STANDARD GRANT AGREEMENT NON-US NGO

GRANT

Between

World Neighbors

And

Olga Corbafo

STANDARD GRANT AGREEMENT (NON US NGO)

NO: 01/USAID-WN/IV/2016

In response to your application dated 3rd March 2016, World Neighbors Indonesia (hereinafter,
referred to as WN) is pleased to award Olga Corbafo (hereinafter referred to as the Grantee), a grant
of $2,180, in support of the USAID-funded Increasing Community Resilience in Oecusse.

Please sign both original copies of this Grant Agreement document to acknowledge your receipt and
acceptance of the grant, and return one original to WN at the address indicated on the Overview Page.

World Neighbors Standard Grant Agreement Non-US NGO

 OVERVIEW PAGE

ISSUED BY: World Neighbors (WN)

Kantor World Neighbors,

Perumahan Taman Asri,
Blok B, No. 2,
Jl Batuyang,
Batubulan,
Gianyar, 80582

Project Manager: Kristina Silaban,

ksilaban@wn.org
HP: +67077242050

Project Manager’s Jasintus Eko; Email: jeko@wn.org;

Technical Representative: Hp: +67077242353

GRANTEE: Olga Corbafo

Fatuhada, Dili,

+670 7826 7852

USAID/OFDA PRIME AWARD NUMBER: AID-472-A-15-00001

PERIOD OF GRANT May 1st 2016 – June 30th 2016

TYPE OF GRANT Standard Grant Agreement
TOTAL AWARD COST $2,180
WN GRANT NUMBER 01/USAID-WN/IV/2016
PLACE OF PERFORMANCE Oecusse, Timor-Leste
DUNS NUMBER 586071719
REGION Timor-Leste
USAID AOTR APPROVAL [X] Received and on file
USAID AO APPROVAL [ ] Not required
[X] Received and on file
AUTHORIZED GEOGRAPHIC CODE 935
SOURCE ORIGIN AND Not required
NATIONALITY WAIVER

World Neighbors Standard Grant Agreement Non-US NGO

ATTACHMENTS:

One: Program Description

Two: Detailed Budget

Three: WN Payment Request Form

Four: Reporting on Payment of Foreign Taxes

Five: Certifications and Assurances

Six: Mandatory Standard Provisions

World Neighbors Standard Grant Agreement Non-US NGO

Article One: Purpose of Grant
The purpose of this grant is to provide support for the program described in Attachment One of this
Grant Agreement.

Article Two: Period of Grant

The effective date of this Grant Agreement is May 1st 2016 and the estimated completion date of the
Grant Agreement is 30th June 2016.

Article Three: Amount of Award

The amount of award is $2,180.

WN will also cover all reasonable food & drink costs incurred by the Grantee during the time spent in
Oecusse, working towards the completion of the Milestone as specified in Article Four below. Payment
will be made through reimbursement, upon presentation of valid receipts.

WN shall not be liable for making payments to the Grantee for any other costs.

Article Four: Milestones

This Standard Grant Agreement with WN is for very specific program elements. The accomplishment
will be based on the completion of the tasks and successful submittal or completion of the outputs
indicated below.

Description Output Estimated Amount

Date of
Completion
1. Preparation of Training Materials 1. CLTS Training Material
Documents submitted
to WN

2. Facilitate a comprehensive CLTS 2. One CLTS facilitator

training in Pante Makassar, Oecusse training successfully 30th June $2,180
Region. Organize at least one organized and 2016
community triggering and immediate conducted for at least
post-triggering activity during the 52 participants.
training

3. Prepare training report, including 3. Training report

outline of plan for implementation of submitted to WN
CLTS across all WN-focused
communities in Oecusse

World Neighbors Standard Grant Agreement Non-US NGO

Article Five: Financial Terms and Conditions
A. Payment
1. The Grantee will be paid a set amount upon programmatic accomplishment of the identified
and established grant milestone. Once the Grantee has presented the documentation
required under the agreement, WN will deposit the corresponding sum in the Grantee’s bank
account.

2. To obtain payment for accomplishment of the milestone the grantee must present
appropriate documentation. Appropriate documentation includes a properly prepared
request for payment in the format provided in Attachment Three, including a certification by
the Grantee that the activity milestone for which it is requesting payment has been completed
in accordance with the program description.

3. Requests for grant payments together with full documentation should be sent to the WN
Project Manager designated on the Overview Page.

Article Six: Other Terms and Conditions

A. The Grantee must certify in writing to WN at the end of the grant that the activity was
completed. This signed statement shall include the following statements:
- The grantee has received all funding due under this grant
- The grantee is due no outstanding funding
- That the grantee has no outstanding debts to WN.
If the grantee cannot certify that the grant has been completed, it shall be expected to return
to WN any funds received that represent reimbursement for any costs determined by WN as
unallowable.

B. Grant close out will be accomplished with WN acceptance of the milestone, approval of final
payment, and submission of certification of completion by Grantee.

C. WN does not assume liability for any third party claims for damages arising out of this grant.

D. The Grantee shall adhere to the following provisions on Termination and Suspension:

1. WN may terminate this award at any time, in whole or in part, upon written notice to
the recipient, whenever it is determined that the recipient has materially failed to
comply with the terms and conditions of the award.

