FONDS SOCIAL DE DEVELOPPEMENT (FSD) 2014 SOCIAL DEVELOPMENT FUND 2014 الصندوق الاجتماعي للتنمية 2014

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1 FONDS SOCIAL DE DEVELOPPEMENT (FSD) 2014 SOCIAL DEVELOPMENT FUND 2014 الصندوق الاجتماعي للتنمية 2014 FORMULAIRE DE DEMANDE DE SUBVENTION APPLICATION FORM FOR A GRANT استمارة طلب التمويل Name of the proposed project: Name of the organisation: Short description of the project (56 lines): Project location: Project duration: Estimated total cost of the proposed project (NIS): FSD grant requested (NIS): Estimated FSD grant request (EUR): Total applicant contribution (NIS): Contribution of other donors (if applicable) (NIS): Name, position and details of contact person at organisation: For more information, please contact: Mrs. Sandrine MENUCELLI Tel : sandrine.menucelli@diplomatie.gouv.fr For administrative use only: Numéro de Dossier Date de Réception 1 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

2 DOCUMENT I OFFICIAL LETTER FOR FINANCING Fonds Social de Développement Application Form 2014 The official letter for financing should include the following elements: Name of the organisation Contact information (address, phone number, fax, ) Main interlocutor (name, position, qualification, address, mobile phone number, e mail) Summary of the project Project title Short description of the project Total amount of the project (NIS) Amount of the grant requested (NIS, maximum 70% of the total amount of the project) Amount of the participation of the beneficiaries (NIS, at least 10% of the total amount of the project) Amount of the possible cofinancing brought by other partners (NIS) Date and signature of the person legally in charge 2 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

3 DOCUMENT II ADMINISTRATIVE DOCUMENT Fonds Social de Développement Application Form 2014 Name (a) INSTITUTION Contact Information Address Phone number Fax number Website (if applicable) Legal status (NGO, municipality, etc.) Date of creation Membership in an NGO network (if applicable, please specify) (b) INSTITUTION Legal Information please enclose legal status Name of the account holder Bank Address of the bank Account number IBAN number (c) INSTITUTION Bank Information please enclose bank details information 3 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

4 (d) INSTITUTION Organisational Information please enclose names of the board Board & General Assembly (please describe, if applicable, rules of functioning, number of members, date of last meeting, etc.) Human resources / permanent, temporary employees or volunteers (please describe) In kind resources (please describe) 4 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

5 (e) INSTITUTION General Information Sectors of intervention (please describe) Geographical areas of intervention (please describe) 5 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

6 (f) INSTITUTION Financial Information 2014 Budget (NIS) Part of the budget dedicated to salaries (NIS) Sources of funding (for 2014): name, nature, amount Last external audit (if applicable): name of the firm, contact, year 6 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

7 (g) INSTITUTION Partnership Information Previous projects in partnership with France (Consulate general, AFD, French NGO, twinning, etc.) (if applicable) Name of the project French partner Description of the project Year Amount of the grant Name of the project Donor(s) Description of the project Year Amount of the grant Main projects in partnership with other donors ( , if applicable) 7 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

8 (h) INSTITUTION Documents to be attached Statute and rules of procedure of the applicant institution Certificate of registration Organisational chart List of Board Members (name, position, number of years in post) Last external audit (if available) Last annual report (if available) Official details of the bank account Precise map of the project location List of the main donors in the last 5 years 8 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

9 DOCUMENT III TECHNICAL DOCUMENT Fonds Social de Développement Application Form 2014 (a) PROJECT General Information Name Sector Location Duration City/village District Summary (please include the following elements: justification/ration ale; main objective; main activities. See more details in section c) Project description) (b) PROJECT MANAGER Contact Information Name Position Phone number 9 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

10 (c) PROJECT Description Context (please describe precisely the background of the project, what the needs in the sector/area are, why you think this project is justified/relevant, how it responds to the needs identified. Indicate also potential previous actions in the sector/area.) Compliance with FSD priorities: support to incomegenerating and job creation activities mainly in Gaza and in refugee camps; education in East Jerusalem; Water and sanitation in area C. Beneficiaries (please indicate the number, age, gender of direct and potential indirect beneficiaries of the project) 10 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

11 Main objective and specific objectives if applicable (please indicate the broad impact of the project) Expected results (qualitative and quantitative) Indicators of success (how the results are to be measured including quantity, quality and duration) Expected results (please indicate the direct/tangible outcomes that the project is expected to deliver, including the expected benefits to the target group) R.1. R.2. Activities (please describe precisely the activities/tasks that have to be undertaken to deliver the desired results, according to each expected result) R.1. R.2. A.1.1. A.1.2. A.2.1. A.2.2. Role of the beneficiaries (if applicable) 11 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

12 Role of the partners (if applicable) Risks in project implementation Appreciation of the project financial, social and economic sustainability (please indicate how you plan to ensure the viability and continuation of the project after the implementation phase) (d) PROJECT Staff assigned to the project Name Position Qualification Responsibilities in the project Staff 12 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

13 Consulat Général de France Fonds Social de Développement Application Form (e) PROJECT Summary table Expected results Activities Quantified indicators of success Human resources Funded by Example : R.1. Ensure direct access to quality water for Example : A.1.1. installation of cisterns; A.1.2. installation of pipes; Example : 50 households have direct access to quality water; 50 cisterns have been installed; 250m of pipes have been installed (5m per family); Example : Project Manager; Water Engineer; Contractor. Example : Consulate General of France 50 families. A.1.3. installation of natural filters. 50 natural filters haven been installed; water is drinkable according to the standards of the World Health Organization. R.1. A.1.1. A.1.2. R.2. A.2.1. A Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

14 Consulat Général de France Fonds Social de Développement Application Form (f) PROJECT Indicative action plan Year Year 1 Year 2 Month Activity 1.1. Activity 1.2. Activity 2.1. Activity Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

15 Consulat Général de France Fonds Social de Développement Application Form (g) PROJECT Monitoring & Evaluation Methods of monitoring (please indicate how and how frequently will the project be monitored, as well as who will be in charge of the monitoring) Methods of final evaluation (please indicate how the project will be evaluated and who will be in charge of the final evaluation) (h) PROJECT General budget Source Amount (NIS) Per Cent (%) FSD grant ( < 70 %) Applicant institution ( > 10 %) Beneficiary community (if applicable) Other donors (if applicable) Total budget 100 % 15 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

16 Consulat Général de France Fonds Social de Développement Application Form (i) PROJECT Indicative detailed budget Item Details Total budget (NIS) FSD contribution (NIS) Example: Activity 1.3. installation of natural filters Material and equipment 50 natural filters 50 filters * 1400 NIS Salaries Contractor (installation of filters) 50h * 100 NIS Trainer on maintenance of the filters (for the beneficiaries) 2h * 200 NIS Activity 1.1. Material and equipment Salaries Others Activity 1.2. General costs of the project Salaries Transports... Communication Visibility (of the project and the French contribution) Potential administrative costs ( < 7% of the French contribution) Stationeries Others TOTAL FSD contribution (EUR) 16 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax:

17 Consulat Général de France Fonds Social de Développement Application Form (j) PROJECT contact information of other donors (if applicable) Name Activity Address Phone number (k) PROJECT Any other information 17 Consulat Général de France à Jérusalem Service de Coopération et d Action Culturelle 3 rue Beibars PO Box 182 JERUSALEM Tel : Fax: