FINANCIAL REPORT FORMAT. [Insert desired format. Include Program Income unless these topics will not be relevant for any of the anticipated GUC grants. We also recommend including the certification required by Subpart E of 2 CFR § 200.415, “Required certifications” (with any additions or other modifications Palladium deems appropriate): “By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (US Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812).” Palladium might wish to insert the following language (or similar) at the end of the first sentence: “ . . . that, as of the date of submission, all applicable Grant requirements have been met and payment of the sum claimed is due and proper under the Grant and applicable law; all representations and certifications previously made or provided by Grantee remain valid; appropriate refund will be made to Palladium in the event of material noncompliance with Grant requirements and/or disallowance by USAID; and such detailed supporting information as Palladium or USAID may reasonably require will be furnished promptly upon request.”] [END OF PART F, FINANCIAL REPORT FORMAT] PART G ASSURANCES AND CERTIFICATIONS The following certifications and assurances are provided by Grantee in consideration of Palladium Grant No. Click here to enter text.], dated [Click here to enter a date.], and form an integral part of the Agreement:
FINANCIAL REPORT FORMAT. Country of implementation: Year: Project number: Project title: Timeframe Donor Implementing Partner Planned Budget Expected Outputs Key Activities Start End Budget Description Man/ month (currency) Amount 1 (Description output 1) 1 (Description activity 1) dd/mm/yyyy dd/mm/yyyy Donor A Personnel costs Donor B Supplies, commodities and material Donor C Equipment, vehicles and furniture Contractual services Imp. Partner A Travel Imp. Partner B Transfers and grants to counterparts Imp. Partner C General operating and other direct costs 2 (Description activity 2) dd/mm/yyyy dd/mm/yyyy Sub total 0,00 2 (Description output 2) 1 (Description activity 1) dd/mm/yyyy dd/mm/yyyy 2 (Description activity 2) dd/mm/yyyy dd/mm/yyyy Sub total 0,00 Total direct costs 0,00 Indirect support cost 0,00 TOTAL 0,00 ANNEX IV Counterpart Staff, Services, Facilities and Property to Be Provided by the Government The Parties agree that the Government commits to provide, at its own expense and at no cost to the UN Partner, the following inputs and information to facilitate successful implementation of this Agreement: Government Staff (qualified experts to work with the UN Partner’s team): [include the list of names, titles, brief qualifications. Indicate “n/a” if none are provided] Surveys and Technical Inputs [for example, surveys, drawings, files, maps, software, etc., or insert “n/a” if none are provided] Services [for example, office cleaning, utilities, communication, etc. , or insert “n/a” if none are provided] Facilities [for example, office space, meeting and conference rooms, etc., or insert “n/a” if none are provided] Property [for example, office or computer equipment, materials, vehicles, etc., or insert “n/a” if none are provided] Travel advice on any restrictions or exceptional travel requirements for the country [for example, information on travel measures and restrictions in the country prior to the commencement of the UN Partner’s mission travel, information on any changes in such measures throughout the full duration of the mission, etc. or insert “n/a” if none are provided] [Other – insert any other inputs by the Government that do not fall under any of the above categories but are required for successful implementation of the Technical Assistance] The extent and timing of provision of counterpart staff and of facilities should be agreed upon and included in this Annex. ANNEX V COSTS OF UNWTO SERVICES