2. This award may be terminated at any time, in whole or in part, by WN with the consent
of the recipient. Both parties shall agree upon termination conditions, including the
effective date and, in the case of partial terminations, the portion of the award to be
terminated. The agreement to terminate shall be set forth in a letter from WN to the
recipient.

3. This award may be terminated at any time in whole or in part by the recipient upon
sending written notification to WN with the following information: the reasons for the

World Neighbors Standard Grant Agreement Non-US NGO

 termination, the effective date, and, in the case of a partial termination, the portion
to be terminated. However, if WN determines in the case of partial termination that
the reduced or modified portion of the award will not accomplish the purposes for
which the award was made, WN may terminate the award in its entirety in accordance
with paragraphs (1) or (2) above.

4. If at any time USAID determines that continuation of all or part of the funding for a
program should be suspended or terminated because such assistance would not be in
the national interest of the United States or would be in violation of an applicable law,
then USAID may directly or through WN, following notice to the recipient, suspend or
terminate this award in whole or part and prohibit the recipient from incurring
additional obligations chargeable to this award other than those costs specified in the
notice of suspension during the period of suspension. If the situation causing the
suspension continues for 60 days or more, then USAID, directly or through WN, may
terminate this award on written notice to the recipient and cancel that portion of this
award which has not been irrevocably committed to third parties.

5. WN and USAID reserve the right to terminate in whole or in part, or suspend

payments, should the Grantee become insolvent during performance of the grant.

6. WN and USAID reserve the right to terminate this Agreement or take other
appropriate measures if the Grantee or a key individual of the Grantee is found to
have been convicted of a narcotics offense or to have been engaged in drug trafficking
as defined in 22 CFR Part 140.

7. Termination and Suspension Procedures. Upon receipt of and in accordance with a

termination notice as specified above, the recipient shall take immediate action to
minimize all expenditures financed by this award. The grantee may submit a claim
within 30 calendar days of such termination for any costs incurred in performance of
any unpaid or incomplete milestones The WN Project Manager will determine the
amount(s) to be paid by WN to the recipient under such claim in accordance OMB
Circular A-122, a full copy of which can be found in the link:
http://www.whitehouse.gov/sites/default/files/omb/assets/omb/circulars/a122/a12
2_2004.pdf

8. The recipient shall not incur costs after the effective date of termination. Any costs
incurred after the effective date of termination will not be reimbursed.

E. The Grantee shall follow USAID policies regarding materials produced under the award. All
materials produced under the terms of this agreement -- written, graphic, film, magnetic tape,
or otherwise -- shall remain the property of the Recipient of the grant. Except as otherwise
provided in the terms and conditions of the award, the author or the recipient is free to
copyright any books, publications, or other copyrightable materials developed in the course
of or under this award, but USAID reserves a royalty-free nonexclusive and irrevocable right
to reproduce, publish, or otherwise use, and to authorize others to use the work for
Government purposes. The rights and duties provided for in this paragraph shall continue,
notwithstanding the termination of the contract or the execution of its other provisions.

World Neighbors Standard Grant Agreement Non-US NGO

 F. USAID policy is that all programs, projects, activities, public communications, and
commodities, partially or fully funded by a USAID grant or cooperative agreement or other
assistance award or subaward must be marked appropriately with the USAID Identity.

G. As a condition of receipt of this subaward, marking with the USAID Identity of a size and
prominence equivalent to or greater than the recipient’s, subrecipient’s, other donor’s or third
party’s is required. In the event the recipient chooses not to require marking with its own
identity or logo by the subrecipient, USAID may, at its discretion, require marking by the
subrecipient with the USAID Identity.

H. The Grantee is responsible for the maintenance of any equipment and/or material received.

I. No lower tier sub-agreements are permitted under the terms of this award without prior
written approval of the WN Project Manager.

J. This agreement may be amended only in writing by the WN Project Manager.

K. Any dispute under or relating to this grant shall be decided by the WN Project Manager.

Signatures
For World Neighbors For the Grantee:

Signature: Signature:

Name and Title: Name:

Date: Date:

World Neighbors Standard Grant Agreement Non-US NGO

ATTACHMENT ONE: PROGRAM DESCRIPTION

To train, through both theoretical and practical sessions, WN staff, local partner staff, CBO volunteers
and key government officials on Community Led Total Sanitation (CLTS).

By the end of the training, the participants will:

- Understand the background, rationale, approach and principles of CLTS.
- Understand the methodology of CLTS and possess the skills required for its
implementation to trigger attitude and behavior changes.
- Possess the necessary knowledge and skills to facilitate CLTS appropriately in the
context of Oecusse.
- Understand how to construct sanitation facilities which are suitable for use by
communities in Oecusse.
- Be able to properly verify communities as ODF.
- Develop a plan of action for implementation of CLTS which covers all WN-focused areas
in Oecusse.

The training will include both classroom and field work activities. The field work will include at least
one community triggering and immediate post-triggering activity during the training.

