Annex 2
EEA Grants 2009-2014: NGO Programme Lithuania. Guidelines for Applicants v.1.2.
PROJECT CONCEPT APPLICATION FORM
EUROPEAN ECONOMIC AREA FINANCIAL MECHANISM
NGO PROGRAMME LITHUANIA
____________________________________________________________________________________
(Name of applicant)
______________________________________
(date)
Project registration No. ________________________
(filled in by Programme Operator staff)
Project concept application form shall not exceed 10 pages (prepared in Times New Roman or Calibri font size 11, single
spacing).
Completed electronic concept application form together with all listed documents and annexes must be sent by e-mail
to registracija@nvoprograma.lt.
Hard copies of the application and supporting documents must be submitted before the deadline by hand-delivery or
sent in one copy to the address of the Programme Operator:
Human Rights Monitoring Institute, Didžioji 5-404, LT-01128 Vilnius, Lithuania.
The form must be filled out in Lithuanian with summaries in Lithuanian and in English.
Text in grey should be deleted when filling the application.
I.
TITILE OF THE PROJECT
II.
AREA OF SUPPORT, OUTCOME AND OUTPUT
From the list provided in the Guidelines for Applicants (Chapter I. Objectives, Areas of Support and Expected
Results) choose 1 or 2 areas of support, one main outcome and – if necessary – one additional outcome as well as
up to 4 outputs in total.
Area of support:
The main outcome:
Results:
No. 1
No. n
Additional outcome:
Results:
No. 1
No. n
III.
INFORMATION ABOUT THE APPLICANT
Information about the Organisation:
1. Full title of Organisation and its acronym
2. Registration code
3. Legal status
4. Founders and/or stakeholders
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EEA Grants 2009-2014: NGO Programme Lithuania. Guidelines for Applicants v.1.2.
5.
6.
7.
8.
9.
10.
Address of registration
Address for correspondence (if different from the address of registration)
Phone number
E-mail
Head of Organisation
Project contact person, phone, e-mail
Provide a short description of objectives and activities of the Organisation as well as the experience in the area of the
outcome(s) selected. Please also indicate administrative and project implementation capacity that will be dedicated to
the Project.
IV.
INFORMATION ABOUT PARTNER/S (IF IDENTIFIED ALREADY)
Information about the Organisation:
1. Name of Organisation
2. Registration code
3. Legal status
4. Founders and/or stakeholders
5. Address of registration
6. Phone number
7. E-mail, website
8. Head of Organisation
Provide a short description of objectives and activities of the Organisation as well as the experience in the area of the
outcome(s) selected. Please also indicate administrative and project implementation capacity that will be dedicated to
the Project.
V.
INFORMATION ABOUT ASSOCIATE PARTNER/S, IF APPLICABLE
Information about the Organisation:
1. Name of Organisation
2. Registration code
3. Legal status
4. Address of registration
5. Phone number
6. E-mail, website
7. Head of Organisation
Provide a short description of objectives and activities of the Organisation. Point out the Organisation‘s role in the
Project.
Comment: Associate partner is a partner in the Project who does not benefit and is not beneficiary of the Project, but
assists the applicant in implementing Project activities and contributes to achieving Project‘s objectives.
VI.
PROJECT CONCEPT/IDEA
Describe the concept of the Project:
- Clearly describe and provide justification for the issues addressed in the project, describe their relevance to the
selected area of support, outcome(s) and output(s).
- Indicate goals and objectives of the Project, as well as activities and indicators to be achieved and explain how
the Project‘s results will match the Programme‘s outcomes and outputs.
Choose categories of the activities from chapter VII of Guidelines for applicants “Categories of eligible activities”
and indicate specific activities within the selected categories (i.e. Art. 26.2. „Human rights“, category b.
Advocacy and watchdog activity: Advocacy campaign against xenophobia). Indicators should be selected from
Annex 1 of Guidelines for applicants “Outcomes outputs and indicators table”.
- Describe the impact of the Project on the strengthening and capacity development of your organisation and the
whole NGO sector, if applicable.
- Describe target groups (those directly participating in the activities) and beneficiaries (those who will
experience impact) of the Project.
- If the project is implemented with partner/s, describe the distribution of roles among partner/s, explain the
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value of partnership for the project, indicate concrete activities that shall be implemented by partner/s, and
partner’s responsibilities.
VII.
PROJECT IMPACT ON HORIZONTAL CONCERNS OF NGO PROGRAMME LITHUANIA
Indicate Project‘s coverage of the horizontal concerns of NGO Programme Lithuania listed below. Indicate concrete
actions that will be taken to achieve maximum impact. Horizontal concerns include:
Combating:
- Hate speech, hate crime and extremism,
- Racism and xenophobia,
- Homophobia,
- Anti-Semitism,
- Roma discrimination,
- Sexual harassment,
- Violence against women and domestic violence,
- Human trafficking.
Fostering:
- Tolerance,
- Multicultural understanding.
VIII.
PROJECT BUDGET
Project budget shall be planned realistically and efficiently, based on adequate market prices. All expenses shall be
clearly and directly linked to implementation of planned activities. The size of the budget shall be adequate to the
achievements and results planned.
Please clearly identify subcontracting cost. It shall not exceed 40% of the total value of the Project. In exceptional
cases, if a clear justification is provided, this percentage may be increased, subject to the approval of the Programme
Operator.
