2021 Ambassador's SSHF Program Guidance - Application Template.pdf

UNITED STATES EMBASSY GABORONE

Ambassador's Special Self-Help Fund Program

2021 APPLICATION FOR ASSISTANCE

Guidelines, Narrative, and Proposal Template

U.S. Embassy, P.O. Box 90, Gaborone, Botswana

TEL: +267 373-2265

E-mail: SSHBotswana@state.gov

1 Website: https://bw.usembassy.gov

The ASSHF Application is FREE of charge and the

Embassy DOES NOT request any payment to receive and evaluate a project.

Notice of Funding Opportunity

Please read the complete Notice of Funding Opportunity and provide requested federal assistance application, supporting documents, and email to SSHBotswana@state.gov or mail to:

U.S. Embassy For Office Use Only

Ambassador’s Special Self-Help Fund Program

ATTN: Small Grants Coordinator

P.O. Box 90

Gaborone DEADLINE for Application Submission: July 5, 2021

All information provided will be verified

ORGANIZATION DETAILS

1. Project Title:

2. Date of Application:

3. Organization/Group Registered Name & Project Title

4. Organizations Federal DUNS #

5. Amount Requested (USD)

6. Mailing Address or P.O Box & District/Region

7. Project location (Town or Village Name)/Physical Address

8. Organization/Office Telephone Number Fax:

9. Organization E-mail/Website

10. Project Manager Name and Phone

The project manager should be a resident of the local community during the implementation of the project. A non-resident project manager who has been approved by the applying organization and/or community is acceptable. This person should be present daily to supervise implementation and should have the authority in the community to guarantee the completion of the project.

11. Name and Phone Number of Person Completing this Application

Received: Responded:

mailto:SSHBotswana@state.gov

2 Website: https://bw.usembassy.gov

DESCRIPTION OF THE ORGANIZATION

12. Provide the following background information about your organization:

When was the organization started?

Date and Type of Registration of the Organization:

☐CBO ☐NGO ☐FBO ☐Other (Specify):

*Include a copy of the registration certificate.

How many people are in the organization? (Attach a list of members: name, position, phone number):

How often do you meet?

Who benefits from the organization’s activities?

List the assets and value of the assets owned by the group (for example land, equipment, bank account balance).

What development activities has your group implemented in support of the community?

Have you ever applied a grant from the U.S.

Embassy? Yes ☐ No ☐

If yes, please provide the following: Year:

Project Site:

Project title/type:

Amount in USD:

Was the project funded? If yes, amount in USD.

Yes ☐ No ☐ USD: $

List any affiliations:

3 Website: https://bw.usembassy.gov

13. Give a brief description of your organization, its purpose, and core activities.

14. What funding sources does your organization have? Please provide details of donors and the amounts provided.

15. What experience does your organization have managing projects?

4 Website: https://bw.usembassy.gov

PROJECT DESCRIPTION AND RESULTS

16. Project Title:

17. Project Goal and Objectives. What problem will it address and how? What results will you achieve?

Continue on additional sheets if required

18. Will your group require any training to carry out the project? If you need training, what are your plans to get this training for your organization?

5 Website: https://bw.usembassy.gov

19. What potential implementation problems do you foresee and how will you overcome these?

20. Will the project generate income for the group? Yes ☐ No ☐ ➔ If yes, YOU MUST SUBMIT AN INCOME GENERATION PLAN with this application ➔ Your income generation plan should answer the following questions:

o What is the product or service you are going to sell?

o Who will buy your product or service?

o How much will you sell your product or service for?

o How many of your products or service will you sell each month?

o What are your anticipated monthly expenses (e.g., the cost of water, electricity, rent, transportation, etc.)?

21. If you want to start an income-generating project, what will the group do with the money from the project?

22. If the project does not generate income for the group, how do you plan to maintain the project and ensure it is self-sufficient?

6 Website: https://bw.usembassy.gov

23. Number of Direct Beneficiaries Do not write percentages.

Male Female Total

24. Marginalized Population (at least 50% of beneficiaries, check up to three)

☐Women ☐Physical Disability ☐Youth (under 30 years of age)

☐Remote Location ☐Ethnic, Religious Minority ☐Elderly

ACTIVITY TIMELINE

25. List the major steps necessary to carry out the project.

# Activity Time required Responsible person

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Please attach additional sheets if required.

BUDGET

The budget should include everything you will need to complete the project, including a substantial contribution in matching funds, supplies and/or labor from your organization. If an item is not listed on this budget, it will not be paid for by the grant. Use additional pages, if necessary, to expand on each budget line item where required. Please note the budget is divided into three sections.

7 Website: https://bw.usembassy.gov

26. Local community contribution: list materials, supplies, equipment, labor or investment/funds that your organization or group will provide.