The completion of the Milestone is estimated to take 14 days. The following should be used as a guide
only:
- Travel time: 2 days (Return travel)
- Training preparation: 2 days
- Training: 8 days – includes pre-triggering, triggering and post-triggering field visits
- Report writing: 2 days

World Neighbors Standard Grant Agreement Non-US NGO

 ATTACHMENT TWO: DETAILED BUDGET

Expenses Unit Cost Quantity Unit Frequency Total

Daily Rate (Coordinator and
140 14 Per Day 1 $1,960.00
Assistant)
Return
55 2 2 $220.00
Travel Dili-Oecusse-Dili Flight/Boat
Oecusse local travel Covered by WN $0.00
Food and Drink Reimbursed by WN $0.00
TOTAL $2,180.00

World Neighbors Standard Grant Agreement Non-US NGO

ATTACHMENT THREE: GRANT PAYMENT REQUEST FORM

Grant Payment Request Form

Grantee: _______________________________(name of organization)

Grant #:__________________________________

Amount Requested: _______________________ (amount and currency)

Supporting documentation attached (if necessary):

1. _____________________________
2. _____________________________
3. _____________________________
4. Etc.

"The undersigned hereby certifies: a) the milestone has been achieved, b) that payment of the sum
claimed as total spent in this request is proper and due and that all funds provided by WN have been
used solely for the purposes described in the Grant Agreement and in accordance with all of the terms
and conditions therein; c) that appropriate refund or credit to the Grant will be made in the event of a
disallowance in accordance with the terms of the Grant, for nonperformance in whole or in part under
this Grant, in the event funds are not expended; d) that any detailed supporting information as WN
may require will be furnished by the Grantee promptly upon request; and, e) that all requirements
called for by the Grant Agreement have been met up to the date of this certification."

By:
Name:
Title:
Date:

World Neighbors Standard Grant Agreement Non-US NGO

ATTACHMENT FOUR: REPORTING ON PAYMENT OF FOREIGN TAXES

Prohibition on Taxation of United States Assistance

The grantee must report to WN any foreign taxes paid to the host government with grant funds on
commodity purchase transactions (e.g., materials, articles, supplies, goods, or equipment) with a value
of US$500 or greater when the grantee cannot be exempted from paying foreign taxes or refunded
the amount of foreign taxes paid. Instructions are below:

A. By April 8 of each year, the Grantee must submit a report containing:

(a) Contractor/recipient name.
(b) Contact name with phone and e-mail.
(c) The total amount of value-added taxes and customs duties (but not sales taxes) assessed
by the host government (or any entity thereof) on purchases in excess of $500 per
transaction of supplies, materials, goods or equipment, during the 12 months ending on
the preceding September 30, using funds provided under this contract/agreement.
(d) Any reimbursements received by April 1 of the current year on value-added taxes and
customs duties reported in (iv).
(e) Reports are required even if the recipient did not pay any taxes or receive any
reimbursements during the reporting period.

B. Submit the reports to: jkaban@wn.org

C. Host government taxes are not allowable where the Agreement Officer provides the
necessary means to the recipient to obtain an exemption or refund of such taxes, and the
recipient fails to take reasonable steps to obtain such exemption or refund. Otherwise, taxes
are allowable in accordance with the Standard Provision, “Allowable Costs,” and must be
reported as required in this provision.

World Neighbors Standard Grant Agreement Non-US NGO

 ATTACHMENT FIVE: CERTIFICATIONS AND ASSURANCES

1. ANTI-TERRORIST FINANCING CERTIFICATION

By signing this Grant Agreement, the Grantee is certifying to the following:

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
this article.

The following steps may enable the Recipient to comply with its obligations under this provision:

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. Treasury’s
Office of Foreign Assets Control (OFAC) and is available online at OFAC’s 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 through WN 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 Committee’s 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 Certification-

a. “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-

World Neighbors Standard Grant Agreement Non-US NGO

 (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 Recipient’s 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.

2. RESTRICTIONS ON LOBBYING
By signing this Grant Agreement, the Grantee is certifying that they will comply with Code
of Federal Regulations, Title 22, Part 227 (22 CFR 227), New Restrictions on Lobbying. The
full text of the applicable regulation can be found in the link:
http://www.gpo.gov/fdsys/pkg/CFR-2011-title22-vol1/xml/CFR-2011-title22-vol1-
part227.xml.

3. PROHIBITION OF ASSISTANCE TO DRUG TRAFFICKERS

By signing this Grant Agreement, the Grantee is certifying that they will comply with ADS
Chapter 206, Prohibition on Assistance to Drug Traffickers. The full text of the applicable
regulation can be found in the link:
http://www.usaid.gov/sites/default/files/documents/1866/206.pdf.

World Neighbors Standard Grant Agreement Non-US NGO

ATTACHMENT SIX: MANDATORY STANDARD PROVISIONS AND REQUIRED AS APPLICABLE
PROVISIONS

This grant incorporates USAID Standard Provisions for Non-US Nongovernmental Recipients. The full
text of the applicable standard provisions can be found in the link:
http://www.usaid.gov/pubs/ads/300/303mab.pdf

World Neighbors Standard Grant Agreement Non-US NGO