Request for Proposals - Aurat Foundation

GENDER EQUITY PROGRAM(GEP)Supported byUSAIDRequest forProposalsProgram Thematic Area: Combating Gender Based ViolenceGrant Cycle:Six (A)RFP Number: GEP/ Grants/ 2012-006AIssued byGEPIssue Date August 29, 2012Closing Date September 6, 2012Who can Apply NGOs, CBOs, civil societyOrganizations

REQUEST FOR PROPOSALSSUBJECT: Request for Proposals/RFP Number: GEP/ Grants / 2011-006ASub-Grants for Cycle Six (A): Combatting Gender-Based ViolenceAurat Foundation in collaboration with The Asia Foundation will award a series of sub-grants tolocal Pakistani organizations with the objective of affecting real behavioral change andcontributing to a productive gender debate within Pakistan. These grants are made possible withthe financial support of USAID under Gender Equity Program (GEP). Various grant cycles willbe advertised over a five year period ending August 2015. The program is envisioned to impacton a national level.Aurat Foundation invites and welcome the submission of proposals against the terms ofreference mentioned in Section Three of this RFP by registered civil society not-for-profitorganizations.Frequently Asked Questions regarding GEP and/or the scope of work delineated in this RFP areavailable on the website. Completed proposals should be submitted via post (hardcopy) byclose of business on September 6, 2012 to the postal address given below, the samedeadline.This RFP does not constitute a commitment to make an award on the part of GEP or any agencyimplementing or financing the project. The project will not pay for any cost(s) for the preparationor submission of proposals. GEP reserves the right to reject any or all proposals in the bestinterest of the project objectives.Grants Management CommitteeGender Equity Program (GEP)Email: info.gep@af.org.pkprocurement.gep@af.org.pkHouse 12, Street 12, F7/2, Islamabad 440002

ContentsSection 1: Summary Information.................................................................................................... 41.1 Vision and Goal .................................................................................................................... 41.2 Objectives/Priority Areas...................................................................................................... 4Section 2: Sub-Grant Information................................................................................................... 52.1 Priority Area for Cycle Two ................................................................................................. 52.2 Financial Allocation.............................................................................................................. 52.3 Closing Date.......................................................................................................................... 52.4 Requests for Information ...................................................................................................... 52.5 Award Information................................................................................................................ 5Section 3: Scope of Work ............................................................................................................... 63.1 Time Period........................................................................................................................... 63.2 Location ................................................................................................................................ 63.3 Detailed Scope of Work for Cycle Two ............................................................................... 6Section 4: Baseline and Reporting................................................................................................ 20Section 5: Proposal Process .......................................................................................................... 205.1 Who should apply............................................................................................................... 205.2 Eligibility Criteria ............................................................................................................... 205.3 How to apply....................................................................................................................... 205.4 Sub-Grant Application Format ........................................................................................... 215.5 Evaluation Criteria.............................................................................................................. 235.6 Award Criteria .................................................................................................................... 245.7 Notification ......................................................................................................................... 24Section 6: Certifications................................................................................................................ 25ANNEX 1: Required Certifications.............................................................................................. 26ANNEX 2: Sample Work plan .................................................................................................... 35ANNEX 3: Sample Budget........................................................................................................... 363

Section 2: Sub-Grant Information2.1 Priority Area for Cycle Six (A)GEP‟s sixth grant cycle will focus largely on combatting gender based violence in Pakistan.Different sub-grants will be awarded to create an enabling environment to raise awareness onGBV, develop and demonstrate a system which leads to the full rehabilitation in society and selffulfillmentof survivors of GBV.2.2 Financial AllocationGEP sub-grant awards will fall into three distinct tiers: Below $25,000 $25,000 - $100,000 Over $100,000Tier 1 awards are expected to be most frequent. Tier 2 and Tier 3 sub-grant awards will be lesscommon. Individual ceilings will be allocated per sub-grant and will be detailed in the sub-grantsolicitations. All budgets will be subject to strict scrutiny to prevent excessive allocation.2.3 Closing DateThe final date for submission of the completed proposal application package and all requireddocuments is September 5, 2012. No extensions will be given.2.4 Requests for InformationPlease note that verbal and telephonic requests will not be entertained. FAQs are posted on theGEP webpage.2.5 Award Information1. Award TypeSimplified Grant or Fixed Obligation Grant (Simplified Grant Format (ADS 303.3.24))2. TimingThe review process for all sub-grants will take 6-8 weeks, following which all successfulapplicants will be contacted.5

Section 3: Scope of Work3.1 Time PeriodEach sub-grant has a suggested time period within which the project activities must becompleted.3.2 LocationSub-grant is located in Punjab. Applicants are requested to mention their selected sub-grantnumber and location clearly in their applications.3.3 Detailed Scope of Work for Cycle Six (A)3.3.1 Objective ThreeViolence against women (and some men) is rampant in Pakistan, as reported by media, observedin society and explored through research. The plethora of laws, religious beliefs, traditions,norms and culture have produced an environment where advantage or justice embedded in onekind of law is often cancelled out by another law or by beliefs, traditions and practices. Deepseated beliefs, misogynistic behavior and social institutions legitimize and therefore perpetuateviolence against women.It is germane to deconstruct the usual approaches to address gender-based violence in theparticular context of Pakistan. This will help to construct and sustain survivor-centered approachcomprising of well-thought out, comprehensive and locally relevant mechanisms for long-termrehabilitation and independence of survivors. Such a response to gender-based violence will needto be cross-cutting and holistic, spreading across initiatives to have long-term impact andeffectiveness.Objective of this grant cycle is to create an enabling environment to raise awareness on GBV,develop and demonstrate a system which leads to the full rehabilitation in society and selffulfillmentof survivors of GBV. GEP‟s vision is to build a Ñseamless service‟ which would be achain of institutions and processes at different levels to help GBV survivors to move easilythrough the components in a sequential manner. GEP does not intend to create parallel structuresand institutions, but instead strengthen the systems and services already in place to link themtogether, increase their outreach, and increase their efficiency and effectiveness. This wouldinclude provide trained personnel at each stage, and coordinated mechanisms to achieve anenabling environment. GEP is, therefore, set to approach gender based violence in a systematicand holistic manner, track GBV survivors and support their needs from identification torehabilitation.6

