Advancing Kosovo Together (AKT) Program
Programi Avancojmë Kosovën së Bashku
Unapredimo Kosovo zajedno
USAID Advancing Kosovo Together Program (AKT)
Request for Applications (RFA) No.004-AKT-2015
Issuance Date: March 25, 2015
Dear Applicant:
The USAID Advancing Kosovo Together, is seeking grant applications from qualified, locally registered
media houses and non-governmental organizations for the media initiatives that include showing success,
human touch and inspirational stories that improve ethnic communications, interaction, understanding
each other, and links between majority and non-majority businesses, CSOs, women associations, youth
groups and other non-formal groups. The grants will be awarded and implemented in accordance with
USAID and US Government regulations governing grants under contracts and Advancing Kosovo
Together’s internal grant management policies.
The project will hold an RFA briefing session on April 3, 2015 from 9:30-11:30 at the Advancing Kosovo
Together office located at:
Advancing Kosovo Together (AKT)
Nazim Gafurri 33,
10000 Pristina, Kosovo
These briefing sessions will allow eligible and interested applicants to ask questions about the RFA 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 participant’s name and the organization’s name to: grants@usaidakt.org. Only
one person may attend from each organization. The USAID Advancing Kosovo Together program will
not cover any costs related to participation in this meeting.
Grants under this request for application will be awarded and implemented in accordance with USAID and
US Government regulations governing grants under contracts and Advancing Kosovo Together’s internal
grant management policies.
Advancing Kosovo Together 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 RFA:
Annex A –Application Form
Annex B – Grant Budget Template
Annex B.1 – Implementation Plan
Annex C – Required Certifications
Annex D – Applicant Self-Assessment Form
Annex E – Representation by Organization Regarding a Delinquent Tax Liability or a Felony Criminal
Conviction
SECTION I. PROGRAM DESCRIPTION
IA.
OBJECTIVE
Advancing Kosovo Together is awarding grants to eligible media houses and non-governmental
organizations to create, produce and implement media initiatives that show success, human touch and
inspirational stories that improve ethnic communications, interaction, understanding each other, and links
between majority and non-majority businesses, CSOs, women associations, youth groups and other nonformal groups. Potential applicants may use innovative approaches, including but not limited to using
traditional electronic media (TV and radio), social media, print media, photography,etc to achieve the
objective of improving ethnic communications between majority and non-majority populations,
understanding, and appreciation of the other. Potential applicants must propose activities in Advancing
Kosovo Together partner municipalities, which include: Gračanica/Graçanicë, Klokot/Kllokot, Novo
Brdo/Novobërdë, Parteš/Partesh, Ranilug/Ranillug, Štrpce/Shtërpcë; Gjilan/Gnjilane, Istog/Istok,
Klinë/Klina, Obiliq/Obilić, Pejë/Peć, Vushtrri/Vučitrn, North Mitrovica/Mitrovica Veriut,
Leposavić/Leposaviq, Zubin Potok/Zubin Potok, and Zvečan/Zveçan.
IB.
BACKGROUND
USAID Advancing Kosovo Together is a three-year program financed by USAID and implemented by
Chemonics International. The goal of the program 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
municipalities² throughout Kosovo.
Overall program objectives are to:
1. Improve autonomous, horizontal communications between: (a) Kosovo Albanian and nonmajority communities; and (b) the Government of Kosovo and non-majority communities;
2. Improve economic opportunities in target municipalities;
3. Increase the efficiency and capacity of targeted municipal administrations to respond to the
needs of all the citizens; and
4. Build capacity of host-country organizations to leverage cross-ethnic leadership to achieve
program objectives and implement USAID Kosovo funded activities.
IC.
DETAILED PROGRAM DESCRIPTION
Under this activity, interested applicants will present applications that propose media initiatives that aim to
showcase positive interaction and cooperation between Kosovo Serbs and Kosovo Albanians in daily life,
to be presented as an inspirational example to influential target audiences such as youth aged 18-27 and
vulnerable groups. These human touch stories will focus on the typical individual and community level
interactions thereby contributing to the program’s objective of eliminating the barriers to inter-ethnic
interaction through improved perceptions of majority and non-majority communities in the partner
municipalities.
Proposed media initiatives should focus on the human element of a story, and not be political in nature.
These stories should be focused on individual interactions supported by the community, and should
highlight day-to-day interactions between majority and non-majority populations.
Media initiative tools may include but are not limited to: television and radio features, social media
(Facebook, YouTube, etc.), print/photography campaign and/or other additional tools proposed by the
applicant.
