CHU TICH CHU TJCH

guyên Van Bay

Ut BAN NHAN DAN HUYN MINH LONG

cQNG HOA xA HQI CHU NGHIA VIET NAM OQe Ip - Ti do - Hh phüc

So: AS /UBND-NC V/v Chuang trmnh vin thy không hoàn Ia cap co' sâ (GRA) cUa Chinh phU

Nhat Ban

Minh Long, ngày AS tháng 01 nàm 2020

Kinh giri: - Phông Giáo dvc và Dào tao huyn; - Phông Lao dng - TB&XH huyn; - Trung tam yT té huyn; - Uy ban nhân cac xâ.

Thuc hiên Cong vAn s 02/SNgV-HTQT ngày 02/01/2020 cUa SO Ngoai vii tinh Quàng Ngäi ye chuang trInh viên trq không hoàn lad cap co sO (GRA) cüa ChInh phü Nht Ban trong nAm tài khóa 2020.

UBND huyên thông báo den UBNID các xA và cac ca quan, dan vj lien quan có nhu câu ye nguôn vin trq không hoàn 'a cüa ChInh phü NNX Bàn dôi vOi môt so du an quy mô nhO nham gop phân thüc day phát triên kinh té - xä hôi ti dia phuang; dé nghj UBND các xä và các các ca quan, dan vj liOn quan 1p ho so', thu ti,ic theo huOng dk tai COng vAn so 02/SNgV-HTQT ngày 02/01/2020 cUa SO Ngoai vi tinh Quãng Ngâi (dInh kern van bàn,).

Th&i gian gui htsa dir an: Các ca quan, dan vj liOn quan vâ [JBND các xã hoân thin ho so' (nOu co) gui ye UBND huyn 'qua phông Ni vy,) chm nhât trong ngày 20/01/2020 dO kjp thôi tong hqp gfri SO Ngoai v'i dUng theo quy djnh./.

Nd nhân: - Nhu trên; - CT, PCT IJBND huyn; - PhOng NV huyn; - CVP huyn; - Lu'u: VT.

UBND TtNB QUANG NUAT SO NGOAI VU

QL /SNgV-HTQT

V/v Chuting trinh viën tro khOng hoàn lai cap Co s& (GRA) eüa

ChinE phü Nht Ban

CQNG HOA XA HQI CHU NGH!A VIETNAM Doe 1p - tkb$J1JaDfrnJnicMn'4n LUft

Quang Ngdi,

KInh gui: - UBND các huyn, thành phd; - Các Sâ: Gião due &Dào tao; Lao ,

dQng, Thuong binh & Xã hQi; y to.

Trên co sO triOn khai pác hoat dng hcrp tác vOi the co quan di din ngoi giao và the tO chüc quOc tO ti Ha Nôi, dông th&i tranh thü, xüc tiOn van dQng nguOn vien tra không hoàn lai cüa ChInE phü N$t Bàn dôi vOi mQt sO dr an quy mO nhó nhAm gop phân thüc dày phát triOn kinh tO - xA hOi eüa dja phuong, cãi thin dOi song ngu&i dan ô cáe dia bàn eOn khó khän, SO' Ngoi vv thông báo và huthig dan vO quy trinh, thu tic hO so trong khuOn khO chuoi'ig trinh vin try không hoàn Iai cap co sO (GRA) do ChInh phü NEat Bàn vin try trong nãm tài khóa 2020, cu thO nhu sau:

1. Thông tin co' ban v chu'o'ng trmnh:

- Myc tiêu chu'o'ng trinh: Dày là chuong trinh vin try khOng hoàn lai cap Ca sO (viOt tat là GRA) và là môt hInh thüc vin try phát triên chinh thc ODA cña Chinh phü Nh9t Bàn, có mi1c tiOu tác dông trvc tiOp tài dOi sOng eng dOng dan Cu.

-Tw each don vj nhân tài tro': ChinE quyn dja phuong nhu UBND cp xä hoc cap huyn; bnh vin; co sO' giáo due, tning tam dy nghO; các to châc phi chinh phü cüa nuo'e sO ti. Các cá than và doanh nghip hot dng vi lçxi nhun khOng phài là dOi tuccng dü tu each xin vin try.

