicable civil and fiscal regulations.

Applicants must be able to demonstrate successful past performance in implementation of


integrated development programs related to Advancing Kosovo Together priority areas as
described in Section 1A..

Applicants must have established outreach capabilities with linkages to the beneficiary group(s)
identified in the program description. This should be reflected by the incorporation of the
beneficiary perspective in the application.

Applicants must display sound management in the form of financial, administrative, and technical
policies and procedures and present a system of internal controls that safeguard assets; protect
against fraud, waste, and abuse; and support the achievement of program goals and objectives.
Advancing Kosovo Together will assess this capability prior to awarding a grant

Applicants must sign the following required certifications prior to receiving a grant. The certifications are
attached to this solicitation (Annex E) and Advancing Kosovo Together grants and procurement staff will
review them with applicants.

Certification Regarding Terrorist Financing (Required for all grants)


Certification Of Recipient (Required for all grants)

Grantees will provide Chemonics with its Duns and Bradstreet Number (DUNS) prior to grant
execution or immediately following execution, and confirm their registration with the System for
Award Management (SAM). In cases where the grantee does not have a DUNS, Advancing
Kosovo Together may help the grantee to obtain one
Annex F includes a Survey on Ensuring Equal Opportunity. Applicants may voluntarily complete and
submit the survey electronically. Absence of a completed survey in an application is not be a basis upon
which the application is determined incomplete or non-responsive./
The program will work with the successful grantee to draft a marking and branding plan which will be
annexed to the grant agreement.
Advancing Kosovo Together encourages applications from new organizations who meet the above
eligibility criteria.
SECTION IV. APPLICATION AND SUBMISSION INFORMATION
IVA.

INSTRUCTIONS TO APPLICANTS

Applicants must propose strategies for the implementation of the program description described above,
introducing innovations that are appropriate to their organizational strengths.
IVB.

GRANT APPLICATION

Instructions and a template to be utilized when developing the full application are provided in Annex A-B.
Applicants shall present their technical application and budget in the formats provided and shall follow
the instructions and guidelines listed in these annexes.
All grant activity costs must be within the normal operating practices of the Applicant and in accordance
with its written policies and procedures. For applicants without an audited indirect cost rate, the budget
may include direct costs that will be incurred by the Applicant to provide identifiable administrative and
management costs that can be directly attributable to supporting the grant objective.

The application must be signed by an authorized agent of the Applicant.

Applicants that submit full applications that meet or exceed the evaluation criteria will be notified of next
steps in the application process. Applications will be reviewed on a rolling basis.

IVC.

APPLICANT SELF-ASSESSMENT

All organizations selected for award are subject to a pre-award responsibility determination conducted by
Advancing Kosovo Together, to ascertain whether the organization has the minimum management
capabilities required to handle US government funds. The applicant self-assessment is the first step in the
pre-award responsibility determination process. The Applicant Self-Assessment Form is contained in
Annex D. The applicant must include this self-assessment with their submission.
IVD. INELIGIBLE EXPENSES
Advancing Kosovo Together grant funds may not be utilized for the following:

IVE.

Private ceremonies, parties, celebrations, or "representation" expenses


Purchases of restricted goods, such as certain agricultural commodities, motor vehicles
(including motorcycles), pharmaceuticals and contraceptive items, pesticides, used
equipment, U.S. Government excess property and fertilizers, without the previous approval
by the CO through Advancing Kosovo Together. If procurement of these restricted goods is
necessary, Chemonics may decide to procure items directly and provide them in-kind to the
grantee after receiving approval from the CO.
Prohibited goods under USAID regulations, including but not limited to: military and
surveillance equipment, police or law enforcement equipment, abortion equipment and
services, weather modification equipment, luxury goods, and gambling equipment.
Purchases of goods or services restricted or prohibited under the prevailing USAID source/
nationality regulations per 22 CFR 228 and relevant Standard Provisions; or from countries
or suppliers as may be identified by USAID's consolidated list of debarred, suspended, or
ineligible grantees at www.sam.gov.
Any purchases or activities deemed unnecessary to accomplish grant purposes as
determined by Chemonics, including any grantee headquarters expenses that are not
directly linked to the implementation of the proposed project
Previous obligations and/or bad debts.
Fines and/or penalties.
Creation of endowments.
Other costs unallowable under USAID and/or federal regulations, such as alcoholic
beverages. Refer to OMB 122 Cost principles for Non-profit organizations and FAR.
Indirect costs such as but not limited to overhead or indirect fringe (unless the applicant
has documented proof of such rates through audits or U.S. Government-issued NICRA). Indirect
costs are never allowed under simplified grants.