Local Community Contribution

Materials, supplies, and equipment:

Description Quantity Unit price Total BWP 1.

2.

3.

Total estimated value of materials, supplies, and equipment:

Unskilled labor:

Description # of people # of days Cost per day Total BWP

1.

2.

3.

Total estimated value of unskilled labor:

Skilled labor (mason, carpenter, well digger, etc.):

Description Cost for the job BWP 1.

2.

3.

Total estimated value of skilled labor:

Money, investment, property value:

Description

1.

2.

3.

Total estimated value of money, investment, or property:

Total estimated value of contribution from applying organization:

27. Other Sources – list funding or supplies donated by an outside organization or individual.

Other sources

Contributions collected from other donors towards this project:

Source Description Total BWP

1.

2.

3.

Total value of contributions from other sources:

8 Website: https://bw.usembassy.gov

28. American Embassy Contribution – list the items you request the Self-Help Fund to purchase.

American Embassy Contribution

Transportation:

From Where To where Number of trips

Cost per trip Total cost BWP

1.

2.

3.

Total value of transportation:

Materials, supplies, and equipment to be funded by the American Embassy

Description Quantity Unit price Total BWP

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Total value of materials, supplies, and equipment:

Total value of contribution from American Embassy:

9 Website: https://bw.usembassy.gov

29. Signature of Applicant

Date

30. District or Local Authority:

We require the approval of the local development committee, tribal authority, local town or district council before submitting the application to the U.S. Embassy.

Printed Name

Signature

Date

Stamp of authority:

10 Website: https://bw.usembassy.gov

Thank you for your interest in the U.S. Ambassador’s Special Self-Help Fund (ASSHF) small grant program. The purpose of this program is to provide small-scale assistance to community-based organizations as part of an ongoing commitment by the U.S. government to support development activities at the local level. This is an annual program and is contingent on U.S. Congressional funding approval.

Final Checklist before Submission of Proposal

Please assure all the following are included in the proposal. Without these items, your proposal will not be complete and we will not consider it for funding. We will need to contact you. Please ensure that all contact information (phone numbers, email addresses, postal addresses, and physical location) is correct.

Note: We do not return proposals, so please make a copy for your records.

______ Summary Coversheet stating the applicant name and organization, proposal date, program title, program period proposed start and end date, and brief purpose of the program.

______ Application completed with proposal details and project description (see Guidelines, Narrative, and Proposal Template and Notice of Funding Opportunity) with Budget Justification.

______Copy of registration certificate of organization (from Ministry of Labor and Home Affairs – Registrar of Societies) or certificate of incorporation. All applicants must be registered associations or community organizations. The organization must be operating for at least one year (applications cannot be accepted from individuals, private businesses or a government entity.)

______ Copy of contact person/project manager’s and alternate contact’s ID card/book.

______ Primary contact and alternate contact’s one-page CV

______ A list of Committee/Board members with names, positions, addresses, and phone numbers.

______ A list of all people working in the organization (including staff and volunteers) with names, positions, addresses, and phone numbers.

______ Approval of proposed project from the local development committee, tribal authority or local town and/or district council. Stamp of authority must be on application.

______ Quotations from vendors for equipment, supplies, construction, and anything else asked for in the budget.

______ Copy of organization’s annual operating budget for the two most recent years.

______ Proof of bank account and copies of most recent bank statement for accounts held by organization.

______ A letter/stamp of approval from local authority.

______ A map showing how to get to your project from the nearest town.

11 Website: https://bw.usembassy.gov

______ Income-generation plan, if starting an income-generating project.

______ Completed SF 424 forms

• SF-424 (Application for Federal Assistance – organizations)

• SF424A (Budget Information for Non-Construction programs)

• SF424B (Assurances for Non-Construction programs)

______ Unique Identifier Number from Dun & Bradstreet (DUNS number)

______ www.SAM.gov registration

DEADLINE for Submission: July 5, 2021 Submit Proposal To:

• Mail:

U.S. Embassy Gaborone Ambassador’s Special Self-Help Fund Program ATTN: Small Grants Coordinator P.O. Box 90

Gaborone

• Email:

SSHBotswana@state.gov

• Hand Deliver:

U.S. Embassy, Government Enclave, Gaborone ATTN: Small Grants Coordinator/Ambassador’s Special Self-Help Fund Program

Questions?

Small Grants Coordinator +(267) 373-2265 sshbotswana@state.gov https://bw.usembassy.gov/our-relationship/self-help http://www.sam.gov/ mailto:SSHBotswana@state.gov mailto:sshbotswana@state.gov https://bw.usembassy.gov/our-relationship/self-help