- Linh vwc dii' an: Giao due co sO; y tê ca sO; dão to ngh; giao thông nông thôn; phüc lyi cong eQng; rnOi trutng.

- Kinh phi tài trçr: ChinE phü NhQi Bàn sê quyM djnh tài try sau khi nghiOn ctru xem xét tfrng dij an vOi tOng s6 tin tài trq eho mOi thy an thu'O'ng khOng qua 10 triu Yen (khoãng 02 t5' dng). Các khoãn myc khOng du'qe tãi trç gOm: do thing, chi phi vn hành và bão du'&ng thiét bj vã chi phi hãnh chinh khác ella t ehü'c xin vin trq.

2. Cách thüt np ho so':

- so' xiii vin trçr bao gOm:

+ Don xin vin try di&n dy dU thông tin (theo mJu dinh kèn'z, g;n 01 bàn tilngAnh và 01 bàn uing Vit).

KT• ClAM DOC AMDOC

+ Bàn dt dánh dtu dia dim thiyc hien dr an.

+ Anh chyp hiên trng ccx s& vt chAt trong dy an.

+ Thi& k vWhoc mô tá k thut cUa dv an (Tiéng Viet+ Tiêng Anh).

+ 03 báo giá kinh phi cho hang hóa hoc djch vv dv djnh xin tài try và 01 Mo giá cUa cOng ty kiêm toan dOe 1p (tJng cong 04 bdo gid).

+ Tài lieu, t& ml hoac bAt ci mt van bàn nào cung cap nhQng thông tin v t chüc/don vi xin du an (nêu cO).

+ So' d b tn h90 sinh elm m& lop hoc lUc tru'o'c vã sau khi thyc hin dv an (dành c/to de an xây dy'ng (ruling hoc).

- Mi ccx quanl dan vi xin viên try cO th4 nôp 01 h so' xin vin tro cho 01 dv an (rnin phi nQp don) trong nàm tài khóa cüa Nht Bàn (ndrn tà/ Ichóa tinh tà ngây 01/4 den ngày 31/3 cña nárn sau).

- Khi chuân bj h so', các dja phtrotg n In ', the h3ng myc nhu' pha! triên nàng 1'c con ngtrôi có the coi là mQt phân cüa dy an néu do là nhãn to can thiêt cho hiu qua cña thy an hoc dwqc xem là rnt phân khOng the thiêu cüa dv' an.

3. Thô'i h4n gui ho so dy' an:

So' Ngoi vv gui kern theo Cong van nay mu Dan xin viên try, gm bàn tiêng Viet va bàn tiêng Anh, trong do bao gôm thông tin chi tiét ye ho so dv an. Dé nghj cac dia phuang, ccx quan, dan vj nghiên cüu, 1p dg an và thông báo cho các dcm vi trçrc thuQc (néu co) xay di,mg dv an; hoan chinh thông tin theo mu Dan vã go'i hO sa du an càng các tãi lieu lion quan vO So' Ngo?i vytrwó'c ngây 25/01/2 020 dë So' Ngoi vi tong hgp, báo cáo UBND tinh có van bàn dO nghj phIaNhãt Bàn kjp th&i xem xét trong nàm 2020. Thông tin liOn he: Phong Hgp tác Quc tO, diên thoai: 3822623, fax: 3822771, e-mail: ntdthaogrnail.com.

No'! nildi,: - Nhis trën; - UBND tinh (b/cáo); - SNgV: PGD (ô.Thành); - Luu VT, HTQT.

CHIIONG TRINH VIEN TRQ KITONG HOAN Li CAP CU SO CUA CHfNH PHU NH4J BAN

(GGP)

From the People of Japan

DAT sO' QUAN NHT BAN TAT VI NAM

Hay gi'ri Doir xiii vifu try' dii 6/liz dy dü thông tin và cik Mi lieu din/i kéni cl/hz din c/ti sau:

Ba Minori Ishii Ban Kinli tê Dai sü quán Nhat Bàn tai Viêt Nam So 27 pM Liu thai, Qt4n Ba Dinh, Ha Nôi Te1:04-3846-3000 Fax:04-3846-0048

Trzthc k/ti nop Doiz xiii viên trp dl ng/zi doc 19 n/i ü'ng mu j5 quail ti'png duo! day.