SUBMISSION INFORMATION

Applications shall be submitted in English and may not be more than 12 pages.
Applications (Technical and budget proposals and supporting documentation) should be submitted in
sealed hard copy to the Advancing Kosovo Together offices at the address below and should reference

APS No.1. Applications will be accepted no later than 16:00 local time beginning on October 24 , 2014,
and on the last day of the month thereafter until March 30, 2015. Late or unresponsive applications will
not be considered.
Advancing Kosovo Together
Nazim Gafurri 34, 10000
Pristina, Kosovo
Grants@usaidakt.org
In addition to the application forms, applicants should submit the following to Advancing Kosovo
Together:
- Grants Application
- Grant Budget Form
- Implementation Timeline
- Signed and dated Required Certifications listed under section III.A
- Applicant Self-Assessment form
- A copy of the Applicants valid legal registration,
- A copy of their latest audited financial statements.
- A copy of Tax Verification Certificate. The certificate can be obtained electronically at
http://evertetimi.atk-ks.org

Please submit all questions concerning this solicitation to the attention of Hekuran Dajaku, Grants and
Procurement Manager, via email to: grants@usaidakt.org. Advancing Kosovo Together will assist
applicants in understanding the application process, and can provide coaching in application development
at the request of applicants.

This Annual Program Statement for application submission is valid through March 30,
2015. Applicants may submit their applications within this timeframe for funding through
September 30, 2015, and applications will be reviewed on a rolling basis. Applicants will
be notified in writing for the status of their application within 2 weeks from the day of
submission.

SECTION V. APPLICATION EVALUATION CRITERIA


Grant Applications will be evaluated according to the degree by which the Applicants proposed
grant-funded program satisfies program principles of design and approach, impact on target
groups and beneficiaries, sustainability and results orientation. All applications will be evaluated against
the evaluation criteria in the table below.
Evaluation Category

Design and Approach


Impact on Target Group
Management Capacity
Sustainability
Cost Efficiency

Rating (Points)

25
25
15
15
10

Past Performance
Overall Rating (out of 100 points)

10
100

These evaluation criteria elements are described more fully below.


Design and Approach. The quality and feasibility of the application, in terms of the appropriateness of
the proposed methodology, innovativeness, and the work plan for achieving grant objectives that are
consistent with helping achieve the goals of the Advancing Kosovo Together Program. Proposed
mechanisms for monitoring and evaluation with objectively measurable indicators will also be appraised
(25 points).
Impact on Target Group. The extent to which the proposed activity corresponds to the needs of the
target group and will directly benefit that group. This includes the participation of and benefit to women,
youth,returnees, and vulnerable groups. Also, the degree to which it will directly or indirectly stimulate
other organizations and resources to develop or implement activities supporting the objectives of the
program (25 points).
Management Capacity. Evidence of management capability to undertake and accomplish the proposed
activities. Appraisal will be based principally on logic of its management approach, the skills,
qualifications of its proposed personnel, and clarity of its staffing plan (15 points).
Sustainability. The extent to which the funded activity will stimulate other organizations and resources to
develop or implement activities supporting the objectives of the program during and after its closure, and
how much it will result in building and strengthening the capacity of the community and local
organizations (15 points).
Cost Efficiency. The degree to which budgeting is clear, reasonable, and realistic, thus reflecting best use
of organizational and grant resources. The local contribution reflects commitment to the project by the
targeted beneficiaries and local institutions. (10 points)
Past Performance. All applicants will be subject to a past performance review, with emphasis on prior
projects, if any, which are similar to that which is proposed. Organizations without prior experience will
receive a neutral rating in this category (10 points)

SECTION VI. AWARD AND ADMINISTRATION INFORMATION


All grants will be negotiated, denominated and funded in EUR currency.
All costs funded by the grant must be allowable, allocable and reasonable. Grant applications must be
supported by a detailed and realistic budget as described in Section IV.

