LIFE +    Environment Policy and Governance
TECHNICAL APPLICATION FORMS
Part A – Administrative information

LIFE+ Environment Policy and Governance 2009- A1

		LIFE+ 2009
			
				for ADMINISTRATION use only

	

		
							
				LIFE+ 09 ENV/

PROJECT

Project title (max. 120 characters):
.....................................................................................................................................................................
Project acronym (max. 25 characters): …………………………………………..……..……..……..……..……
The project will be implemented in the following:
Country(ies) ………………………………………………………………………………………………………….
Administrative region(s)……………………………………………………………………………………………..
Expected start date: …………………………		 Expected end date: ……………………………..
BeneficiarIES

Name of the coordinating beneficiary (1): ..................................................................................................
Name of the associated beneficiary (2): ………………………………………………………………………...
Name of the associated beneficiary (3): …………………………………………………………………………
Name of the associated beneficiary (4): …………………………………………………………………………
 (Continue as necessary)
Project Budget and REQuested EC funding
Total project budget:  			……………. €
Total eligible project budget:  		……………. €
EC financial contribution requested: 	……………. €   ( = …….. % of total eligible budget)

PROJECT POLICY AREA 

You can only tick one of the following options: 

□ Climate Change	□ Urban environment		□ Waste and natural 
									resources

□ Water				□ Noise			□ Forests

□ Air					□ Chemicals			□ Innovation	

□ Soil					□ Environment and Health	□ Strategic approaches

LIFE+ Environment Policy and Governance 2009 – A2

	Coordinating Beneficiary Profile Information 	
Short Name 		Beneficiary n°	1	
Legal information on the Coordinating Beneficiary	
Legal Name 		Legal Status	
VAT No		Public body
Private commercial
Private non- commercial			
Legal Registration No					
Registration Date					
Legal address of the  Coordinating Beneficiary	
Street Name and No		PO Box 		
Post Code 		Town/City		
Country Code 		Country Name 		
Coordinating Beneficiary contact person information	
Title  		Function		
Surname		First Name		
E-mail address		
Department / Service		
Street Name and No		PO Box		
Post Code		Town/City		
Country		
Telephone No		Fax No		
Coordinating Beneficiary details	
Year 			
Annual turnover 		Annual Balance Sheet Total 		
Number of employees		
Website		
	
Brief description of the Coordinating Beneficiary's activities and experience in the area of the proposal	

	
YOU MAY NOT DUPLICATE THIS PAGE

LIFE+ Environment Policy and Governance 2009 – A3

COORDINATING BENEFICIARY DECLARATION 

The undersigned hereby certifies that:

1.	The specific actions listed in this proposal do not and will not receive aid from the Structural Funds or other Community financial instruments. In the event that any such funding will be made available after the submission of the proposal or during the implementation of the project, my organisation will immediately inform the European Commission.

2.	My organisation (add name) …………………………………………………….. has not been served with bankruptcy orders, nor has it received a formal summons from creditors.  My organisation is not in any of the situations listed in Articles 93.1 and 94 of Council Regulation 1605/2002 of 25/06/2002 (OJ L248 of 16/09/2002).

3.	My organisation (which is legally registered in the European Union) will contribute (add amount) …………………… €  to the project.  My organisation will participate in the implementation of the following actions (add action code(s)): ……………………… .  The estimated total cost of my organisation's part in the implementation of the project is (add amount) …………………… €.

4.	Should one or more associated beneficiary or co-financier reduce or withdraw its financial contribution, my organisation will ensure that a corresponding additional contribution is made available.

5.	My organisation will conclude with the associated beneficiaries and co-financiers any agreements necessary for the completion of the work, provided these do not infringe on their obligations, as stated in the grant agreement with the European Commission. Such agreements will be based on the model proposed by the European Commission. They will describe clearly the tasks to be performed by each associated beneficiary and define the financial arrangements.

6.	I am aware that my organisation is solely legally and financially responsible to the Commission for the implementation of the project (Article 4 of the Common Provisions).

I am legally authorised to sign this statement on behalf of my organisation.  

I have read in full the Common Provisions (attached to the Model Grant Agreement provided with the LIFE+ application files).