MJi cc quazi/don vj xin vifn try có i/il ,z3p 1 (nzt) 1,6 so' xiii vi?n try c/to 1 (nit) dr tin hong ninr Mi k/iOn cnn Nhflt Bàn (nãin Mi khOa du'pc thzh tfr ngày 1 (hang 4 den ngày 31 h/thug 3 train sail,)

Mi&z pill np Den xiii vifn try: fl vây, Dgi sth' qudn Nhit Bàn cling n/Ire n/ian viên cüa sá' qudn se không So giàyêu c6u ben n5p ho sop/Mi nç3p bdt ca nit khofln p/ri, yêu thu (rich tiên hon hông hay môt khoàn tiên nào khdc cô h/en quail /zoc c/to inuc dick (go sy' thuOmi (p1/ion, un tiên /101, k/il xét day ft/to so xiii vifn trg

N/zli'ng /zgmzg nzyc n/zu',p/uit tHIn niuzg lwc con ngw&i cd thl coi /à nz5tpIiã;z can On nla 66 là n/ran 10 can IbM c/ic hifu qua cüa dc On /zoc du'p'c xe,n là zntp/iân k/tOng the thiêu cnn dy On.

N/zü'ng Mi lieu duvr liêt kê dzró'i dày Ia n/i 1mg giây tà Mt bzic p/Mi du'p'c c/i ufln bj day dfi trong bô ho so xiii vin tip'. VI viy, hay kiêm Ira th?It kj b 1,0 so'xin v/S try triró'c k/ti gui den Dyi sfr qudit.

Dan xin vin trcx theo mu (bàn ti&ng Viêt)

fl Don xin vin trg theo mu (bàn ti&ng Anh)

fl Bàn d dãnh dAu vi tn dii an

AnE chup th& hiên tinE trang hiën tai cQa cong tnInii (vi d phang hoc xuông cAp, thi&t bj nghêo nan...)

fl ThiAt k& k thut cUa cong trinh hoac däc tinh k9 thuât cUa thiEt bj trong dv an (vi dw bàn ye thiEt k& xây drng cUa du an, bàn thông s k9 thuAt thiEt bi, ành cUa thit bi dir ki&ri mua sam cüa dii an ...)

E Báo giá cüa 3 (ba) cong ty xây thing khác n.hau nëu là d\r an xây dung hoac 3 (ha) cOng ty cung cAp thiët bj khac nhau nu là dr an cung cAp thi&t bi

fl 1 (rnt) báo giá ki&m toãn cUa mOt Cong ty kiërn toán dc ip. Cong ty Kiam toán nay có khà näng tâi kiêrn tra tri,rc tip cOng trmnh, chyp ành cOng trinh vâ xác niinh vic sr dpng hqp l nguôn vin trg, các giao dich tài chinE lien quan (viëc chup ành có thA dirge lam thay bâi don vi xin d? an)

fl 111 lieu, tä wi hoc bAt th mt van bàn nào cung cap nhüng thông tin ye t6 chüc/dan vi xin dii an (nêu co)

fl (Dành cho dv an xAy drng truäng hoc) So d b tn hoc sinE cUa mi lap hoc lác tnuOc va sau khi thuc hién dii an (rnk so d ló'p hgc duot dInh kern theo nu don xin viên tro)

Page 2 of 7

H

H u

S

PHAN I — THÔNG TIN yE Co. QUAN/TO CHIIC LAM DON XIN VISN TRQ

Hay chdc chdn rang nhirng thông tin ca bàn càa tá cht?c/dan vf xin viên trp dwqc didn t.rong phan nay là thông tin chinh xác và cop nhdt. Thông tin lien lqc nhw dia chi và so 0/en thoai là nhiThg thông tin dOc biçt quan trpng.

1. Thông tin co bàn

a. Ten t chc/dan vi.: b. Lânh dao cüa M chik/don vi (ten vã chüc vu):

Xin hat) ring cá nhan nay se' là ngu-ái thay mOt td chvèc/dan V/ 195 hgp ddng v/en Ira khi dr an dwcrc chinh phü Nhat Bàn phê duyet. c. Dia chi d. DAu m61 lien lac (ten, chUc vu, s dién thoai, email)

Xin iwu j5 rang Odu mdi lien lac cO thi là ngwOJ khOc, khOng nhdt thiltphOi lalanh dgo cüa to' ch&c/dan v/. Ngzthi nay sJ tip nhqn lien lac vó,i nhôn viCn cüa Dqi s,,2 quOn và phdi hpp th 1) cOc vthi dphOt sin/i lien quan iol don xin v&n tip'.