Issuance of this APS and assistance with application development do not constitute an award or
commitment on the part of Advancing Kosovo Together, nor does it commit Advancing Kosovo Together
to pay for costs incurred in the preparation and submission of an application. Further, Advancing Kosovo
Together reserves the right to accept or reject any or all applications received. Applicants will be informed
in writing of the decision made regarding their application.
LIST OF ANNEXES

- Annex A Grant Application Form


- Annex B Grant Application Budget Form
- Annex C Implementation Timeline
- Annex D Applicant Self-Assessment Form
- Annex E Required Certifications
-Annex F -- Survey on Ensuring Equal Opportunity

ANNEX A
GRANT APPLICATION TEMPLATE
A.1. General Instructions
Advancing Kosovo Together will assist applicants in understanding the application process, answer
questions from applicants, and may provide coaching in application development at the request of
applicants. Annex B includes a detailed budget format that must be completed and submitted with your
application. Annex C,and Implementation Plan Timeline,should also be completed at the time of
submission of the grant application. This application may not exceed 12 pages in length. Pages exceeding
10 will not be reviewed (does not include Annex B, Detailed Grant Budget or Annex C, Implementation
Plan Timeline and any other annex certifications).
A.2. Instructions by Section
Templates for presentation of both the technical and budget aspects of the application are provided in
Annexes B and C. Applicants shall present their proposals in the formats provided. Those applications
that are not submitted according to the formats requested and in accordance with the instruction in this
RFA will be considered as non-responsive and will be disqualified.
The application elements and guidelines are summarized below:
Section I (Basic Information). The Applicant provides basic contact information and information
regarding the status of the organization. This section must not exceed 3 page in length
Items 1-2: Organizations name, date organization was founded, and current registration status.
Item 3:

Contact Information Contact name, title, address, telephone, fax, e-mail, etc. The contact
person (agent) is responsible for communications between Advancing Kosovo Together and
the Applicant. This applies to all aspects of the grant, from initial application, negotiation,
award, and close out. 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.

Item 4:

Organizational Structure List board members (or founding members if you do not have a
formal board of directors) and key staff (president, directors, treasurer, etc). If available,
please attach an organizational chart.

Item 5:

Briefly describe the organization and its activities Should introduce the Applicant and its
background: how it was formed, its mission or purpose, major accomplishments in the area of
the targeted activity, current activities, past related experience, and clients. This section must
not exceed 1 page in length.

Item 6:

ReferencesList three donors, partner organizations, or community leaders that can provide
references for your organizations ability to successfully carry out the financial,
administrative, and technical requirements of the grant activity. Briefly describe your
relationship to the reference and the nature and duration of your work together. If the
reference is a previous donor, list the activity and location of the activity(s) they funded. Be
sure to provide complete information, including a point of contact, with telephone and email
address.

Section II (Program Description). The Applicant describes overarching program elements such as
objective of the grant and the linkage to AKTs objectives, results, the activitys beneficiaries, and plan
for disseminating activity deliverables. This section must not exceed 4 page in length.
Item 7:

Grant Activity TitleThe title given to the activity should relate to the grant activity
objective.

Item 8:

BackgroundIdentify the problem that the grant activity proposes to address. This section
must not exceed 1 page in length.

Item 9:

Grant Objective Briefly state the objective of the proposed grant activity.

Items 10:

Grant Activity Detail Provide a thorough, detailed description of the activity, including how
the activity links to AKTs objectives, and the expected results. This section must not exceed
2 pages in length. Please refer closely to the evaluation criteria and program description
sections of the APS.

Item 11:

Beneficiaries Identify beneficiaries/participants, disaggregated by gender if possible,


estimated number, and location. Identify how the grant activities will reach the intended
beneficiaries, how they will benefit from the grant, and how the beneficiaries will be
identified or selected.

Section III (Program Implementation Plan). This section covers information regarding activity
implementation, including proposed personnel and descriptions of each task. This should be the most
detailed section and must not exceed 3 pages in length, depending on the nature of the grant activity and
tasks involved.
Item 12:
Item 13:

Anticipated duration should be stated with a degree of accuracy of plus or minus two weeks.
Main tasks of the activity Provide details regarding the specific tasks of the activity in
Annex C.The implementation plan must be supported by Annex C, Implementation Plan
Timeline, listing all identified main tasks over the duration of the activity. Please include all
events, trainings, publications, etc. For each task, provide the following information:
Task # / Title
1.
Task description
2.
Target Audience
3.
Grant-financed resource required & detailed explanation of use
4.
Non-grant-financed resources required
5.
Start and end dates
6.
Person(s) responsible
7.
Milestone or indicator of achievement
Each task must be:
Complete and sound
Integrated and scheduled with dependent tasks
Assigned to a responsible party
Defined in terms of resources required
Concluded with a viable milestone of achievementmilestones must be linked to
results.
The tasks listed must show a logical, thoughtful approach to the overall implementation plan.
Tasks should describe actions and be logically sequenced. The Applicant should also describe

any relevant material assumptions made and/or conditions or precedent required for the
achievement of the tasks.
Item 14:

Applicant lists the location(s) of the activity, adding rows as needed.