I certify to the best of my knowledge that the statements made in this proposal are true and the information provided is correct.

At ................................................. on........................................................

Signature of the Coordinating Beneficiary:
Name(s) and status of signatory: ...............................................................................................

LIFE+ Environment Policy and Governance 2009 – A4

ASSOCIATED BENEFICIARY DECLARATION (complete for each Associated Beneficiary)

The undersigned hereby certifies that:
1.	My organisation (add name) …………………………………………………….. has not been served with bankruptcy orders, nor has it received a formal summons from creditors.  My organisation is not in any of the situations listed in Articles 93.1 and 94 of Council Regulation 1605/2002 of 25/06/2002 (OJ L248 of 16/09/2002).
2.	My organisation (which is legally registered in the European Union) will contribute (add amount) …………………… €  to the project.  My organisation will participate in the implementation of the following actions (add action code(s)): ……………………… .  The estimated total cost of my organisation's part in the implementation of the project is (add amount) …………………… €.
3.	My organisation will conclude with the coordinating beneficiary an agreement necessary for the completion of the work, provided this does not infringe on our obligations, as stated in the grant agreement with the European Commission. This agreement will be based on the model proposed by the European Commission. It will describe clearly the tasks to be performed by my organisation and define the financial arrangements.
4.	For the purposes of the implementation of the agreement regarding this project between the European Commission and the coordinating beneficiary: 
a) My organisation grants power of attorney to the coordinating beneficiary, to act in our name and for our account in signing the above-mentioned agreement and its possible subsequent riders with the European Commission. Accordingly, my organisation hereby mandates the coordinating beneficiary to take full legal responsibility for the implementation of such an agreement. 
b) My organisation hereby confirms that we have taken careful note of and accept all the provisions of the above agreement with the European Commission, in particular all provisions affecting my organisation and the coordinating beneficiary. In particular, my organisation acknowledges that, by virtue of this mandate, the co-ordinator alone is entitled to receive funds from the Commission and distribute to my organisation the amount corresponding to our participation in the action.
c) My organisation hereby agrees to do everything in our power to help the coordinating beneficiary fulfil his obligations under the above agreement. In particular, my organisation hereby agrees to provide him whatever documents or information may be required, as soon as possible after receiving his request.
d) The provisions of the above agreement, including this mandate, shall take precedence over any other agreement between my organisation and the coordinating beneficiary which may have an effect on the implementation of the above agreement between the coordinating beneficiary and the Commission.

I am legally authorised to sign this statement on behalf of my organisation.  
I have read in full the Common Provisions (attached to the Model Grant Agreement provided with the LIFE+ application files).
I certify to the best of my knowledge that the statements made in this proposal are true and the information provided is correct.

At ................................................. on........................................................
Signature of the Associated Beneficiary:
Name(s) and status of signatory: ...............................................................................................

LIFE+ Environment Policy and Governance 2009 – A5

ASSOCIATED BENEFICIARY PROFILE (Complete for each Associated Beneficiary)

Associated Beneficiary profile information	
  Short name		  Beneficiary n°		
Legal information on the Associated Beneficiary	
Legal Name 		Legal Status	
VAT No		Public body
Private commercial
Private non-commercial			
Legal Registration No					
Registration Date					
Legal address of the Associated Beneficiary	
Street Name and No		PO Box 		
Post Code 		Town/City		
Country Code 		Country Name 		

Brief description of the Associated Beneficiary's activities and experience in the area of the proposal	

YOU MAY DUPLICATE THIS PAGE

LIFE+ Environment Policy and Governance 2009 – A6

CO-FINANCIER PROFILE AND COMMITMENT FORM (Complete for each co-financier)

Legal Name and full address on the co-financier	
	
Financial commitment 	
We will contribute the following amount to the project:	….. Euro	
Status of the financial commitment	
	
Signature of the authorised person	
Name and status of the authorised person (obligatory):		
Date of the signature
(obligatory):		
Authorised signature (obligatory):		

YOU MAY DUPLICATE THIS PAGE

LIFE+ Environment Policy and Governance 2009 – A7

OTHER PROPOSALS SUBMITTED FOR COMMUNITY FUNDING

Please answer each of the following questions :

•	Have you or any of your associated beneficiaries already benefited from previous LIFE co-financing? (please cite LIFE project reference number, title, year, amount of the co-financing, duration, name(s) of coordinating beneficiary and/or partners involved):

•	Have you or any of the associated beneficiaries submitted any actions related directly or indirectly to this project to other Community financial instruments? To whom? When and with what results, and how are these related to the present proposal?

