AKT Grant Scheme Application
Content
Grant Application Template
Section I. Basic Information
1. Organization name: “Sportski Savez Gracanica”
2. Date organization was founded and registration status: 07/05/2014
3. Contact information:
Key contact person(s) and title: Miodrag Dimitrijevic, director
Office address: Gracanica
Office phone: Not applicable
Mobile: 049 137 136
Fax: Not applicable
Email: [email protected]
Website: Not applicable
4. Organizational Structure – The board members and founders of organization are: Ivica
Dimitrijevic, Goran Marinkovic and Miodrag Dimitrijevic
5. Briefly describe the organization, its purpose, and past related experience: The organization was
recently established. The organization deals with the organization of different tournaments, sports
schools, activities and competitions. Lack of capacities is something we are having issues with, and it
really makes it difficult for us to continue our work during the winter.
6. List contact information for three (3) references from previous donors or organizations (U.S. and
other) that your organization has collaborated with in the last two years:
Donor Agency
or
Organization
Nature of Relationship or
Title of Project, Location
Start & End Dates of
Collaboration
Municipality
of Gracanica
International football
tournament in Italy for
children born after 2001.
(11.000e)
12.05.201417.05.2014
Municipality
of Gracanica
Tenis Camp in
Aranjelovac, tournament
and different events.
(5000e)
9.07.201416.07.2014
Establishing tenis school
in Gracanica
27.05. 2014- present
Municipality
of Gracanica
Contact Person
Name & Position: Ivan
Tomic, Adviser to the
Mayor
Email:
[email protected]
m
Tel: 049/436-061
Name & Position: Ivan
Tomic, Adviser to the
Mayor
Email:
[email protected]
m
Tel: 049/436-061
Name & Position: Ivan
Tomic, Adviser to the
Mayor
Email:
[email protected]
m
Tel: 049/436-061
Section II. Program Description
7. Title of the proposed grant activity: Promoting and increasing inter-ethnic sports activities
8. Background: The municipality of Gracanica has implemented a project of building a sports complex
in Gracanica. However, the football court has not been adjusted for rain and winter conditions, and
this has impact on the youth engagement in sports activities in our municipality. Bearing in mind that
Serbs and Roma community are using this court we want to install a construction which will cover
the court and adjust it for usage in winter purposes. If we were to implement this project there will be
conditions for organizing a football tournaments during the winter where Albanian teams would be
invited as well. We were already informed that Albanian teams from Lipljan and Pristina showed
interest in organizing some events together, and this is why we want to create conditions for these
events to happen.
9. Objective of the proposed grant activity: Inter- ethnic communication and youth engagement
during the winter days are the two key objectives of these project.
10. Describe the proposed activity and expected results in detail (or attach a project description).
Describe the main tasks that are proposed to meet the grant objective, the expected results to be
achieved, and how the tasks are linked to the grant objective. Describe any relevant material
assumptions made and/or conditions or precedent required for the achievement of the grant
objective. This activity detail should keep in mind the evaluation criteria contained in the
solicitation:
The main activity this project is supposed to finance is the construction of the roof for the football
field. This activity will create conditions for improving autonomus communication between Kosovo
Albanian, Kosovo Serbian and Roman community interaction during extreme rain and winter
conditions. We are very aware of the importance of sports during the time of the year when conditions
for that are not the same as during the spring and summer. Young people should be engaged in sports
activities throughout the year and young people are the ones who should take the initiative for interethnic events that will promote equality and tolerance, where football is the best tool to achive such
objectives.
We expect, through our organization, to bring people together and make them gather around the most
popular game in the world where the only difference there is between them is the quality they present
on the field.
Once we have the roof construction we will engage in organizing different events, football
tournaments and after parties which will bring all communities closer together and create necessary
preconditions for their more frequent interaction in the future. Government and municipalities are
very much in favor in the interaction between different ethnic groups and we want to be the first one
in our municipality to initiate something of this kind.
11. Describe the proposed participants and/or beneficiaries, and your method for identifying or
selecting participants and beneficiaries: We will seek to engage different Serbian and Albanian
municipalities through an open call for participation, where we will expect them to find teams that
will participate in the events we organize. We already have a few teams from the Municipality of
Gracanica who will be playing in this tournament.
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)
5
15th December 2014 to 15th May
2015
13. All implementation plans must be supported by Annex C that lists all identified tasks over the
duration of the activity.