Item 15:

Applicant lists the personnel who will be involved in implementing the grant activity. Attach
updated CVs and Annex B.1, Salary History Form, for all grant activity personnel.

Section IV (Experience and Capacity).


Item 16:

Applicant should describe past experience or on-going carrying out similar technical
activities. This is a critical factor in assessing the capacity of the applicant to implement the
activity. If the applicant does not have similar experience, state that here and describe any
other relevant qualifications that will allow you to successfully implement the grant activity.

Section V (Cost). This is a summary of the information provided in the application budget forms, and
includes total grant request, Grantee's cash or in-kind contributions (cost-sharing) for the activity (if
applicable), and contributions from other sources (co-funding) for the activity. Applicant also describes
any other US Government funding they are currently receiving for other purposes. Applicant must
identify any long-term, recurrent commitments resulting from activity, and Applicants plan for
sustainable coverage.
Item 17:

Detailed cost of this activity (cash, in-kind [i.e. donated goods or services], and third-party
sources)

Item 18:

Discuss strategies for ensuring the sustainability of the proposed activity and organization,
including proposed cost share, expected program income generation (if any), and third party
leveraging of funds (if any). Program income is defined as gross income earned by the
Grantee that is directly generated by a supported activity or earned as a result of this grant,
during the period of the grant.

Item 19:

List any major donor-funded activities (U.S. and other) that your organization has managed in
the last two years, currently receives, or expects to receive within the duration of the grant
activity.

Applications must be supported by Annex B, Detailed Grant Budget. This excel budget template, when
properly completed, reviewed, and approved by Advancing Kosovo Together, will serve as the mutually
agreed-upon guide for activity financial management. All activity costs must be identified. Cost data must
be accurate; proposed amounts should not be unrealistically high or low.
It is important that the budget clearly indicate where specific project funds are to come from (from
USAID, co-funding by another donor, or the applicants cost-sharing contribution). Furthermore,
contribution from other donors and Applicant resource commitment will be investigated and documented.
In order to avoid double financing/ billing, Advancing Kosovo Together will require full disclosure by all
involved parties and will maintain contact with co-funders to verify their contributions. Budgeted
amounts must also be supported by justification, and the applicant must be able to provide such backup to
Advancing Kosovo Together if requested.
All grant activity costs must be within the normal operating practices of the Applicant and in accordance
with its written policies and procedures. For applicants without an audited indirect cost rate, the budget

may include direct costs that will be incurred by the Applicant to provide identifiable administrative and
management costs that can be directly attributable to supporting the grant objective.
Section A.3. Grant Application Form
The application must be signed by an authorized agent of the Applicant.
This application is in response to ASP No.___________________
Section I. Basic Information
1. Organization name:
2. Date organization was founded and registration status:
3. Contact information:
Key contact person(s) and title:
Office address:
Mobile:
Email:

Office phone:
Fax:
Website:

4. Organizational Structure List board members (or founding members if you do not have a formal
board of directors) and key staff (president, directors, treasurer, etc). If available, please attach an
organizational chart.
5. Briefly describe the organization, its purpose, and past related experience:
6. List contact information for three (3) references from previous donors or organizations (U.S. and
other) that your organization has collaborated with in the last two years:
Donor Agency
or
Organization

Nature of Relationship or
Title of Project, Location

Start & End Dates of


Collaboration

Contact Person
Name & Position:
Email:
Tel:
Name & Position:
Email:
Tel:
Name & Position:
Email:
Tel:

