Attachment 5. Proposal Template.pdf

APPLICATION CHECKLIST

Application: Organization:

Amount Requested: Organization POC:

***Before you submit your application, please make sure the following documents are included and this cover sheet is attached to the application***

ATTACHED? REQUIRED DOCUMENTS

☐ Signed and Completed SF-424

☐ Completed SF-424A

☐ Proposal Narrative

☐ Budget Narrative

☐ Proof of SAM.gov registration

☐ Applicant Organization Information Survey

☐ Key Personnel CVs

☐ Audit Reports (if applicable)

☐ Other Documents (if applicable)

U.S. Embassy Grants Program Application

Read the instructions provided in this document carefully.

Applications that do not follow the guidelines and instructions provided within this form will not be reviewed.

Questions can be directed to: TashkentGrant@state.gov.

1. GENERAL INFORMATION

Applicant Organization:

Organization Name:

Address:

Street Address

City/Town

District

Website (if applicable)

Social Media Page (if applicable, platform and link)

Organization Director:

First Name, Last Name

Title

Telephone

Mobile

Email

Preferred method of contact

2. BACKGROUND OF ORGANIZATION

2.1 Registration Information:

Is the organization registered, incorporated, or licensed as a legal entity? ☐ Yes* ☐ No *If yes, attach a copy of organization’s registration form.

Date of incorporation or registration (MM/DD/YYYY):

Date organization was founded:

How organization is primarily funded:

CVs attached in Appendix A for each staff member on the project? ☐ Yes ☐ No

2.2 Organization Mission:

mailto:TashkentGrant@america.gov

2.2.1 What is the purpose (or mission statement) of your organization?

2.2.2 How, if at all, is your organization different than other organizations that work in this field?

2.3 Summary of Expertise: Detail your past work in this area so PAS can better understand your organizations’ record of performance and ability to succeed in future projects.

2.3.1 Describe past work in this topic area:

2.3.2 Describe any best practices or lessons learned in previous projects:

2.3.3 From previous work in this area, have you developed networks with other organizations or groups that also work in this field? How, if at all, will this award contribute to those networks?

2.4 Project Partners: Are you going to carry out project activities in partnership with other organizations?

If yes, list the organization name and describe their role in the project.

3. PAST GRANTS

3.1 Grants funded by U.S. Embassy

Have you ever received a previous grant from the U.S. Embassy? USAID, Public Affairs, or another US

Government entity? ☐ Yes ☐ No

If yes, list:

Project name:

Project amount:

Period of performance:

Results achieved on this program to date:

3.2 Grants funded by other donor organizations

Have you ever received funding from any other donor organization? ☐ Yes ☐ No

If yes, list:

Project name:

Project amount:

Period of performance:

Results achieved on this program to date:

4. PROPOSED PROJECT DESCRIPTIONS

4.1 Project Information

Project Name:

Duration (months)

Projected Start and End Date:

Funding Requested

4.2 Project Goals and Justification

4.2.1 Problem Statement: What problem do you intend to address by implementing this grant?

4.2.2 Problem Statement Justification: What evidence, experience or other information supports your problem statement? Why is this a priority?

4.2.3 Goals: What does success look like on this program?

Short-term Outcomes: What specific change(s) do you expect to occur during the grant as a direct result of program activities?

Long-term Outcomes: What specific change(s) do you expect to occur after the program ends that are a direct result of program activities?

4.2.4 What potential obstacles exist that could the effect the implementation of the program? For example:

obtaining government approval, media/press concerns, availability of electricity/internet

4.2.5 How does your program plan to address the obstacles listed above?

4.3 Participants

4.3.1 Describe the target participants in this program. Be as specific as possible. Possible participant characteristics may include: gender, age-range, education level, geographic location, occupation, socio-economic level, level of education, interests, etc.

4.3.2 Why are these individuals an important population to reach?

4.3.3 How will your organization access those participants?

4.3.4 Explain the criteria you will use to choose participants.

4.3.5 Explain the steps of your participant selection process to ensure you reach the target audience above.

5. PROPOSED WORK PLAN

Proposed Project Activities: Provide a detailed work plan that clearly identifies each step you will take to plan and implement this project. Please include an activities calendar divided by months/weeks and responsible people as in the example below.

Implementation Activities Time period Personnel/Responsible

Organization Resources required, if any

Planning Activities (meetings, obtaining venues, equipment and/or staff)

(for example: staff time, and funding for office space)

Major Project activities

Follow-on activities

6. BUDGET

6.1 Budget Summary

Category Description/Details Amount Requested

Personnel

Fringe Benefits

Travel

Equipment

Supplies

Contractual

Other Direct Costs

Indirect Costs

Total Requested

Project Total

6.2 Budget Note

1. All project expenses should be calculated in advance and must be realistic.

2. Please prepare the project budget in USD. However, you will receive your grant in the UZS. Please use CBU (Central Bank of Uzbekistan) rate in preparing the calculations.

3. Some expenses will need to be explained in the Budget Narrative below, please see box 6.3 for details.

4. Please put in the description/details on the budget summary the number of hours of work per week that each person will spend on this project.

5. Cocktail parties, receptions, and entertainment costs are not allowed. Coffee breaks for conferences and seminars must be justified and are limited to a maximum of 10% of the total award amount.

6. If applicable, please list on the description of the budget summary contribution of your organization – they can be voluntary work, use of premises, vehicles, classroom supplies, equipment or payment of a program event from your own funds (e.g. rental of a hall, printing of announcements, meals, travel, etc.).

6.3 Budget Narrative

Some expenses require further explanation in the Budget Narrative, including the following:

A. Equipment – please explain why your organization needs this equipment and this exact model. Also, to any piece of equipment costing over $US500, please provide three quotes and the names of the company to each quote.

B. If your professional salaries are above $US300/month for full- time 8 hour/day work, please explain these rates.

If the rental of your office or your venue is more than $US200/month in the regions or $US400/month in Tashkent please provide an explanation for that rate.

Write your budget narrative here.

7. CERTIFICATION

I am aware that any false statements or claims may disqualify my organization from receiving this and any future awards.

☐ I agree.

By marking the checkbox below I certify that I have read and understood the instructions provided in this form before filling out this document.

☐ I have read the instructions provided with this form.

By signing this application, I certify that the statements contained in this form are true, complete and accurate to the best of my knowledge.

Signature of Authorized Representative

Date Signed