1.
2.
3.
Task #1
Construction of the roof for the football court
All people in the municipality of Gracanica
15.000e (AKT Grant) plus 2000e from the Municipality of Gracanica, all to be used for the
construction
Municipality of Gracanica
4.
5. 15th December 2014 to 1st January 2015
6. Miodrag Dimitrijevic
7. Successful completion of the roof and a football field with conditions for football matches during
the winter
Task #2
1. Organizing a football tournaments
2. Kosovo Serbs, Albanians, Romas and other minority communities
3. None
4. Municipality of Gracanica will finance some basic needs necessary for the tournament
5. 15th of January to 15th of May
14. Location(s) of the activity (add rows and columns as needed ).
# Community
1 Serbian
Municipality
Gracanica
Target Group
1. Kosovo Serbs,
Albanians, Romas
and other minority
communities
2
3
4
5
15. List personnel who will be involved in implementing this project. CVs & salary history forms are
required for all project personnel. See Annex B.1, Salary History Form.
Section IV. Experience and Capacity
16. Describe the organization’s experience implementing similar activities: We have already
implemented a few projects with the Municipality concerning the sports life of young people. We
attended, with our young and talented children, international tournaments in Italy and Arandjelovac
which were proven to be a great success for us. In addition to that, we have taken the initative in
establishing the tenis school and since May this school is operating with its full capacity.
Section V. Cost
Note: All applications must be supported by the attached Annex B, Detailed Grant Budget.
17. Cost in local currency per the attached budget:
18.
15.000e
Amount requested from AKT project:
In-kind (i.e. donated goods or services) or other contribution
from organization:
People involved in the
organization, everything
necessary for tournament
organization.
Other donors or third-party resources:
Municipality of
Gracanica: 3.575e
18.575e
D
i
s
c
u
s
s
Total Estimated Grant Activity Cost:
strategies for ensuring the sustainability of the proposed activity and organization, including
proposed cost share, expected program income generation (if any), and third party leveraging
of funds (if any). The organization will always be the initiator of sport events and it will promote
tolerance and inter-ethnic events throughout time. We want everyone to feel safe while playing in
Gracanica and the sustainability of such environment will be ensured thanks to our great partner
Municipality of Gracanica. We don’t plan to make this project being profit oriented, as we want sports
to be free and not the luxury of the few. The Municipality of Gracanica is always helping us with
everything we might need for our events and this cooperation will continue in the future as well.
19. List any major donor-funded activities (U.S. and other) that your organization has managed in the last
two years, currently receives, or expects to receive within the duration of the grant activity. Add
additional lines if necessary:
Donor Agency
Municipality
of Gracanica
Title of Project, Location, & Start &
End Dates
Inter- ethnic tournaments between
Serbs, Albanians and other
minorities
Total
Funding
(in local
currency)
500e
Donor Contact Person
Name: Ivan Tomic
Email:
[email protected]
Tel: 049/436-061
Name:
Email:
Tel:
Email:
Tel:
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): _____________Miodrag Dimitrijevic, director________________
Signature: _____________________________________ Date: _______21/11/2014__________
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 B – DETAILED GRANT BUDGET TEMPLATE (EXCELATTACHED AS SEPARATE DOCUMENT)
ANNEX B.1- SALARY HISTORY FORM
This is an external form for completion by employees and consultants of grantee organizations. The form
should be signed by the employee/consultant and also the organization’s legal representative.
Instructions
Include within this form the last 3 years of salary earnings. If you have worked as a full time employee,
then complete #7, noting your monthly gross salary in the currency in which you were paid. Do not
include 13th month salary benefits, bonuses, commissions or overtime. If you received a salary raise then
include it as a separate row, indicating the start date.
For your current job, include ‘Present’ in the ‘To’ column.
If you were a short term consultant, note in #8, the number of days and daily salary rate (based on an 8
hour day) in the currency in which you were paid. The daily rate should be exclusive of per diem (meals
and incidentals and lodging payments), and transportation.
CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET
1. Name (Last, First, Middle)
2. Contractor’s Name
3. Employee’s Address (include ZIP code)
4. Contract Number
5. Position Under Contract
6. Proposed Salary
7. Duration of Assignment
8. Telephone Number (include area
code)
9. Place of Birth
10. Citizenship (If non-U.S. citizen, give visa status)
11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment
12. EDUCATION (include all college or university degrees)
NAME AND LOCATION OF
INSTITUTION
MAJOR
DEGREE
DATE
13. LANGUAGE PROFICIENCY (see Instruction on
Page 2)
Proficienc
Proficienc
LANGUAGE
y
y
Speaking
Reading
2/S
2/R
2/S
2/R
2/S
2/R
14. EMPLOYMENT HISTORY
1
Give last three (3) years. List salaries separate for each year. Continue on
separate sheet of paper if required to list all employment related to duties of
proposed assignment.
2
Salary definition – basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions,
consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.
EMPLOYER’S NAME AND
Dates of Employment (M/D/Y)
Annual Salary
ADDRESS
POSITION TITLE
POINT OF CONTACT
From
To
Dollars
&TELEPHONE #
15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)
SERVICES PERFORMED
16. CERTIFICATION:
EMPLOYER’S NAME AND
ADDRESS
POINT OF CONTACT
Dates of Employment
(M/D/Y)
From
To
To the best of my knowledge, the above facts as stated are true and correct.
Signature of Employee
17. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)
Date
Days at
Rate
Daily Rate
In Dollars
Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to
verify the information contained in this form. Contractor understands that USAID may rely on the accuracy of such information in
negotiating and reimbursing personnel under this contract. The making of certifications that are false, fictitious, or fraudulent, or
that are based on inadequately verified information, may result in appropriate remedial action by USAID, taking into consideration
all of the pertinent facts and circumstances, ranging from refund claims to criminal prosecution.
Signature of Contractor’s Representative
Date
IMPLEMENTATION PLAN
Target
Task
Audience
List each task. Please be as Who is the
specific as possible. Use
audience
additional pages if
targeted for
necessary.
the task?
Non-Grant
Resources
Required
Grant
(Grantee or Third
Resources
Party
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
About
17.000e
Building the roof
construction
Organizing tournaments
Serbs,
Albanians,
Roma and
other
communitie
s in Kosovo
2 3
4
5 6
X
500e, for balls,
drinks,
sandwiches,
trophies.
X X X X
7
8 9
Person(s)
Responsible
Who is responsible
for overseeing and
implementing the
task?
Evaluation
Indicators and
Milestones
How will you
measure the succe
of the task?
Miodrag
Dimitrijevic
The completion
the project and b
choosing the bes
possible materia
be used for build
the roof
construction.
Participation of
Albanian and ot
minority teams
10 11 12
Miodrag
Dimitrijevic
ANNEX C.1: SAMPLE IMPLEMENTATION PLAN TIMELINE
ANNEX D: 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:
”Sportski savez Gracanica”
2. Activity Title: Recostruction of sports field
3. Name, Title, Contact Information of Individual Completing Questionnaire:
Miodrag Dimitrijevic, director, 049 137 136
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,
No
c. Accounting records are complete, accurate, and kept on a regular basisYes
No
Yes
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:___Goran Marinkovic_______
2. Title:_______Cashier______________
3. Telephone number:___044 502 261____
3. The name, position/title, and telephone number for the individual responsible for
maintaining accounting records:
1. Name:________Dejan Zivic____
2. Title:_______Secretary________
3. Telephone number:____049 554 922
4. List the name, position/title, and telephone number for the individual responsible for
preparing financial reports:
1. Name:_____Nenad Milic______________
2. Title:_______Financial officer__________
3. Telephone number:_____045 699 528___
5. List the name, position/title, and telephone number for the individual responsible for
preparing narrative reports:
1. Name:_______Miodrag Dimitrijevic____
2. Title:__________Director____________
3. Telephone number:____049 137 136___
6. Does the organization keep timesheets for each paid employee?
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,
Yes
Yes
No
No
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
11.