Section II. Program Description


7. Title of the proposed grant activity:

8. Background: What is the issue or problem that the activity will address? Why is it critical to address
this issue?
9. Objective of the proposed grant activity:
10. Describe the proposed activity and expected results in detail (or attach a project description).
Describe the main tasks that are proposed to meet the grant objective, the expected results to be
achieved, and how the tasks are linked to the grant objective. Describe any relevant material
assumptions made and/or conditions or precedent required for the achievement of the grant objective.
This activity detail should keep in mind the evaluation criteria contained in the solicitation:
11. Describe the proposed participants and/or beneficiaries, and your method for identifying or selecting
participants and beneficiaries:
Section III. Implementation Plan
12. Anticipated duration of the grant activity:
Overall length (total number of months)
Start and end date (day, month, and year)
13. All implementation plans must be supported by Annex C that lists all identified tasks over the
duration of the activity.
14. Location(s) of the activity (add rows and columns as needed ).
# Community
1
2
3
4
5

Municipality

Target Group

15. List personnel who will be involved in implementing this project. CVs & salary history forms are
required for all project personnel. See Annex B.1, Salary History Form.
Section IV. Experience and Capacity
16. Describe the organizations experience implementing similar activities:
Section V. Cost
Note: All applications must be supported by the attached Annex B, Detailed Grant Budget.
17. Cost in local currency per the attached budget:

18.

D
i
s
c
u
s
s

Amount requested from AKT project:

In-kind (i.e. donated goods or services) or other contribution


from organization:
Other donors or third-party resources:

Total Estimated Grant Activity Cost:


strategies for ensuring the sustainability of the proposed activity and organization, including proposed
cost share, expected program income generation (if any), and third party leveraging of funds (if any).
19. List any major donor-funded activities (U.S. and other) that your organization has managed in the last
two years, currently receives, or expects to receive within the duration of the grant activity. Add
additional lines if necessary:
Donor
Agency

Title of Project, Location, & Start &


End Dates

Total
Funding
(in local
currency)

Donor Contact Person


Name:
Email:
Tel:
Name:
Email:
Tel:
Name:
Email:
Tel:

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 Application, (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.
Grants and Procurement Manager_____________________ Date ________________

ANNEX B DETAILED GRANT BUDGET TEMPLATE (EXCELATTACHED AS SEPARATE DOCUMENT)


ANNEX B.1- SALARY HISTORY FORM

This is an external form for completion by employees and consultants of grantee organizations. The form
should be signed by the employee/consultant and also the organizations legal representative.
Instructions
Include within this form the last 3 years of salary earnings. If you have worked as a full time employee,
then complete #7, noting your monthly gross salary in the currency in which you were paid. Do not
include 13th month salary benefits, bonuses, commissions or overtime. If you received a salary raise then
include it as a separate row, indicating the start date.
For your current job, include Present in the To column.
If you were a short term consultant, note in #8, the number of days and daily salary rate (based on an 8
hour day) in the currency in which you were paid. The daily rate should be exclusive of per diem (meals
and incidentals and lodging payments), and transportation.

CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET


1. Name (Last, First, Middle)

2. Contractors Name

3. Employees Address (include ZIP code)

4. Contract Number

5. Position Under Contract

6. Proposed Salary

7. Duration of Assignment

8. Telephone Number (include area


code)

9. Place of Birth

10. Citizenship (If non-U.S. citizen, give visa status)

11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment
12. EDUCATION (include all college or university degrees)
NAME AND LOCATION OF
INSTITUTION

14. EMPLOYMENT HISTORY

MAJOR

DEGREE

DATE

13. LANGUAGE PROFICIENCY (see Instruction on


Page 2)
Proficienc
Proficienc
LANGUAGE
y
y
Speaking
Reading
2/S

2/R

2/S

2/R

2/S

2/R

Give last three (3) years. List salaries separate for each year. Continue on
separate sheet of paper if required to list all employment related to duties of
proposed assignment.

Salary definition basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions,
consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.
EMPLOYERS NAME AND
Dates of Employment (M/D/Y)
Annual Salary
ADDRESS
POSITION TITLE
POINT OF CONTACT
From
To
Dollars
&TELEPHONE #

15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)


EMPLOYERS NAME AND
SERVICES PERFORMED
ADDRESS
POINT OF CONTACT

16. CERTIFICATION:
Signature of Employee

Dates of Employment
(M/D/Y)
From
To

Days at
Rate

Daily Rate
In Dollars

To the best of my knowledge, the above facts as stated are true and correct.
Date

17. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)


Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to
verify the information contained in this form. Contractor understands that USAID may rely on the accuracy of such information in
negotiating and reimbursing personnel under this contract. The making of certifications that are false, fictitious, or fraudulent, or
that are based on inadequately verified information, may result in appropriate remedial action by USAID, taking into consideration
all of the pertinent facts and circumstances, ranging from refund claims to criminal prosecution.
Signature of Contractors Representative
Date

IMPLEMENTATION PLAN

Task
List each task. Please be as
specific as possible. Use
additional pages if
necessary.

