Cooperatives, Driving Change in Northern Ghana!

Cooperative Time, 10 Minutes Before!

PILOT PROJECT SUPPLEMENTARY FUND APPLICATION FORM 1

A) FBC/FBO profile
Region:
District:
Group name:
Group type:(FBC/Joint/Union)
PP asset won:
Name of contact person:
Position: Chairman/Secretary/Treasurer
Current total membership Males:
Females:

B)Pilot Project implementation progress

Budget Allocation for Previous PP won

1. Status of Pilot Project : Completed ( ) Uncompleted( )

2. Initial PP budget KOICA: GHS…………………………………………….

3. Initial match by Coop: GHS………………………………………………..

4. Progress on PP asset and benefits derived so far ( please indicate figures on financial
benefits)
 …………………………………………………………………………..
 …………………………………………………………………………..
 ………………………………………………………………………….
 ………………………………………………………………………….
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 ……………………………………………………………………………

1
This PP call is strictly for the completion of ongoing pilot projects or to complement the effectiveness of existing PP assets that are found to require such
support to make the asset or facility functional and effective.

1
 Cooperatives, Driving Change in Northern Ghana!
Cooperative Time, 10 Minutes Before!

C) Pilot Project governance

4. Does the coop have an Asset Management Committee(AMC) in place? Please tick one
a) Yes ( ) b) No ( )
If yes attach list

5. Does the coop have documented or written asset management guidelines? a) Yes ( )b) No
( ). If yes attach guidelines

6. Initiatives taken by coop to address funding PP gap:

 ……………………………………………………………………………………………………………………
 ……………………………………………………………………………………………………………………
 ……………………………………………………………………………………………………………………
 …………………………………………………………………………………………………………………..

D) Purpose of PP supplementary funds

7. Project Modelling
Identification of Pilot Project complementary needs:Please list if applicable

Needs Purpose/Why
1

8. What will be the purpose for the additional support funds:Please tick one or both if applicable
8.1 Complete the current PP ( )
8.2 Complement the functionality of the PP ( )

9. If uncompleted, please state reason (s)

2
 Cooperatives, Driving Change in Northern Ghana!
Cooperative Time, 10 Minutes Before!

 ………………………………………………………………………….
 ………………………………………………………………………….
 ………………………………………………………………………….

10. If PP is completed state purpose of supplementary fund

 …………………………………………………………………………..
 ………………………………………………………………………….
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..

11. Amount required to complete or complement PP: GHS ………………………

E) Justification
Please explain why you think the needs identified above is relevant and how the
KOICA supplementary support could contribute to solving it. And indicate the
impact of the solution to your group members and the community (about a
page).

3
 Cooperatives, Driving Change in Northern Ghana!
Cooperative Time, 10 Minutes Before!

12. Financial Plan

NB: Limit the plan within the scope of this proposal.

12.1 Investment Plan

Unit Source of
Amount Quantity/ fund
Investment Item/activity (GHS) Frequency
Cost Specification (KOICA
(GHS) or Group)

Subtotal

Subtotal

Subtotal
KOICA:
Total (GHS)
Group:

4
 Cooperatives, Driving Change in Northern Ghana!
Cooperative Time, 10 Minutes Before!

13. a)Workplan
No Activities 2021 (Feb-March) Collaborators
W1 W2 W3 W4 W5
1
2
3
4
5
6

13. b) Are you able to execute this plan within 5 weeks? Explain
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

NB.
IF SELECTED, PLEASE COME ALONG WITH ALL DOCUMENTATIONS ON YOUR
OPERATIONS