•	For those actions which fall within the eligibility criteria for financing through other Community financial instruments, please explain in detail why you consider that those actions nevertheless do not fall within the main scope of the instrument(s) in question and are therefore included in the current project. 

	

LIFE +    Environment Policy and Governance
TECHNICAL APPLICATION FORMS
Part B – Objectives and expected results 

•	No financial information should be included in these forms.
•	All forms in this section may be lengthened, so as to include all essential information.

	LIFE+ Environment Policy and Governance 2009- B1

SUMMARY DESCRIPTION OF THE PROJECT (Max. 3 pages; to be completed in English)

Project title: ......................................................................................................................................................................................................................................................................................................................................................................................................

Project objectives:

Actions and means involved:

Expected results (outputs and quantified achievements):

Can the project be considered to be a climate change adaptation project?		Yes	□
											No	□

	LIFE+ Environment Policy and Governance 2009- B2

Environmental problem TARGETED

State of the art and Innovative aspects of the project
Note: for forests monitoring projects this box should not be filled in 

	
LIFE+ Environment Policy and Governance 2009- B3

Demonstration character 
Note: for forests monitoring projects this form should be not filled in

EU added value of the PROject and its actions

Efforts for reducing the project's "carbon footprint"

LIFE+ Environment Policy and Governance 2009- B4

Stakeholders involved and main target audience of the project (other than project participants)

	

LIFE+ Environment Policy and Governance 2009- B5

Expected constrainTs and risks related to the project implementation and how they will be dealt with (contingency planning)

	

LIFE+ Environment Policy and Governance 2009- B6

Continuation and valorisation of the project
results after the end of the project

•	Which actions will have to be carried out or continued after the end of the project?

•	How will this be achieved, what resources will be necessary to carry out these actions?

•	To what extent will the results and lessons of the project be actively disseminated after the end of the project to those persons and/or organisations that could best make use of them (please identify these persons/organisations)?

LIFE +    Environment Policy and Governance
TECHNICAL APPLICATION FORMS
Part C – detailed technical description of the proposed actions

Important note: 

•	All calculations and detailed cost breakdowns necessary to justify the cost of each action should be included in the financial forms F. In order to avoid repeating the financial information (with the risk of introducing incoherencies), Part C should only contain financial information not contained in the financial forms.
•	All forms in this section may be duplicated, so as to include all essential information.
•	Any action that is sub-contracted should be just as clearly described as an action that will be directly carried out by the beneficiaries.

LIFE+ Environment Policy and Governance 2009- C1

DETAILS OF PROPOSED ACTIONS

	For each action or set of actions specify the following:

	ACTION 1: name of the action

	Description (what, how, where and when):

	Methods employed:

	Constraints and assumptions:

	Beneficiary responsible for implementation:

	Expected results (quantitative information when possible):

	Indicators of progress: 

	ACTION 2: etc…

LIFE+ Environment Policy and Governance 2009- C2
DELIVERABLE PRODUCTS OF THE PROJECT
Name of the Deliverable	Code of the associated action	Deadline	

			

MILESTONES OF THE PROJECT
Name of the Milestone	Code of the associated action	Deadline	

			

ACTIVITY REPORTS FORESEEN
Please indicate the deadlines for the following reports: 
•	Inception Report (to be delivered within 9 months after the project start); 
•	Progress Reports n°1, n°2 etc. (if any; to ensure that the delay between consecutive reports does not exceed 18 months); 
•	Mid-term Report with payment request (only for project longer than 24 months)
•	Final Report with payment request

Type of report	Deadline	

		

LIFE+ Environment Policy and Governance 2009- C3

TIMETABLE

List all actions ordered by number and using their numbers or names. Tick as appropriate.
(Remember that projects cannot start prior to the date of the signature of the grant agreement)