2. Thông tin chi ti& v t chfre/do'n vj xin vin trq

a. T chüc/dan vi xin vien trq thuc loai hinh nào dithi day?

Don vi chInh quyn cap dia phuang Truäng trung hoc, cao ding, và các ca sâ dào tao BÔIIh viên vã các co sO cham sOc khám chua bénh T6 chic phi chinli phü, phi 1?i nhun ('NGO/NPO) Ti chüc khac (nêu rO 0 duOi day)

Can lu-u j ränz các cc quan chInhphñ cOp trung wang khOnz t/iuOc 001 twang Cu-ac xciii xél cOp vOn viên tra nay,

b. Nãrn thãnh lap:

c. Ca cAu chüc cUa t6 chOc/don vi:

Hay cung c4v thông tin vA cc cdii quOn 5 cac phông ban và sd litp-ng nhOn i'iCn (vi dy: sO hu'qng can ho cüa UBND xa, sO lwng ?iá0 viCn, hoc sinh, hOc s9, y tO . .. thy thea loai h/nh to ch&c/do'n vi da Ira chon a trén). Se rOt him ich nëu tO chü-c/don v/ gui kern thea don xin viên tn nay sa do cc cdu to chüc cOa dun vj mink

0. Cac hoat dông cña t chik/dan v

Dé ngh cung cap thông tin thea nhUng gui 9 dixOi day thy thea phân 1°a1 cUa to chrc/dan vi xin viên tra dà Iua chon.

• Chinh quyEn c4 0/a phuv'ng: thông tin vl tinh hinh kinh tE xd hOi cüa 0/a phu-ang 'dOn sO, ngành sOn xuOt chink sOn phOrn chinh, thu nh4p b/nh qudn dOu ngu'ài, nhiing

vdn ad kinh tl xd hai dang gOp k/id k/ian...); • Trzthng (rung hQc. cao ddng, và cdc cc s& dào tao: thông tin cOc k/ida hoc, cOc k/ida

dào tao nghe, các mon hoc...; • Bênh viên và cdc cc so chäm soc khOrn cht?a bënh: cdc dch vu y é, so giuOng bênh,

so bnh nhOn nOi ngoqi (ni.; • T8 chüc phi chInh phi phi Iqi nhudn: inuc didi thank lap. cdc hogt dng chhih, Mt

qua dgt dwcc • Td chzk khOc: cOc hoot dng cüa td chilc, tnyc tiêu và Mt quO dqt du'ac

e. Mo tã nhung dv an ma tO chüc cüa ban da thvc hien gãn dày vói nhthig thông tin niw ten dv an, khoàn viGn trq (so lien và nguOn viën tra), thai gian thuc hiën, nOi dung dii an, két qua dat duoc. Co the thay the viëc niô là bang bàn báo cáo hoàn thành dv an hoc báo cáo hoãn thành mua sam thiêt bj cho yeu càu O mic e. nay.

f. Tinh hin.h tài chinh

(1) Vic thu chi cüa t chótldan vj cüa ban trong 2 (hai) nàm gkn day nhAt.

Hay cung c4i thông tin ngãn gqn vd l'iêc thu chi cza to ch&c/dcn v/ cüa ban trong 2 näzn qua. Thông tin cd the duçc cung cOp thco hinh tht'rc cüa hông cOn doi thu chi (xe;mi ;nOu, cho tt'cng nOin tài khda.

BOng can dái thu chi ('mJu)

Thu Chi Thug VND Luong VND L phI VND Phi quãn 1 VND Trg cAp VND Du lii cOng VND Két dir nàm truác VND Phüc igi xa hi VND Khác (tiên quyên gop, cac loai tiên chuyên klioan den...)

VND Khác VND

T6ng thu VND T6ng chi VND

(2) Nêu cO thârn hut thu chi Ihi x& 19 nhu the nào (vi dv nguOn tro cAp bO sung, vay ngàn hang, that cht ngân sach nãm ké tiëp ...) ?