Applications should detail the targets and results that the proposed grant activity shall fulfill, and also
should detail which local media outlets will be used for dissemination of these stories. Additionally
applicants must include the following information in their applications:
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Description of the proposed target audience, detailing why the target audience was selected; and
how gender, age, urban/rural and regional differences will be affected and addressed;
Detailed methodology for researching groups/individuals targeted by these human touch stories to
determine message and format;
Proposed media channels to be utilized (television, radio, social media, print, or other) and the
rationale for their selection;
Proposed narrative content; examples include but are not limited to: TV and radio features,
interviews, mini-documentary, “A Day in the Life Of” or other narrative content/storyline to be
proposed by the applicant;
Proposed broadcast or dissemination plan;
Simple plan for monitoring and evaluating the effectiveness of the message, format, and attitudes
of target audience groups; and
Implementation schedule.
The duration for the each activity can be determined on an individual basis; however, all activities should
be completed within a 6-month period. 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 USAID’s Advanced 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 two additional regulatory documents issued by the U.S. Government’s Office of
Management and Budget (OMB) and the U.S. Agency for International Development:
- 2 CFR 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for
Federal Awards, Subpart E (U.S. applicants are subject to 2 CFR 200 in its entirety)
Full text of 2 CFR 200 can be found at http://www.gpo.gov/fdsys/pkg/FR-2013-12-26/pdf/201330465.pdf and 2 CFR 700 at http://www.ecfr.gov/cgibin/retrieveECFR?gp=1&SID=102cd1c4eb042c8040ebfcb0e923edfc&ty=HTML&h=L&r=PART&n=pt2
.1.700. Advancing Kosovo Together is required to ensure that all organizations receiving USAID grant
funds comply with the guidance found in the regulations referenced above, 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 100,000 Euros through up to five individual grant
award in the range of 10,000-20,000 Euros each. The final amount will be dependent upon grant
activities and final negotiation and may be lower or higher than that range. The duration of any grant
award under this solicitation is expected to be no more than 6 months. The estimated start date of grants
awarded under this solicitation is end of May, 2015.
SECTION III. ELIGIBILITY
IIIA.
ELIGIBLE RECIPIENTS
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Applicants must be a registered media house or non-governmental organization in Kosovo. All
applicants should be formally constituted at the time of grant award; recognized by and in good
standing with appropriate Kosovo authorities; have their principle place of business in the recipient
country; be majority owned by individuals who are citizens or lawful permanent residents of
Kosovo; and be compliant with all applicable civil and fiscal regulations.
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Applicants must be able to demonstrate successful past performance in implementation of
integrated development programs related to USAID Advancing Kosovo Together priority areas as
described in Section IA.
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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.
USAID Advancing Kosovo Together will assess this capability prior to awarding a grant.
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Applicants must also be:
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Operational in the last 18 months and have experience working in the sectors mentioned in
Section IC;
Able to fully comply with Advancing Kosovo Together environmental requirements;
Applicants must sign the following required certifications prior to receiving a grant. The
certifications are attached to this solicitation (Annex C), and USAID Advancing Kosovo
Together grants and procurement staff will review them with applicants.
 Certification Regarding Terrorist Financing (Required for all grants)
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Certification Of Recipient (Required for all grants)
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Advancing Kosovo Together will work with the successful grantees to draft a branding
strategy and marketing plan which will be annexed to the grant agreement.
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For any grant award(s) resulting from this solicitation that is other than in-kind and
equivalent to $25,000 USD or more, grantees will be required to provide a Data Universal
Numbering System (DUNS) number at the time of award. If the applicant already has a
DUNS number it should be included in their application. Otherwise, applicants will be
expected to get a DUNS number before an award is made. The Advancing Kosovo Together
project will assist successful applicants with this process. DUNS numbers can be obtained
online at http://fedgov.dnb.com/webform/pages/CCRSearch.jsp
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Faith-based and community groups will receive equal opportunity for funding in accordance
with the mandated guidelines laid out in ADS 303.3.28 except for faith-based organizations
whose objectives are for discriminatory and religious purposes, and whose main objective of
the grant is of a religious nature.
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.
IVA1. APPLICANT SELF-ASSESSMENT
All organizations selected for award are subject to a pre-award risk assessment 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
risk assessment process. The Applicant Self-Assessment Form is contained in Annex F.
Instructions and a template for the full applications are in Annex B. Applicants that submit full
applications that meet or exceed the merit review criteria will be notified of next steps in the application
process.
IV.A.2. GRANT APPLICATION
Templates to be utilized when developing the application are provided in Annex B-D. 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.
IV.A.3 INELIGIBLE EXPENSES
Advancing Kosovo Together grant funds may not be utilized for the following:
 Construction or infrastructure activities of any kind.
