(Printed on main beneficiary's letter headed paper)
European Commission
Consumers, Health, Agriculture and Food Executive Agency (CHAFEA )
To the attention of Mr Luc Briol, Director
L-2920 LUXEMBOURG
Date:
Place: dd-mm-yyyy place
Object:
Project:
Grant decision number:
Dear Mr Briol,
Request of Balance Payment
Xxxxxxxxxxxxxxx
Xxxxxxxxxxxxxxx
With reference to aforementioned grant agreement and in accordance with the terms of the grant, we hereby request the balance payment.
We confirm that any reports, deliverables and other documents drawn up in accordance with the relevant provisions of the grant agreement have been submitted to the Executive Agency or are annexed to this document.
You will find in annex the reports and other documents drawn up in accordance with the relevant provisions of the grant agreement and the individual certificate of costs.
With kind regards,
Name of signatory: Xxxxx Xxxx
Function of signatory: Xxxxx (Authorised representative)
Signature: _______________________________
1 of 2

List of annexes:
I.
Final Technical Implementation Report, and if necessary deliverables and other documents drawn up in accordance with the relevant provisions of the grant agreement
(in line with Annex IV-V) not yet submitted to the Executive Agency
II.
Final Financial Cost statement presented as follows:
(in line with Annex IV-V)

Final consolidated and detailed cost statements prepared in accordance with the structure of the estimated budget in Annex II (x copies)

External audit report on the beneficiary's accounts for the period in question if the payment request equals or exceeds EUR 100.000 per financial year 1.
(one copy)

Balance sheet, profit and loss accounts and statement on the beneficiary's incomes and expenditures accounts for the period in question (one copy);
 Financial independence form (see Annex IV-V B) completed for the period for which the EU operating grant was given and certified by an independent auditor.
(does not apply to public bodies).
III.
Original "Individual Certificate of costs" signed by the beneficiary's authorised representative accompanied by relevant annexes
IV.
Others
1 The audit certificate shall certify that the costs declared by the beneficiary in the financial statements on which the request for payment is based are real, accurately recorded and eligible in accordance with the grant agreement
2 of 2