Target
Audience
Who is the
audience
targeted for
the task?

Non-Grant
Resources
Required
Grant
(Grantee or Third
Resources
Party
Required and Contribution) and
Detailed
Detailed
Explanation of Explanation of
Use
Use(if applicable)

12 Month Timeline
Place an X in the appropriate box to
indicate the first and last month of the task,
with approximate start and end dates. (Add
more months if necessary)
1

2 3

5 6

8 9

10 11 12

Person(s)
Responsible
Who is responsible
for overseeing and
implementing the
task?

Evaluation
Indicators and
Milestones
How will you
measure the succe
of the task?

ANNEX C.1: SAMPLE IMPLEMENTATION PLAN TIMELINE


ANNEX D: GRANTEE SELF-ASSESSMENT FORM
Accepting a grant from the Advancing Kosovo Together creates a legal duty for the Grantee to use the
funds according to the Grant Agreement and to United States federal regulations. Before awarding a
grant, the Advancing Kosovo Together must assess the adequacy of the financial and accounting systems
of a prospective grantee to ensure accountability. To complete this form, answer each question
as completely as possible, using extra pages if necessary.
APPLICANT INFORMATION
1. Name of Organization:
2. Activity Title:
3. Name, Title, Contact Information of Individual Completing Questionnaire:
INTERNAL CONTROLS
1. Internal controls are procedures that ensure:
a. Financial transactions are approved by an authorized individual
and follow laws, regulations, and the organization's policies,
Yes
b. Assets are kept Safely,
No
c. Accounting records are complete, accurate, and kept on a regular basisYes

No
Yes
No

Please complete the following concerning your organization's internal


controls:
2. The name, position/title, and telephone number for the individuals
responsible for verifying allowability of expenditures:
1. Name:____________________________
2. Title:_____________________________
3. Telephone number:__________________
3. The name, position/title, and telephone number for the individual responsible for
maintaining accounting records:
1. Name:___________________________
2. Title:_____________________________
3. Telephone number:_________________
4. List the name, position/title, and telephone number for the individual responsible for
preparing financial reports:
1. Name:___________________________
2. Title:_____________________________

3. Telephone number:_________________
5. List the name, position/title, and telephone number for the individual responsible for
preparing narrative reports:
1. Name:___________________________
2. Title:_____________________________
3. Telephone number:_________________
6. Does the organization keep timesheets for each paid employee?

Yes

No

ACCOUNTING SYSTEM
1. The purpose of an accounting system is to:
a. Accurately record all financial transactions,
b. Ensure that all financial transactions are supported
by invoices, timesheets and other documentation,

Yes
Yes

No
No

2. Briefly describe your organization's accounting system including: (A) any manual ledgers
used to record transactions (general ledger, cash disbursements ledger, suppliers ledger etc.);
(B) any computerized accounting system used (please indicate the name); and (C) how
transactions are summarized in financial reports, (by the period, project, cost categories):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
3. Does your organization have written accounting policies and procedures? Yes
4. Are your financial reports prepared on a:

No

Cash basis:
Accrual basis:
(Accrual = bill for costs before they are incurred)

5. Can your accounting records separate the receipts and payments of the grant from the
receipts and payments of your organization's other activities?
Yes
No
6. Can your accounting records summarize expenditures from the grant according to different
budget categories such as salaries, rent, supplies, and equipment?
Yes
No
7. How do you allocate costs that are shared by different funding sources, such as rent,
utilities, etc.?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

8. How often are financial reports prepared?

Monthly:

Quarterly:

Annually:

If financial reports are not prepared, then briefly explain why they are not:
___________________________________________________________________________________
___________________________________________________________________________________
9. How often do you input entries into the financial system?
Daily
b. Weekly
c. Monthly
10.How often do you do cash reconciliation?
Daily
b. Weekly
11.

c. Monthly

d. Ad hoc/as needed

d. By accountants decision

Do you keep invoices, vouchers and timesheets for all payments made from grant funds?
Yes
No

FUNDS CONTROL
1. Do you have a bank account registered in the name of your organization?