Action	2010	2011	2012	etc.	
Number/name of action	September	IV	I	II	III	IV	I	II	III	IV	I	II	III	IV	

															

															

															

															

															

															

LIFE +    Environment Policy and Governance
TECHNICAL APPLICATION FORMS
Part D – Output indicator forms

Important note: 

•	The purpose of the D forms is to collect information for statistical purposes only (for the evaluation of the achievements of a project the EC will use the information contained in forms A, B and C). However, applicants should ensure that the information entered in the D forms corresponds as far as possible to the project outputs defined in proposal forms A, B and C.
•	The forms in this section may not be duplicated.

LIFE+ Environment Policy and Governance 2009- D1

LIFE+ Environmental Policy and Governance output indicators	

OUTPUTS	 	 	
Part 1 - Preparatory actions			
Table 1			
Types of preparatory actions	No.	Budgeted cost (€)	
Feasibility studies	 	 	
Legislative reviews	 	 	
Cost-benefit studies	 	 	
Market analysis	 	 	
Permit studies	 	 	
Permit applications	 	 	
Permits obtained	 	 	
Environmental impact assessment studies	 	 	
Scientific studies	 	 	
Detailed engineering studies	 	 	
Monitoring actions	 	 	
Action plans	 	 	
Management plans	 	 	
Inventories & Studies	 	 	
Ex ante environmental monitoring	 	 	
Ex post environmental monitoring	 	 	
Other (please specify)	 	 	
Total budgeted cost (€)	 	

LIFE+ Environment Policy and Governance 2009- D2

OUTPUTS	 	 	
Part 2 - Concrete actions			
Table 2 - Main project deliverables (project implementation phase)	
Deliverable	No.	Budgeted cost (€)	
Prototypes	 	 	
Pilot plants	 	 	
Techniques/Methodologies developed	 	 	
Software	 	 	
Successful implementation of demonstration actions	 	 	
Monitoring techniques developed	 	 	
Monitoring performed	 	 	
Guidelines	 	 	
Manuals	 	 	
Others (please specify)	 	 	
Total budgeted cost (€)	 	

Table 3 - Training activities	
No. of training sessions	Total no. of persons trained	Budgeted cost (€)	

LIFE+ Environment Policy and Governance 2009- D3

OUTPUTS	 	 	 	 	 	 	 	 	 	
Part 3 – Awareness-raising and communication										
Table 4 - Workshops, seminars and conferences										
Target audience:	General public	Specialised audience (e.g. decision-makers)	Very specialised audience (e.g. experts, academics)	
Number of participants:	Local/ Regional	National	EU/ International	Local/ Regional	National	EU/ International	Local/ Regional	National	EU/ International	
0-25 participants	 	 	 	 	 	 	 	 	 	
25-75 participants	 	 	 	 	 	 	 	 	 	
75-100 participants	 	 	 	 	 	 	 	 	 	
More than 100 participants	 	 	 	 	 	 	 	 	 	
Total budgeted cost (€)	 									

LIFE+ Environment Policy and Governance 2009- D4

Table 5 - Media and other communication and dissemination work			Table 6 - Publications				
Type of media	No.		Type of publication	No. published	No. of copies	Languages	
Project website: average number of visitors per month	 		Layman's report	 	 	 	
Press releases made by the project	 		Manuals	 	 	 	
General public article in national press	 		Leaflets	 	 	 	
General public article in local press	 		Brochures	 	 	 	
Specialised press article	 		Posters	 	 	 	
Internet article	 		Books	 	 	 	
TV news/reportage	 		Technical publications	 	 	 	
Radio news/reportage	 		Other (please specify)	 	 	 	
Film produced	 		Total budgeted cost (€)	 			
Film played on TV	 								
Film presented in events/festivals	 								
Exhibitions attended	 								
Information centre/Information kiosk	 								
Project notice boards	 								
Other (please specify)	 								
Total budgeted cost (€)	 								

LIFE+ Environment Policy and Governance 2009- D5

Table 7 - Educational activities		
Establishment involved	No. of students	
Kindergartens/Primary schools	 	
Secondary schools	 	
Higher education establishments	 	
Total budgeted cost (€)