Application #: Region: Date of receipt: For internal use only 1. Project name: 2. Organization name: 3. Project director name and title: 4. Project Start and End dates: 5. Project Geographical Coverage: Program United States Agency for International Development - USAID Holt International Children s Services Holt Charities Aid Foundation CAF APPLICATION FORM Fifth Grant Competition Cover page 6. Project area according to the directions. Please identify just one of the below boxes: Abandonment Prevention Family-based Alternatives Social Adaptation for Development and Promotion Services for Families to Institutionalization of Children Leaving of Child Rights and Children at Risk, Abandoned Children and Government Institutions Protection Practices including Special Needs Children without Children Parental Care 7. Beneficiaries of the Project (Target Groups): 8. Project Summary: 9. Requested amount for the Project implementation: I hereby confirm the authenticity of the information provided herein. Organization Director (signature): Project Director (signature): 1
Date: Stamp: Program United States Agency for International Development (USAID) Holt International Children s Services (Holt) Charities Aid Foundation (CAF) APPLICATION FORM Fifth Grant Competition This package of documents is required to apply for a grant from the Program. If the application lacks the required information it may be returned to the applicant for further revision. The application should be typed in Russian or English. The application and all attachments should be presented in four copies, and include the following sections: I. Information on the applying organization 1. Organization Name: 2. Legal status of the organization (please, attach a copy of the organization's By-Laws, and a copy of the certificate of state registration as a legal entity): 3. Date of the organization s founding: 4. Registration date: 5. Organization's address: Zip code Address Legal Address Actual Address 6. Telephone #: 7. Fax #: 8. E-mail address: 9. Names of the organization's directors: 2
10. Bank details (please, attach a copy of the certificate of registration by the State Taxation Inspection): Official name of the organization (as in payment orders) INN Rouble settlement account Payee's bank Bank branch (if applicable) Correspondent account BIK City Names of persons eligible to sign bank documents: Name Position Phone # 11. Founders of the organization: Private individuals: Legal entities: Founding organization 1. 2. 3. Legal status 12. Names of the organization's branches/sub-programs/sub-divisions (if applicable). Does the organization participate in other associations, unions? (a relevant official document may be required at a later date). 13.Are you currently applying for or have you already received grants from other donor organizations? If yes, please specify names of the projects, main goals of the projects, grant amounts. Project name Main goals of the project (briefly) Project timeframe/grant amount 14. How did you learn about the Program? 15. Organization's current sources of funding: 3
16. Organization's annual budget for the previous two years (relevant official documents may be required at a later date). 1998 1999 17. Geographical coverage for the organization's activity (please, specify in which regions your organization works): 18. Number of staff in the organization: 19. Brief summary of the organization's activities and achievements: 20. You may attach other information about your organization relevant to this project (publications, brochures, reports, etc.), recommendations and/or letters of support. II. Project summary. Please, try to provide as complete and clear information as possible for the following sections. Please identify your project area according to the directions. Check in just one of the below boxes: Abandonment Prevention Family-based Alternatives Social Adaptation for Development and Promotion Services for Families to Institutionalization of Children Leaving of Child Rights and Children at Risk, Abandoned Children and Government Institutions Protection Practices including Special Needs Children without Children Parental Care 1. Urgency of the project (justify the need for the project): 2. Project goals: 2.1 How are the project goals related to the objectives? 3. Project objectives: 4
4. Specific expected results (please, describe what results you expect to get upon the completion of each stage of the project, in particular, and upon the completion of the project, in general): 5. Geographical coverage for the project (specific area where the project will be implemented): 6. Please describe the project s target group(s) (provide as detailed a description as possible including, for example, children s legal status, age, length of placement in family, specific psychological, medical, or learning challenges to be addressed, etc ) 7. Number of expected participants from the target group(s): 8. How do you attain information about the target group(s)? 9. How do you intend to recruit participants from the target group(s)? 10. How will participants from the target group(s) be selected and what are the selection criteria? 11. Identify the types of services and assistance you are planning to offer to the beneficiaries of the project. 12. Describe the specific methodology for attaining the expected results. 5
13. Justify the feasibility of implementing the project in the selected region(s) (Please describe how the proposed project conforms to local legislation related to the services provided) 14. Project work plan (please provide a detailed description of the proposed activities: organization of the work at each stage, persons/organizations involved in each stage, users of each separate service, resources involved): Project Implementation - Monthly Plan: I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. If you involve other organization(s) (partner(s)): 15. Please provide a list of partner organizations (name and legal status of the partner(s)): 6