3. Th chüc/don vj cüa ban dä tfrng nhân dwqc sir try: giñp (h6 trq tãi chinh hoc k thut) cüa cac chinh phü nu'&e ngoài, cac tO chüe quOc té hoc các tO chfre phi ehinh phü nào khác trong qua khü chu'a?

Eco flChira

P/lu cOu trd lOi là "Cd ", ad nghj cung cdp thông tin khái quOt vd khoOn vin tmv dO, bao gOrn thông tin ye nOni thcc hiQn, tOng kinh phi the On và ngudn vin trq.

Page 4 of 7

PHANH—NQIDUNGrnJAN

1. Ten dir an dê xut

2. Dia Sm thut hiên dir an

Hay cung cOp thông tin yE dja diem thyc hin dy On cOng chi tiêt cOng tot, bao gOni ten xd, ten huyên, ten tInh vO khoOng cOch tf. thành pho HO N/ den thOnh phO/th/ xa/thi trOn trung tOrn gOn nhOt cüa dy an.

3. Muc tiêu

Hay mO tO myc tiéu chung cüa dy On. VI dii, dy On së gOpphOn

- cdi thiçn ä'iCu kin giáo dyc cüa xi! - diêu kien sOng cüa ngwOi nghèo

4. TInh trng hin tai

Hay rnO tO cOng clv tilt COng tIt tinh trqng hien Iqi cüa khu vuc xung quanh dy On muOn cat th:ên Hay sit dung nhilng sO hCu tat lieu san co Anh chup tinh (rang hien tam (Vi dy: kliu nhO hpc xuOng cOp, thiCt bAy tC nghèo nan, hông hOc ...) së rOt hihi ich de thông báo h/en trczng cOng tuinh.

5. FIng myc cong trInh dy an

Hay mO tO hoac cung cdp tOi lieu cia the On. Ddi vOl dy On xOy dyng se cdn bOn ye thiCt Ice. 1)0/ vOl dii an cung cOp trang thiCt bj sC khOng the (h/eu dçic tinh Aj thual ci?a (h/Ct hi vii Onh thiêt hf

6. Hiu qua ruong dci cüa dl?' an

Hay cho chüng tOi bitt dOnh giO Cüa tI chác/dan vj yE hiu quO thvc hi n dy an, bao gOni CO 56 ngwài dLCQ'C huOng iqi tie dii On, cO the the hin sy dOnh giO bang con so.

7. Thôi gian thc hin diy an

Xin hay hwu) rang thai gian thuc h/en dii On khOng thE Mo dài han I (mnç5t) nOrn IcE (it ngOy két HQp dOng vin trp' dü vol bat I 1) do vii trong bat hoin cOnh niio.

8. Thông tin khác

TO chtht/dan vi cOa ban cO dang np hd sa de On nOy hoc die kiln xin hJ Ir ui/ chinh cho dy On nay tái cOc nha tOi tr khOc hoac các cOp chinh quyCn cao hon nhu UBND huyen hay UBND tinh khOng?

NCu cOu trO lUl hO"CO ', hay cho biét tinh hinh h/en tai cüa viçC nôp ho so do (xeni Muc III 3.)

PHAN LII — KE HOJ.CH TAT CHINH

1. 3 (ba) báo giá (nhir trong tài Iiu dinh kern)

Hay cungcdp 3 bOo gid IthOc nhau, nii bOo gid chi phi die On thcçc xdy drng bO'i I (mat,) nhà thdu tiêin ndng.

2. Chi phi chi tit

Hay trinh bay chi tilt chi phi ddu tie dy' On d(ea trén hOn bOo giO cáo cOng có bOo giá tSp nhOt Lieu ,)5 quail 119ng: Thuegid ti'iia tang (VA?) khOng thcac tinh bao z5n tron,g khoOn viCn tro GOP Hay chac chan rãn bOo gld khOn2 boo gOm thuê VAT vii tO chi?c/do'n vi xiii v/en tm cho die On phOi tie c/il ti-a cho phOn thue VATnthy. Môt lieu j5 nia ma tO chüc/don vi dy' djnh xin die On can b/el là nguOn viCn ti-u GOP sir khOng dieuc dàng de thanh toOn chi phi tie vOn, phi qudn 1) thc On, chi phi giái phong môt bOng dOi vâi die On xOy dieng, k/nh phi dy'phong, coc log) thul boo gôm cO time VAJ cOc khothn lien và cOc chi phi khác khOngphue hgp vOl chInh sOch v/fr ti-c cáo Chinhphá N/ia! Bàn.