Indirect costs of up to 20% of total direct eligible costs, excluding its direct eligible costs for subcontracting and the
costs of resources made available by third parties which are not used on the premises of the project promoter, are
allowed. The total amount of indirect costs cannot exceed 50,000 LTL (14,481 EUR).
Please clearly describe own contribution of the applicant and/or partner/s to the Project. This contribution must not
be less than 10% of the total value of the Project. Indicate the exact amount of own contribution in the table below.
The applicant may include voluntary work as in-kind contribution worth up to 5% of the total value of the Project. For
the calculation of the in-kind contribution, the price for each hour of voluntary work shall be LTL 18,13 (including all
obligatory employer and employee taxes).
Provide a summary of the Project Budget, breaking funding requested by categories of expenditure:
Categories of expenditure
Amount, LTL
Amount, EUR
Direct expenditure of Project implementation
Task/Activity 1*
Task/Activity 2*
Task/Activity n*
Direct administrative expenses
Indirect costs
TOTAL VALUE OF THE PROJECT
Funding of NGO Programme Lithuania
Own contribution
* Direct project cost shall be apportioned distributed according to Project tasks or categorized activities.
IX.
OTHER INFORMATION RELATED TO THE PROJECT (if the Applicant would like to add something)
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X.
PROJECT SUMMARY IN LITHUANIAN AND IN ENGLISH (section must not exceed 1 page)
Please provide the following information in Lithuanian and in English:
Lithuanian
Pareiškėjo organizacijos pavadinimas
Partnerio(ių) ir/arba asocijuoto(ų) partnerio(ų)
organizacijos(ų) pavadinimas(ai)
Projekto pavadinimas
Kokią problemą siekiate spręsti Projektu?
Koks yra šio Projekto tikslas ir uždaviniai?
Koks poveikis bus pasiektas Projektu?
Kokie rezultatai bus pasiekti įgyvendinus projektą?
Kokia Projekto tikslinė grupė ir naudos gavėjai?
Projekto partnerio (-ių) ir/ ar asocijuoto (-ų) partnerio (ių) vaidmuo Projekte, Donorų šalies partneris ir jo
vaidmuo (jei taikytina)?
Kokių rezultatų tikimasi iš sudarytos partnerystės (jei
taikytina)?
XI.
English
Title of applicant organization
Title(s) of partner organization(s) and/or associate
partner(s) organization(s)
Title of the project
Project justification (describe problems /challenges that
project aims to solve. Include reference to wider public
plans or priorities, where relevant)
What is the objective of the project?
What is the project expected to achieve?
(describe project outcome(s))
How will the project address these challenges?
(describe project outputs)
Who is expected to benefit?
(the target groups and beneficiaries)
Donor partner and role of partner (if applicable)
What will the partnership achieve? (if applicable)
DOCUMENTS TO BE SUBMITTED WITH THE PROJECT
CONCEPT APPLICATION FORM
The following documents must be provided by project applicant:
1.
2.
3.
4.
5.
6.
7.
8.
Project concept form (Annex 2A);
Authorized copy* of Statute of the applicant organisation (if the statute was modified during the 2012-2014
period, the earlier version must be provided as well);
Authorized copy* of the applicant organization’s registration certificate;
Authorized copy* of the letter of authorisation (if the application is signed not by the head of the
organisation);
Applicant declaration (original) (Annex 4);
CVs (signed by a respective person) and short description of relevant experience in project area of project
implementation team;
List of completed projects in the area where funding is requested (indicating project name, dates of
implementation, source and amount of funding, project objective, main activities and results) (Annex 7);
Annual report on received and used support in 2012-2013 (Form FR 0478).
The following documents must be provided by project partner, if applicable. In case project has no partners, please
delete the list indicated below.
1.
2.
3.
4.
5.
6.
Authorized copy* of Statute of the partner organisation (if the statute was modified during the 2012-2014
period, the earlier version must be provided as well);
Authorized copy* of partner organization’s registration certificate;
Partner declaration (original) (Annex 5);
Authorised copy* of the memorandum of understanding;
CVs (signed by a respective person) and short description of relevant experience in project area of the
partner’s project implementation team;
List of the partner’s completed projects in the area where funding is requested (indicating project name,
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EEA Grants 2009-2014: NGO Programme Lithuania. Guidelines for Applicants v.1.2.
7.
dates of implementation, source and amount of funding, project objective, main activities and results)
(Annex 7);
Annual report on received and used support in 2012-2013 (Form FR 0478 for the Lithuanian partner and a
relevant form applicable to a non-Lithuanian partner).
The following documents must be provided by associated project partner, if applicable. In case project has no
associated partners, please delete the list indicated below.
1.
2.
Copy of associated partner(s) declaration (Annex 6).
Authorised copy* of the memorandum of understanding;
NB. Please print the complete application form with annexes and supporting documents, label them „True Copy“ (if
necessary), sign the documents and scan them to a PDF format. All these documents together with application form in
Word format must be sent by e-mail to registracija@nvoprograma.lt following the deadline indicated in Chapter IX of
Guidelines for Applicants „Application process“.
* Authorized copy must have a label “True Copy” (“Kopija tikra”) and must be signed by chief executive officer of the
organization or other authorized person.
___________________________________________________________________________
Job title and name, surname, signature of the Head of Organisation or authorised person, date
<stamp>
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