 Ceremonies, parties, celebrations, or “representation” expenses.
 Purchases of restricted goods, such as: restricted agricultural commodities, motor vehicles
including motorcycles, pharmaceuticals, medical equipment, contraceptive products, used
equipment; without the previous approval of Advancing Kosovo Together, or prohibited goods,
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prohibited goods under USAID regulations, including but not limited to the following: abortion
equipment and services, luxury goods, etc.
Alcoholic beverages.
Purchases of goods or services restricted or prohibited under the prevailing USAID source/
nationality (Burma (Myanmar), Cuba, Iran, North Korea, (North) Sudan and Syria).
Any purchase or activity, which has already been made.
Purchases or activities unnecessary to accomplish grant purposes as determined by the Advancing
Kosovo Together Project.
Prior obligations of and/or, debts, fines, and penalties imposed on the Grantee.
Creation of endowments.
IV. B. APPLICATION AND SUBMISSION INFORMATION
Applications shall be submitted in English, Albanian or Serbian language and may not be more than 15
excluding pages certifications.
Applications, including supporting documentation, should be submitted in sealed hard copy to the USAID
Advancing Kosovo Together offices at the address below and should reference (RFA) No.4-AKT-2015.
Applications will be accepted no later than 16:00 local time on April 24, 2015. Late or unresponsive
applications will not be considered.
Advancing Kosovo Together (AKT)
Nazim Gafurri 33,
10000 Pristina, Kosovo
Grants@usaidakt.org
In addition to the application form, applicants should submit the following to Advancing Kosovo Together:
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Signed and dated Required Certifications listed under section III.A
A copy of the Applicant’s 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.
Applicants will be notified in writing for the status of their application within a month from the day of
submission.
SECTION V. APPLICATION EVALUATION
VA1 MERIT REVIEW CRITERIA
Full applications will be evaluated against the merit review criteria in the table below.
Merit Review Category
Feasibility of design and technical approach
Reaching target groups and impact on target group
Management and operational capacity
Rating (Points)
35
20
20
Past performance
Cost efficiency
Overall Rating (out of 100 points)
15
10
100
These merit review criteria elements are described more fully below.
A. Feasibility of design and technical approach. The quality and feasibility of the application in terms of
how well proposed activities and proposed media help meet objectives and positively impact increasing
communications between Kosovo Albanians and Kosovo Serbs through creative storytelling. Evaluation
of approaches may include either approaches proven to be effective or new untried approaches with
promise. Proposed methodology for selecting individuals/communities to highlight in human touch
stories, as well as broadcasting plan will also be evaluated. (35 points)
B. Reaching target groups and impact on target group. Potential to broadly reach the target groups and
the extent to which the proposed activity directly benefits them. Applications must demonstrate how the
applicant intends to reach target groups, as well as how they will measure the impact of the human touch
stories on the target group. (20 points)
C. Management and programmatic capacity. Evidence of the capability to undertake and accomplish the
proposed activities and dissemination through proposed media initiatives of human touch stories. The
application should demonstrate the organization’s effectiveness in terms of internal structure, technical
capacity, and key personnel, in developing media campaigns. In addition, the organization must
demonstrate adequate financial management capability. The evaluation will be based principally on the
background, qualifications, reputation, appropriateness and skills of its key personnel; and the “track
record,” reputation, and achievements (including development of self-sufficient, sustainable activities) of
the organization. (20 points)
F. Past Performance. Previous or ongoing experience implementing similar activities. This examines an
Applicant’s references and experience, which is a critical factor in assessing the capacity of the
organization to implement the activity. (15 points)
E. Cost effeciency. The degree to which budgeting is clear and reasonable and reflects best use of
organizational and grant resources. (10 points)
Additionally, Advancing Kosovo Together will ensure environmental soundness and compliance in
design and implementation as required by 22 CFR 216.
SECTION VI. AWARD AND ADMINISTRATION INFORMATION
All grants will be negotiated, denominated and funded in Euros.
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 RFA 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 and reserves the right to ask
further clarifications from the offerors. Applicants will be informed in writing of the decision made
regarding their application.
