The Programme Local Development, Poverty Reduction and Enhanced Roma Inclusion

funded by EEA and Norway Grants

[OFFICIAL HEADING OF THE ORGANIZATION]

In the attention of: The Romanian Social Development Fund (RSDF/PO)

Bucureşti, str. Eugeniu Carada, nr. 1, etaj 3, sector 3

REQUEST FOR [ADVANCE PAYMENT]/ [INTERIM PAYMENT]/ [REINBURSEMENT]

Date.................... [dd/mm/yyyy]

EEA and Norway Financial Mechanisms 2014 – 2021 – Local Development Programme
Title of the bilateral activity/ application form for bilateral activities:
Code of the project financed by the PO (if the case):
Name of the Beneficiary:
Fiscal Registration Code:
Duration of implementation of bilateral activity 1:

We hereby request the transfer of the amount of ...... LEI/EUR, representing [the advance for
expenses]/ [the interim payment/ reimbursement related to the expenses incurred] in accordance
with Contract no. ... from ......... [dd/mm/yyyy].
Please make the payment in the account with the following IBAN code [...], opened at the Treasury/
Bank [...].

Please note that under the applicable national law we have the status of [public entity]/ [NGO] and
that the requested amount [is part of]/ [represents] the total budget of ... LEI/EUR, approved by the
PO.

Statement,

I certify that I am authorized to sign the Payment Request, which is supported by appropriate
supporting documents.

The information contained in this Payment Request is complete, consistent and true, and the
activities [to be] / [that have been] implemented are in line with those approved by the PO through
the contract concluded between the PO and the Beneficiary.

I certify that the eligible activities and expenditures carried out under this bilateral initiative financed
under contract no ... from ... have not been and are not currently funded, in part or in full, from
other Community or similar non-reimbursable funds or from other public sources. If any case of
double funding, in part or in full, related to this bilateral initiative is discovered to have occurred at
any time before or after the signing of the financing contract for its implementation, I understand
that the funding will be withdrawn and the amounts already granted will be recovered.

[Name, first name and position of legal representative 2]

[Signature]
[Stamp - if applicable]

1
please specify the period: from [day/ month/ year] ... - until [day/ month/ year], according to the contract concluded between the PO
and the Beneficiary
2
or the person empowered by the Beneficiary (in this case, the authorization shall be provided in original, signed by the legal
representative and, if applicable, stamped by the Beneficiary)