16. How long have you cooperated with your partner(s)? Please y reasons for your collaboration. What joint activities have you accomplished already (brief description): 17. Which specific activities are you planning to implement together with your partner(s) under this project? How will functional responsibilities be shared between the partners? 18. How will the partnership(s) impact your organization? How will the partnership(s) benefit project implementation? 19. Project methodology (forms and types of activities): In this section, please provide a detailed explanation of the activities you are planning to implement under the project. In particular: If the project contains a social or psychological assistance component for children and placement families, please describe the component in detail including the steps in its implementation, the issues the component addresses, the quantity of participants receiving the assistance, who specifically will implement this component, duties and responsibilities for implementation., etc. If your project focuses on rehabilitation activities, please describe completely the rehabilitation process, its basic principles and the rehabilitation goals, what type of specialists will be involved into the process, the role of parents in the process, if any, etc. If your project contains a socialization component, please describe the socialization process, the proposed socialization methodology, the qualifications of specialists working on this component, the roles of project staff in the socialization process, etc. If you propose to create a new service, please describe its purpose and objectives, stages for its development, working plan, etc. If your project will assist placement families, please detail exactly what assistance will be provided, how this assistance will be provided, what issues does this assistance address, the types of placement families to be assisted, who specifically will provide the assistance, etc. If the project includes the publication of materials, state clearly the subject of publication, number of pages, volume of your publication, list of publication recipients, the dissemination process, etc. If applicable, please submit an annotation of the proposed publication. If your project contains a training component, please provide the basic elements of your training program, quantitative and qualitative lists of the potential trainees, training plan and schedule, etc. 7
If your project aims to shape/change public opinion, please list the key concepts/opinions you will target, method of implementation, addressees of this component, expected results, etc. 20. Project staff (please attach a resume of key participants and a list of all participants). Briefly describe titles and functional responsibilities of each project staff member. 21. Post-project development/financial sustainability (How are you planning to continue the project upon the completion of funding?). If the application addresses activities which require funding after the end of the grant, please present a properly developed and justified plan for the project continuity as an attachment. 22. Organization sustainability (staff/facilities (owned or rented)/equipment/office equipment): 23. Partnership sustainability: 24. Project evaluation criteria (please specify how you plan to evaluate the project s impact): 25. Project's long-term impact: 26. If you plan to disseminate the project results, please specify the forms of dissemination you plan to use: 27. Specify possible obstacles during the project implementation. What would you do to overcome them: 8
III. Budget The following tables should contain information on expenditures with exact and justified amounts for your project. All amounts should be in unit equivalents (y.e.). All applicants must provide a comprehensive narrative budget. If necessary, use additional sheets to present the budget. If some of the listed line items in this form are not applicable to your project, leave the relevant fields blank. If you are awarded a grant, you will have to present detailed quarterly projections and financial reports. 1. OVERALL BUDGET BUDGETARY LINE-ITEM 1 Salaries for the project participants (incl. Taxes other charges) 2 Equipment and relevant goods 3 Travel and transportation costs 4 Administrative and other direct costs 5 Other expenditures (besides those included in other forms) Total: Requested amount/ unite equivalents (y.e) Match/ unite equivalents (y.e) TOTAL/ unite equivalents (y.e) Applicant/ Project director (signature) Date: 9
2.1. Salaries for the project participants 2. LINE-ITEM BUDGET Name Category I (project staff) 1. 2. 3. Category II (consultants, trainers) 1. 2. Position in the project Salary (per month for category I, per day, hour for category II), unit equivalents (y.e.) Total salaries for the project participants Duration of work (months for category I; hours, days for category II) % of working time (for catego ry I) Total, unite equivalents (y.e.) 2.2. Equipment and relevant goods This table should include information about equipment needed to implement the project. List each item, quantity and suggested price. If you envisage any accompanying costs for this line-item (such as transportation costs, installation, maintenance, etc.), include them in the cost of the equipment. # Item Price for a unit, (y.e) 1. 2. 3. Total cost of equipment: Quantity, pcs. Total cost, (y.e.) 10
2.3. Travel and transportation costs Type of expenditure 1. Tickets (specify the itinerary, number of traveling persons and estimated prices for round trip tickets) Total, (y.e) 2. Per diem (number of days and participants) 3. Fees and miscellaneous costs 4. Lodging (number of days and the price of a hotel room per day) Total travel and transportation costs: In case you plan several trips, it is necessary to fill out a similar table on a separate sheet for each. 2.4. Administrative and other direct costs This budget line item includes all costs related to the administrative activity within the project. This table should include the information on types of expenditures: rent of facilities, utilities, postal costs, etc. 1. 2. 3. Type of expenditure Total administrative costs: Amount, (y.e.) 2.5 Other costs (besides those included in other forms) Type of other costs Amount, (y.e.) Total other costs: 11
3. NARRATIVE BUDGET A. Any matching funds or other resources contributed to the project should be clearly listed in this section. Any amounts budgeted over the grant cost should be clearly explained and information provided on the planned source for the additional funds. B. This section should contain a detailed and clearly stated narrative budget 12