LIST ANNEXES –
- Annex A – Certification of “Representation by Organization Regarding a Delinquent Tax Liability or a
Felony Criminal Conviction (AAPD 14-03, August 2014)”
-Annex B – Grant Application Form
- Annex C – Grant Application Budget Form
- Annex D – Implementation Timeline
- Annex E – Required Certifications
- Annex F – Applicant Self-Assessment Form
ANNEX A -REPRESENTATION BY ORGANIZATION REGARDING A DELINQUENT
TAX LIABILITY OR A FELONY CRIMINAL CONVICTION (AAPD 14-03, August 2014)
(a) In accordance with section 7073 of the Consolidated Appropriations Act, 2014 (Pub. L. 113-76)
none of the funds made available by that Act may be used to enter into an assistance award with any
organization that –
(1)Was “convicted of a felony criminal violation under any Federal law within the preceding 24
months, where the awarding agency has direct knowledge of the conviction, unless the agency has
considered, in accordance with its procedures, that this further action is not necessary to protect the
interests of the Government”; or
(2)Has any “unpaid Federal tax liability that has been assessed for which all judicial and
administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely
manner pursuant to an agreement with the authority responsible for collecting the tax liability, where
the awarding agency has direct knowledge of the unpaid tax liability, unless the Federal agency has
considered, in accordance with its procedures, that this further action is not necessary to protect the
interests of the Government”.
For the purposes of section 7073, it is USAID’s policy that no award may be made to any
organization covered by (1) or (2) above, unless the M/OAA Compliance Division has made a
determination that suspension or debarment is not necessary to protect the interests of the
Government.
(b) Applicant Representation:
(1)The Applicant represents that it is [ ] is not [ ] an organization that was convicted of a felony
criminal violation under a Federal law within the preceding 24 months.
(2)The Applicant represents that it is [ ] is not [ ] an organization that has any unpaid Federal tax
liability that has been assessed for which all judicial and administrative remedies have been
exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement
with the authority responsible for collecting the tax liability.
(End of provision)
_________________________
Signature
_________________________
Type or Print Name
_________________________
Position Title
_________________________
Date of Execution
ANNEX B – APPLICATION FORM
The application must be signed by an authorized agent of the Applicant. The Applicant must also provide
a copy of its individual business plan as part of its application.
This application is in response to RFA No. 4-AKT-2014
Section I. Basic Information
1. Business name:
2. Date business was founded and registration status:
3. Contact information:
Name of business representative and title:
Official 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 business, its purpose, and past related experience:
6. List contact information for three (3) references from previous donors or other organizations (business
partners, suppliers etc.) that your organization has collaborated with in the last two years (U.S. and
other):
Donor Agency
or
Organization
(business
partner,
supplier etc.)
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 business need that the activity will address? Why is it critical to address this
issue?
9. Please explain the objective of applying for this grant. How will your business’ proposed activity
contribute to the growth of your business as outlined in your business plan? How will your
businesses proposed activity create inter-ethnic linkages? Please describe how you will deliver
measurable business development benefits such as job creation, investment, capacity building and
revenue generation, and how the proposed activity is relevant to the objectives of the grant program:
10. Describe the proposed activity and expected results in detail (or attach a project description). Describe
the main tasks that are proposed under the activity, the expected results to be achieved, and how the
tasks are linked to the grant objective and your business’ business plan. 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 B.1 that lists all identified tasks over the
duration of the activity.
14. Location(s) of the activity (add rows as needed).
# Community
1
2
3
4
5
Municipality
Department
State
15. List personnel who will be involved in implementing this project. CVs are required for all project
personnel.
Section IV. Experience and Capacity
16. Describe the business’s experience implementing similar activities:
Section V. Cost
Note: All applications must be supported by the attached Annex B, Grant Budget template.
Cost in local currency per the attached budget:
Amount requested from Advancing Kosovo Together project:
In-kind (i.e. donated goods or services) or other contribution
from business:
Other donors or third-party resources:
Total Estimated Grant Activity Cost:
Discuss strategies for ensuring the sustainability of the proposed activity and business, including
proposed cost share, expected program income generation (if any), and third party leveraging of funds (if
any).
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 C – DETAILED GRANT BUDGET TEMPLATE (EXCEL-ATTACHED AS
SEPARATE DOCUMENT)
ANNEX D 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
(Grantee or Third
Grant
Party
Resources
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 4 5 6 7 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 success
of the task?
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. 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 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 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 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.
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______________________________________________________________________
Grantee’s Authorized Representative Name________________________________________________
Grantee’s 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 in-kind, 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
ANNEX F: 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,
Yes
c. Accounting records are complete, accurate, and kept on a regular basisYes
No
No
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
Yes
No
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,
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
c. Monthly
d. Ad hoc/as needed
d. By accountants decision
11. 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 organization’s authorized agent has signed and dated this page.
The Accounting Questionnaire must be signed and dated by the organization’s authorized Agent who
has either completed or reviewed the form.
Approved by:
Print Name
Title
__________________________
Signature
__________________________
Date