Yes

No

2. Are the bank account and its signatories authorized by the organization's Board of Directors,
Trustees, or other authorized persons?
Yes
No
AUDIT
Please provide the following information on prior audits of your organization.
1. Does your organization contract and pay for regular independent
audits?
Yes (please provide the most recent copy) No audits performed
2. If regular independent audits are performed, who performs the audit?
1. Name:___________________________
2. Title:_____________________________
3. Telephone number:_________________
3. How often are audits performed?
Quarterly:

Yearly:

Every two years:

Other: (explain)
___________

4. If your organization does not have a current audit of its financial statements, please provide a
copy of the following financial information, if available:
a. "Balance Sheet" for your prior fiscal or calendar year; and
b. "Revenue and Expense Statement" for your prior fiscal or calendar year.

5. Are there any reasons (local conditions, laws, or institutional circumstances) that would
prevent an independent accountant from performing an audit of your organization?
Yes
No
If yes, please explain:

CHECKLIST AND SIGNATURE PAGE


The project requests that your organization submit a number of documents along
with this completed questionnaire. Complete this page to ensure that all
requested information has been included.
Please complete the checklist below, then sign and return the questionnaire and
any other requested documents.
1. Complete the checklist:
Incorporation Papers or Certificate of Registration and Statute have been
provided to the project.
Organizational chart, if available, has been provided to the project.
Copy of your organization's most recent audit has been provided to the
project (Alternatively, if
there has been no recent audit, then a "Balance
Sheet" and "Revenue & Expense Statement" for the prior fiscal year must be
provided).
All questions on this questionnaire have been fully answered.
The organizations authorized agent has signed and dated this page.
The Accounting Questionnaire must be signed and dated by the organizations
authorized Agent who has either completed or reviewed the form.
Approved by:
Print Name
Title

__________________________
Signature
__________________________
Date

ANNEX E REQUIRED CERTIFICATIONS

CERTIFICATION REGARDING TERRORIST FINANCING


TEMPLATE
Certification Regarding Terrorist Financing, Implementing
Executive Order 13224
By signing and submitting this application, the prospective recipient provides the
certification set out below:
1. The Recipient, to the best of its current knowledge, did not provide, within the
previous ten years, and will take all reasonable steps to ensure that it does not and
will not knowingly provide, material support or resources to any individual or entity
that commits, attempts to commit, advocates, facilitates, or participates in terrorist
acts, or has committed, attempted to commit, facilitated, or participated in terrorist
acts, as that term is defined in paragraph 3.
2. The following steps may enable the Recipient to comply with its obligations under
paragraph 1:
a. Before providing any material support or resources to an individual or entity, the
Recipient will verify that the individual or entity does not (i) appear on the master
list of Specially Designated Nationals and Blocked Persons, which list is maintained
by the U.S. Treasurys Office of Foreign Assets Control (OFAC) and is available online
at OFACs website: http://www.treas.gov/offices/eotffc/ofac/sdn/t11sdn.pdf, or (ii) is
not included in any supplementary information concerning prohibited individuals or
entities that may be provided by USAID to the Recipient.
b. Before providing any material support or resources to an individual or entity, the
Recipient also will verify that the individual or entity has not been designated by the
United Nations Security (UNSC) sanctions committee established under UNSC
Resolution 1267 (1999) (the 1267 Committee) [individuals and entities linked to
the Taliban, Usama bin Laden, or the Al Qaida Organization]. To determine whether
there has been a published designation of an individual or entity by the 1267
Committee, the Recipient should refer to the consolidated list available online at the
Committees website:
http://www.un.org/Docs/sc/committees/1267/1267ListEng.htm.

c. Before providing any material support or resources to an individual or entity, the