c. Monthly
d. Ad hoc/as needed
d. By accountants decision
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
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_____________”Sportski Savez Gracanica”_____________________________________
Grantee’s Authorized Representative Name_________Miodrag Dimitrijevic_______________________
Grantee’s Authorized Representative Title_______________Director____________________________
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 inkind, 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
_________________________
Date of Execution
Page 18 of 19
Annex F: Survey on Ensuring Equal Opportunity for Applicants
Please access this document at the following link:
http://www2.ed.gov/fund/grant/apply/appforms/surveyeo.pdf
Page 19 of 19
Section I. Basic Information
1. Organization name: “Sportski Savez Gracanica”
2. Date organization was founded and registration status: 07/05/2014
3. Contact information:
Key contact person(s) and title: Miodrag Dimitrijevic, director
Office address: Gracanica
Office phone: Not applicable
Mobile: 049 137 136
Fax: Not applicable
Email: [email protected]
Website: Not applicable
4. Organizational Structure – The board members and founders of organization are: Ivica
Dimitrijevic, Goran Marinkovic and Miodrag Dimitrijevic
5. Briefly describe the organization, its purpose, and past related experience: The organization was
recently established. The organization deals with the organization of different tournaments, sports
schools, activities and competitions. Lack of capacities is something we are having issues with, and it
really makes it difficult for us to continue our work during the winter.
6. List contact information for three (3) references from previous donors or organizations (U.S. and
other) that your organization has collaborated with in the last two years:
Donor Agency
or
Organization
Nature of Relationship or
Title of Project, Location
Start & End Dates of
Collaboration
Municipality
of Gracanica
International football
tournament in Italy for
children born after 2001.
(11.000e)
12.05.201417.05.2014
Municipality
of Gracanica
Tenis Camp in
Aranjelovac, tournament
and different events.
(5000e)
9.07.201416.07.2014
Establishing tenis school
in Gracanica
27.05. 2014- present
Municipality
of Gracanica
Contact Person
Name & Position: Ivan
Tomic, Adviser to the
Mayor
Email:
[email protected]
m
Tel: 049/436-061
Name & Position: Ivan
Tomic, Adviser to the
Mayor
Email:
[email protected]
m
Tel: 049/436-061
Name & Position: Ivan
Tomic, Adviser to the
Mayor
Email:
[email protected]
m
Tel: 049/436-061
Section II. Program Description
7. Title of the proposed grant activity: Promoting and increasing inter-ethnic sports activities
8. Background: The municipality of Gracanica has implemented a project of building a sports complex
in Gracanica. However, the football court has not been adjusted for rain and winter conditions, and
this has impact on the youth engagement in sports activities in our municipality. Bearing in mind that
Serbs and Roma community are using this court we want to install a construction which will cover
the court and adjust it for usage in winter purposes. If we were to implement this project there will be
conditions for organizing a football tournaments during the winter where Albanian teams would be
invited as well. We were already informed that Albanian teams from Lipljan and Pristina showed
interest in organizing some events together, and this is why we want to create conditions for these
events to happen.
9. Objective of the proposed grant activity: Inter- ethnic communication and youth engagement
during the winter days are the two key objectives of these project.
10. Describe the proposed activity and expected results in detail (or attach a project description).
Describe the main tasks that are proposed to meet the grant objective, the expected results to be
achieved, and how the tasks are linked to the grant objective. Describe any relevant material
assumptions made and/or conditions or precedent required for the achievement of the grant
objective. This activity detail should keep in mind the evaluation criteria contained in the
solicitation:
The main activity this project is supposed to finance is the construction of the roof for the football
field. This activity will create conditions for improving autonomus communication between Kosovo
Albanian, Kosovo Serbian and Roman community interaction during extreme rain and winter
conditions. We are very aware of the importance of sports during the time of the year when conditions
for that are not the same as during the spring and summer. Young people should be engaged in sports
activities throughout the year and young people are the ones who should take the initiative for interethnic events that will promote equality and tolerance, where football is the best tool to achive such
objectives.
We expect, through our organization, to bring people together and make them gather around the most
popular game in the world where the only difference there is between them is the quality they present
on the field.
Once we have the roof construction we will engage in organizing different events, football
tournaments and after parties which will bring all communities closer together and create necessary
preconditions for their more frequent interaction in the future. Government and municipalities are
very much in favor in the interaction between different ethnic groups and we want to be the first one
in our municipality to initiate something of this kind.
11. Describe the proposed participants and/or beneficiaries, and your method for identifying or
selecting participants and beneficiaries: We will seek to engage different Serbian and Albanian
municipalities through an open call for participation, where we will expect them to find teams that
will participate in the events we organize. We already have a few teams from the Municipality of
Gracanica who will be playing in this tournament.
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)
5
15th December 2014 to 15th May
2015
13. All implementation plans must be supported by Annex C that lists all identified tasks over the
duration of the activity.