3. Các ngun tài tr khác

NAzi &A xudt xin vijn trg GOP nay là mat phdn trong mat dy' an Ian hc;i, de nghj cung cOp thong tin ye tOng nuk ddu tie dy' On, mO là ngOn ggn nai dung cáo cOc hgng myc dOu lie khOc va chi rö hop p/iOn th dung nguOn vign tr GOP trong dy' On lan dO.

Xin lieu) rOng nguOn vi&n trg GOP can phOi diept sz} dyng nhie mpt ei'y' On "dac lap theo nghio là pSi hoàn bàn tOch bit vOl cOc hap phan khOc trong dy- On iOn ye cO nØt 101 chin/i và vat lj VI du nhie GOP cO the v/en trp dC xOy dy'ng I khu nba hong sO 2 khu nhà hpc ma nba trieàng die kiën ddu lie. Khu n/ia hoc k/a cO the xOy dyng bang nguOn viCn lrp khá NuOn viên tra GOP khOng the dung de xOy dung 3 phOng hpc trong sO 4 phOng hoc dir kiên dOu tie và phOng hoc cOn iqi sir duc hal Ira bOi môt to chüc khàc.

Ngày tháng nAm HovaTên Chfrc vu Chuk

29hoc sinh

(lOp 3)

29hoc sinh

(lOp 3)

30hoc sinE

(lop 4)

30hoc sinE

26liçc sinE

(lOp 5)

27hgc sixth

(lOp 5) (lOp 4)

29 hoc sinh

(lOp 3)

29 hoc sinE

(lOp 3)

29 hoc sinh

(lOp 4)

29 hoc sinh

(lOp 4)

27 hQc sinh

(lOp 5)

27 hoc sinh

(lOp 5)

Hc buOi sang

Hoc buôi chieu

Hoc nüa ngày

(Tái lieu dinh kern)

VI d v so dè hgc sinh

Tru*c khi thut hiên dir an

SO phông hçc hien có: 12 phOng SO hoc sinh: 341 hgc sixth (18 lop)

31 hçc sinh 31 hpc sixth 31 hoc sinh 31 hoc sinE 31 hoc sinh 31 hoc sinE (1 1) (1 1) jp 1) (lOp 2) (lOp 2) (lop 2)

Hoc cã ngày

Sau khi thuc hen dir an

Hai phOng hgc së b da bô do qua xu&ng cAp'. SO phông h9c: 18 phOng SO hoc sinh: 341 h9c sixth (18 lop)

31 hoc sinh 31 hQc sinE 31 hoc sinE 31 h9c sixTh 31 hçc sinh 3 1 hc sinh (lop 1) (lOp 1) (lOp 1) (lOp 2) (lOp 2) (lOp 2)

Hoc cä ngãy

29 hçc 29 h9c sinE 29 hoc si 29 hoc sinh sinE (lOp 3) (lOp 3) (lOp 3)

(lOp 3)

H9c cã ngày

2 tang s phOng

hoc mOi xay

dvng

30 hoc sixth (lOp 4)

30 hçc sinE (16p 4)

26 hpc sinh (lOp 5)

27 hpc sinh (lOp 5)

29 hoc sinE (lOp 4)

29 hoc sixth (lOp 4)

27 hoc sixth (lOp 5)

27 hoc sinh (lOp 5)

Hoc cá ngày

ChU 9: Truaiig hap cãc phOng hoc cü không cOn s dvng duqc vã cO th phài pM be sau thi dv an throc trién khai thi cOng can mU tà cv thU Irong sa dO hgc slab trtr&c khi thuc hin dtr an. Trong vi dy ô wOn, có hal phOng hpc së bi do bO do qua xuOng cap, khOng sü dyng dtrgc nsa.