Recipient will consider all information about that individual or entity of which it is
aware and all public information that is reasonably available to it or of which it
should be aware.
d. The Recipient also will implement reasonable monitoring and oversight
procedures to safeguard against assistance being diverted to support terrorist
activity.
3. For purposes of this Certificationa. Material support and resources means currency or monetary instruments or
financial securities, financial services, lodging, training, expert advice or assistance,
safehouses, false documentation or identification, communications equipment,
facilities, weapons, lethal substances, explosives, personnel, transportation, and
other physical assets, except medicine or religious materials.
b. Terrorist act means(i) an act prohibited pursuant to one of the 12 United Nations Conventions and
Protocols related to terrorism (see UN terrorism conventions Internet site:
http://untreaty.un.org/English/Terrorism.asp); or
(ii) an act of premeditated, politically motivated violence perpetrated against
noncombatant targets by subnational groups or clandestine agents; or
(iii) any other act intended to cause death or serious bodily injury to a civilian, or to
any other person not taking an active part in hostilities in a situation of armed
conflict, when the purpose of such act, by its nature or context, is to intimidate a
population, or to compel a government or an international organization to do or to
abstain from doing any act.
c. Entity means a partnership, association, corporation, or other organization,
group or subgroup.
d. References in this Certification to the provision of material support and resources
shall not be deemed to include the furnishing of USAID funds or USAID-financed
commodities to the ultimate beneficiaries of USAID assistance, such as recipients of
food, medical care, micro-enterprise loans, shelter, etc., unless the Recipient has
reason to believe that one or more of these beneficiaries commits, attempts to
commit, advocates, facilitates, or participates in terrorist acts, or has committed,
attempted to commit, facilitated or participated in terrorist acts.
e. The Recipients obligations under paragraph 1 are not applicable to the
procurement of goods and/or services by the Recipient that are acquired in the
ordinary course of business through contract or purchase, e.g., utilities, rents, office
supplies, gasoline, etc., unless the Recipient has reason to believe that a vendor or
supplier of such goods and services commits, attempts to commit, advocates,
facilitates, or participates in terrorist acts, or has committed, attempted to commit,
facilitated or participated in terrorist acts.

This Certification is an express term and condition of any agreement issued as a


result of this application, and any violation of it shall be grounds for unilateral
termination of the agreement by USAID prior to the end of its term.

Grantee Name______________________________________________________________________
Grantees Authorized Representative Name________________________________________________
Grantees Authorized Representative Title_________________________________________________
Grantee Authorized Representative Signature______________________________________________
Date____________________________

CERTIFICATION OF RECIPIENT TEMPLATE


Certification of Recipient
To:
Chemonics International
I,______________________, _____________________, as a legally authorized
Name (Printed or Typed)
Title
representative of ________________________________
Organization Name
do hereby certify that, to the best of my knowledge and belief, this organization's
management and other employees responsible for their implementation are aware of the
requirements placed on the organization by OMB Circulars, and Federal and USAID
regulations with respect to the management of, among other things, personnel policies
(including salaries), travel, indirect costs, and procurement under this agreement and I
further certify that the organization is in compliance with those requirements and other
applicable U.S. laws and regulations.
I, we, understand that a false, or intentionally misleading certification
on could be the cause for possible actions ranging from being found not responsible for this
award, termination of award, or suspension or debarment of this organization in accordance
with the ADS 303 Standard Provision for Non-U.S. Nongovernmental Organizations (for inkind, standard, and simplified grants) entitled Award Termination and Suspension and the
ADS 303 Standard Provision for Fixed Obligation Grants to Nongovernmental Organizations
entitled Debarment and Suspension.
I, we, further agree that by signing below, we provide certification and assurance for the
following:
(1) Certification Regarding Terrorist Financing
These certifications and assurances are given in consideration of and for the purpose of
obtaining any and all U.S. Federal grants, loans, contracts, property, discounts, or other U.S.
Federal financial assistance extended after the date hereof to the recipient by Chemonics,
including installment payments after such date on account of applications for U.S. Federal
financial assistance which was approved before such date. The recipient recognizes and
agrees that such U.S. Federal financial assistance will be extended in reliance on the
representations and agreements made in these assurances, and that the United States will
have the right to seek judicial enforcement of these assurances. These assurances are
binding on the recipient, its successors, transferees, and assignees, and the person or
persons whose signatures appear below are authorized to sign these assurances on behalf of
the recipient.
I declare under penalty of perjury that the foregoing is true and correct.

_________________________
Signature
_________________________
Type or Print Name
_________________________
Position Title
_________________________
Date of Execution
Page 27 of 28

Annex F: Survey on Ensuring Equal Opportunity for Applicants

Please access this document at the following link:


http://www2.ed.gov/fund/grant/apply/appforms/surveyeo.pdf

Page 28 of 28