1.
2.
3.
Task #1
Construction of the roof for the football court
All people in the municipality of Gracanica
15.000e (AKT Grant) plus 2000e from the Municipality of Gracanica, all to be used for the
construction
Municipality of Gracanica
4.
5. 15th December 2014 to 1st January 2015
6. Miodrag Dimitrijevic
7. Successful completion of the roof and a football field with conditions for football matches during
the winter
Task #2
1. Organizing a football tournaments
2. Kosovo Serbs, Albanians, Romas and other minority communities
3. None
4. Municipality of Gracanica will finance some basic needs necessary for the tournament
5. 15th of January to 15th of May
14. Location(s) of the activity (add rows and columns as needed ).
# Community
1 Serbian
Municipality
Gracanica
Target Group
1. Kosovo Serbs,
Albanians, Romas
and other minority
communities
2
3
4
5
15. List personnel who will be involved in implementing this project. CVs & salary history forms are
required for all project personnel. See Annex B.1, Salary History Form.
Section IV. Experience and Capacity
16. Describe the organization’s experience implementing similar activities: We have already
implemented a few projects with the Municipality concerning the sports life of young people. We
attended, with our young and talented children, international tournaments in Italy and Arandjelovac
which were proven to be a great success for us. In addition to that, we have taken the initative in
establishing the tenis school and since May this school is operating with its full capacity.
Section V. Cost
Note: All applications must be supported by the attached Annex B, Detailed Grant Budget.
17. Cost in local currency per the attached budget:
18.
15.000e
Amount requested from AKT project:
In-kind (i.e. donated goods or services) or other contribution
from organization:
People involved in the
organization, everything
necessary for tournament
organization.
Other donors or third-party resources:
Municipality of
Gracanica: 3.575e
18.575e
D
i
s
c
u
s
s
Total Estimated Grant Activity Cost:
strategies for ensuring the sustainability of the proposed activity and organization, including
proposed cost share, expected program income generation (if any), and third party leveraging
of funds (if any). The organization will always be the initiator of sport events and it will promote
tolerance and inter-ethnic events throughout time. We want everyone to feel safe while playing in
Gracanica and the sustainability of such environment will be ensured thanks to our great partner
Municipality of Gracanica. We don’t plan to make this project being profit oriented, as we want sports
to be free and not the luxury of the few. The Municipality of Gracanica is always helping us with
everything we might need for our events and this cooperation will continue in the future as well.
19. List any major donor-funded activities (U.S. and other) that your organization has managed in the last
two years, currently receives, or expects to receive within the duration of the grant activity. Add
additional lines if necessary:
Donor Agency
Municipality
of Gracanica
Title of Project, Location, & Start &
End Dates
Inter- ethnic tournaments between
Serbs, Albanians and other
minorities
Total
Funding
(in local
currency)
500e
Donor Contact Person
Name: Ivan Tomic
Email:
[email protected]
Tel: 049/436-061
Name:
Email:
Tel:
Email:
Tel:
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): _____________Miodrag Dimitrijevic, director________________
Signature: _____________________________________ Date: _______21/11/2014__________
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 B – DETAILED GRANT BUDGET TEMPLATE (EXCELATTACHED AS SEPARATE DOCUMENT)
ANNEX B.1- SALARY HISTORY FORM
This is an external form for completion by employees and consultants of grantee organizations. The form
should be signed by the employee/consultant and also the organization’s legal representative.
Instructions
Include within this form the last 3 years of salary earnings. If you have worked as a full time employee,
then complete #7, noting your monthly gross salary in the currency in which you were paid. Do not
include 13th month salary benefits, bonuses, commissions or overtime. If you received a salary raise then
include it as a separate row, indicating the start date.
For your current job, include ‘Present’ in the ‘To’ column.
If you were a short term consultant, note in #8, the number of days and daily salary rate (based on an 8
hour day) in the currency in which you were paid. The daily rate should be exclusive of per diem (meals
and incidentals and lodging payments), and transportation.
CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET
1. Name (Last, First, Middle)
2. Contractor’s Name
3. Employee’s Address (include ZIP code)
4. Contract Number
5. Position Under Contract
6. Proposed Salary
7. Duration of Assignment
8. Telephone Number (include area
code)
9. Place of Birth
10. Citizenship (If non-U.S. citizen, give visa status)
11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment
12. EDUCATION (include all college or university degrees)
NAME AND LOCATION OF
INSTITUTION
MAJOR
DEGREE
DATE
13. LANGUAGE PROFICIENCY (see Instruction on
Page 2)
Proficienc
Proficienc
LANGUAGE
y
y
Speaking
Reading
2/S
2/R
2/S
2/R
2/S
2/R
14. EMPLOYMENT HISTORY
1
Give last three (3) years. List salaries separate for each year. Continue on
separate sheet of paper if required to list all employment related to duties of
proposed assignment.
2
Salary definition – basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions,
consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.
EMPLOYER’S NAME AND
Dates of Employment (M/D/Y)
Annual Salary
ADDRESS
POSITION TITLE
POINT OF CONTACT
From
To
Dollars
&TELEPHONE #
15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)
SERVICES PERFORMED
16. CERTIFICATION:
EMPLOYER’S NAME AND
ADDRESS
POINT OF CONTACT
Dates of Employment
(M/D/Y)
From
To
To the best of my knowledge, the above facts as stated are true and correct.
Signature of Employee
17. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)
Date
Days at
Rate
Daily Rate
In Dollars
Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to
verify the information contained in this form. Contractor understands that USAID may rely on the accuracy of such information in
negotiating and reimbursing personnel under this contract. The making of certifications that are false, fictitious, or fraudulent, or
that are based on inadequately verified information, may result in appropriate remedial action by USAID, taking into consideration
all of the pertinent facts and circumstances, ranging from refund claims to criminal prosecution.
Signature of Contractor’s Representative
Date
IMPLEMENTATION PLAN
Target
Task
Audience
List each task. Please be as Who is the
specific as possible. Use
audience
additional pages if
targeted for
necessary.
the task?
Non-Grant
Resources
Required
Grant
(Grantee or Third
Resources
Party
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
About
17.000e
Building the roof
construction
Organizing tournaments
Serbs,
Albanians,
Roma and
other
communitie
s in Kosovo
2 3
4
5 6
X
500e, for balls,
drinks,
sandwiches,
trophies.
X X X X
7
8 9
Person(s)
Responsible
Who is responsible
for overseeing and
implementing the
task?
Evaluation
Indicators and
Milestones
How will you
measure the succe
of the task?
Miodrag
Dimitrijevic
The completion
the project and b
choosing the bes
possible materia
be used for build
the roof
construction.
Participation of
Albanian and ot
minority teams
10 11 12
Miodrag
Dimitrijevic
ANNEX C.1: SAMPLE IMPLEMENTATION PLAN TIMELINE
ANNEX D: 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:
”Sportski savez Gracanica”
2. Activity Title: Recostruction of sports field
3. Name, Title, Contact Information of Individual Completing Questionnaire:
Miodrag Dimitrijevic, director, 049 137 136
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,
No
c. Accounting records are complete, accurate, and kept on a regular basisYes
No
Yes
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:___Goran Marinkovic_______
2. Title:_______Cashier______________
3. Telephone number:___044 502 261____
3. The name, position/title, and telephone number for the individual responsible for
maintaining accounting records:
1. Name:________Dejan Zivic____
2. Title:_______Secretary________
3. Telephone number:____049 554 922
4. List the name, position/title, and telephone number for the individual responsible for
preparing financial reports:
1. Name:_____Nenad Milic______________
2. Title:_______Financial officer__________
3. Telephone number:_____045 699 528___
5. List the name, position/title, and telephone number for the individual responsible for
preparing narrative reports:
1. Name:_______Miodrag Dimitrijevic____
2. Title:__________Director____________
3. Telephone number:____049 137 136___
6. Does the organization keep timesheets for each paid employee?
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,
Yes
Yes
No
No
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
11.
c. Monthly
d. Ad hoc/as needed
d. By accountants decision
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
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_____________”Sportski Savez Gracanica”_____________________________________
Grantee’s Authorized Representative Name_________Miodrag Dimitrijevic_______________________
Grantee’s Authorized Representative Title_______________Director____________________________
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 inkind, 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
_________________________
Date of Execution
Page 18 of 19
Annex F: Survey on Ensuring Equal Opportunity for Applicants
Please access this document at the following link:
http://www2.ed.gov/fund/grant/apply/appforms/surveyeo.pdf
Page 19 of 19