GRANT ASSISTANCE FOR GRASSROOTS HUMAN SECURITY PROJECTS

(GGP)

From the People of Japan

EMBASSY OF JAPAN IN VIETNAM

Please send this application fornz, duly filled out, and other required documents to:

Ms. Minori Ishii Economic Section Embassy of Japan in Vietnam 27 Lieu Giai Street, Hanoi Tel: 04-3846-3000Fax: 04-3846-0048

IMPORTANTNOTES

-An eligible applicant can apply for ONE project during one Japanese fiscal year (1 April — 31 March).

- There is no app lication fee, and the Embassy of Japan and the staff thereof will never ask the applicant to pay fees, commissions or any other charges in relation to or for the purpose offacilitating the application process.

- Soft components such as human capacity development can be a part of a project where they are deemed indispensable for the effectiveness of the project or are considered an integral part of it.

The documents listed below are prerequisite for the Embassy to examine the proposed project Please make sure to prep are all of them upon app !yingfor the GGR

fl Application form (Vietnamese)

fl Application form (English)

[1 A map showing the location of the project site

fl Pictures showing the current situation (e.g. damaged building, inadequate equipment)

El Specifications of the project (e.g. design drawing for a construction project, product specification sheets and product pictures for an equipment donation project)

fl Three (3) quotations of procurement cost (e.g. construction cost, equipment prices) from three different prospective contractors

fl A quotation of audit fee from an independent auditing company capable of carrying out a site visit to verify appropriate use of fund and take photographs of the site as well as auditing financial transactions (photographs may be substituted by those taken by the applicant.)

El Applicant's organization's brochure or anything that can provide basic information of the organization (if any) fl (Only for a school construction project) Student allocation diagram showing the number of students placed in each classroom both before and after the implementation of the project (sample attached at the end)

Page 2 of 7

SECTION I—APPLICANT'S INFORMATION Please make sure the information contained here is correct and up-to-date. Contact information is especially important.

1. Basic Information

a. Name of organization:

b. Head of organization (name and title):

Please note that this person is supposed to be the signatory to the grant contract once your project proposal has been approved by the Government of Japan.

c. Address:

d. Point of Contact (name and title, phone number and e-mail address):

Please note that this person can be c4ffèrent from the head of organization. This person is supposed to be able to communicate with the Embassy to coordinate issues arising from your project proposaL

2. Detailed Information

a. Type of organization fl Local government

E Educational institution

E Hospital or other medical/health care institution Non-governnental/non-profit organization (NGOINPO)

fl Others (describe below)

Please note that central government agencies are not eligible applicants.

b. Year of establishment:

c. Organizational structure

Please include information on the management structure, departments and number of staff (e.g. the number of commune people committee officials, teachers and students, doctors and

nurses, etc., depending on the type of organization). It would be helpful (fan organizational

chart is attached to supplement the information here.

d. Activities

Please provide information on the following items that correspond to the type of your organization.

• Local government: brief description of local socio-economic situation (population, main industry, main products, annual income per head, socio-economic challenges) etc.)

• Educational institution: brief description of academic courses, vocational training courses, school subjects, etc.

Page 3 of 7

• Hospital or other )nedzcal/health care institution. medical services on offe;; number of beds, number of in-p atients/o ut-patients. etc.

• NGO/NPO: vision and mission, main activities, major achievements, etc. • Others: brief description of the organization ' activities, goals and achievements, etc.

e. Describe some of the recently completed projects implemented by your organization with

the information on the project name, budget (amount and funding source), implementation

period, major project components, achieved goals. A project completion report or the

equivalent can substitute for this section.

£ Financial status

(1) Income and expenditure of your organization for the last TWO (2) years.

Please provide concise information on your organization & income and expenditure for the past two years. Tins can be done by means of balance sheets (samp1e below,), one for each yea;:

Sample Balance Sheet

Income Expenditure

Taxes xxx VND Salaries xxx VND

Fees xxx VND Management costs xxx VND Subsidies xxx VND Public works xxx VND Transfers xxx VND Transfers xxx VND Others xxx VND Others xxx VND

Total income xxx VND Total expenditure xxx VND

(2) If there was a deficit, how was it compensated for? (e.g. additional subsidies, bank borrowing, tighter budget for the following year, etc.)

3. Has your organization received any development assistance (financial and/or technical) from foreign governments, international organizations or NGOs in the past?

Eyes flNo

If the answer is 5,'es', please describe the outline of the assistance including information on year of assistance, total project cost, andfunding source.

Page 4 of 7

SECTION H — PROJECT PROPOSAL

1. Suggested project title

2. Project location

Please provide as much detail as possible, including the names of the commune, district, and province, distance from Hanoi andfrom the nearest well-known city/town.

3. Objectives

Please describe the overarching goal of the project

For example, this project will help improve

- the educational environment of the commune,

- the living conditions of the pooi; etc.

4. Current situation

Describe the current situation surrounding the area this project aims at improving as detailed as possible. Use data where available. Photos depicting the current situation (e.g. dilapidated school building, inadequate medical equipment, etc.) may very well help us understand the situation.

5. Project components

Please describe or provide a table of activities that comprise this project. For a construction project, design drawing is necessary For an equipment donation project, product specj'Ications aiid photos are indispensable.

6. Expected effects

Provide your assessment of the expected outcome of the project including the number of beneficiaries. Use numerical assessment where possible.

7. Project period

Please note that the project period cannot, under any circumstances, exceed one year from the date of signing the grant contract.

8. Others Have you already applied or do you plan to apply for funding support for this project from any other donors or higher authorities such as provincial or district people committee?

If the annl'er is 5es', please describe the current status of such application (see also Section III 3.).

Page 5 of 7

SECTION III — BUDGET PROPOSAL

1. Three (3) Quotations (provide as attachments)

Please provide three quotations, one from each of three different prospective contractors, of the project costs.

2. Cost breakdown

Please show the cost breakdown from the lowest priced quota/ion.

IMPORTANT NOTE: Value-added Tax (VAT) CANNOT be covered by GGR P/ease make sure the quotations do not include VAT and the applicant appropriates a budget to cover VAT on its own.

Also note that GGP will not finance consulting fee, project management fee. land clearance for a construction project, contingency taxes including VA2 levies and any 0/her costs that do not match the grant policy of/he Government of Japan.

3. Other financial sources

If this GGP proposal is for a part of a bigger project, please provide information on the total budget of the entire project and brief description of the project components that will articulate how and where the GGP part will sit.

Please note that GGP needs to be a 'standalone 'project in the sense that it can be completely separable from other components of a larger project both physically and financially For example, GGP can construct one of the two school buildings in a school where the other building is financed by an outside source. However; GGP cannot construct 3 classrooms of a 4-classroom school building while the 1/4 of the total cost is financed by somebody else.

Date

Name

Title

Signature

Page 6 of 7

(Attachment)

Sample of Student Allocation Diagram

Before the project

Number of classrooms: 12 Number of pupils: 341 (18 classes)

31 pupils 31 pupils 31 pupils 31 pupils 31 pupils 31 pupils (1st grade) (1st grade) (1st grade) (2nd grade) (2nd grade) (2nd grade)

All day lear ling

Morning

Afternoon

29 pupils (3rd

grade)

29 pupils (3rd

grade)

30 pupils (4th

grade)

30 pupils (4th

grade)

26 pupils (5th

grade)

27 pupils (5th

grade)

29 pupils (3rd

grade)

29 pupils (3rd

grade)

29 pupils (4th

grade)

29 pupils (4th

grade)

27 pupils (5th

grade)

27 pupils (5th

grade)

Half day

learning

After the project

2 seriously degraded classrooms will be demolished'. Number of classrooms: 18 Number of pupils: 341 (18 classes)

31 pupils 31 pupils 31 pupils 31 pupils 31 pupils 31 pupils (1st grade) (1st grade) (1st grade) (2nd grade) (2nd grade) (2nd grade)

All day learning

29 pupils 29 pupils 29 pupils 29 pupils (3rd grade) (3rd grade) (3rd grade) (3rd grade)

All day learning

New 30 pupils 30 pupils 26 pupils 27 pupils All day 2-storey (4th grade) (4th grade) (5th grade) (5th grade) learning

8 classroom 29 pupils 29 pupils 27 pupils 27 pupils building (4th grade) (4th grade) (5th grade) (5th grade)

1 Note: In the case that some rooms are too degraded that they will be demolished after the project, you should describe that too. For example, in this case 2 seriously degraded rooms will be demolished after the project.