To this end, GEP will award a series of synergetic and inter-linked sub-grants that will betargeted around the following components necessary for combating gender based violence:identification & reporting, protection & counseling, & rehabilitation.2- Psycho-Social and Legal Support to four Private Shelters in PunjabSub-grant no. 124: Punjab (1 sub-grant up to $40,000)Sub-grants will be awarded to facilitate psycho-social and legal counseling program for GBVsurvivors seeking services in 4 private shelters in Punjab (Lahore, Sargodha and Muzaffargarh)to be supported under GEP cycle 6a.The selected organizations will be expected to provide support to the respective shelters byconducting a needs assessment of the existing facilities so as to develop two customizedprograms focusing on psycho-social and legal aspects. These programs will respond to thespecific intangible needs of women during their stay at the shelter, and better equip them toreintegrate into society once they leave the premises.The first component of the sub-grant should be based on a spectrum of psycho-socialinterventions maintaining a strong emphasis on providing post-traumatic support to women andchildren equipping them with emotional strength for successful reintegration into the society.The support should be actively directed at pulling them out of the psychological distress, anxietyand equipping them with confidence, sense of worth, improving their interpersonal skills,enhancing their self-esteem and faith in their abilities.By taking a systematic approach, this portion of the sub-grant will focus specifically on thefollowing: Conducting needs assessment exercises to assess the gaps in the existing services at theshelter Employing experienced and well-trained counselors who are fully equipped to deal withand respond to the needs of women in distress.Development of a comprehensive training plan for the existing shelter staff based on aneeds assessment exercise.Providing appropriate/ psycho-social rehabilitation support based on the individual needsof each survivor based on their emotional state.Put in place referral mechanisms with a hospital or psychologists for advancedpsychological care and rehabilitation if requiredDevelop a sustainability plan to cater to the socio-psychological needs of survivors postGEP support. This would involve in-depth skill transfer to the core staff at the shelterhomes and development of clear set of standard operating procudes.The second component of this sub-grant caters to the development of a legal counseling programthat provides facilitation and aid to women at the shelter seeking justice or those involved in7

legal processes/procedures. Specifically, this component of the sub-grant should focus on thefollowing: Conducting a needs assessment exercise to assess the gaps in the existing legal servicesat the shelter Based on the need-assessment exercise establish a modest but holistic legal counselingunit at the shelter by employing a lawyer with expertise in family law Provide free voluntary assistance to women in documentation, guidance in mattersrelated to khula/divorce, child custody, reconciliation with family, maintenance, recoveryof dowry articles and fabricated criminal cases Put in place strong referral mechanisms by developing linkages with bar councils, legalclinics and institutions in order to create a sustainable and cost-effective legal counselingprogram Develop a sustainability plan to cater to the legal needs of survivors post GEP support.This would involve in-depth skill transfer to the core staff at the shelter homes anddevelopment of clear set of standard operating procedures.It is anticipated that during the sub-grant period, the organization will build the capacities of thededicated psycho-social and legal units within the shelters - equipping them with the requiredskill-sets to effectively run the above mentioned sub-grant functions on their own. In order toensure the sustainability of this initiative, the shelters will adopt this role and make the servicesavailable for GBV survivors in the future. Strong emphasis should be given to the inclusion ofshelter management and the designated coordinator in the process to allow smooth transition andhanding over of both programs to the management towards the end of the grant-period.Suggested time period: 12 monthsMinimum Suggested Outputs:Below are the minimum outputs expected, however, the precise number of beneficiaries willvary in accordance to the private shelters under consideration: Participation in the orientation and mid-term review meetings conducted by the sheltermanagement to coordinate the process Undertake concurrent needs assessment exercises for psycho-social and legal counselingprogram Undertake an extensive planning meeting with the management to discuss the plan ofaction vis-‡-vis both the counseling programs Customized psycho-social plans formulated for 200 GBV survivors living in each of thedesignated private shelters Linkages created with at least two hospitals, psychological clinics per shelter foradvanced care Free legal assistance to 300 GBV survivors living in the respective private shelters Linkages created with at least two bar councils or legal institutions per shelter for referralcases Participate in an end of the project Ñlearning review‟ meeting organized by the sheltermanagement8

Who should apply?NGOs, CBOs and training institutions with experience in psycho-social & legal programmingand capacity building initiatives are encouraged to apply for these sub-grants.* Actual costs will be determined on the final number of shelters selected for supportSection 4: ReportingThe proposal must also include a detailed monitoring and reporting plan outlining output andoutcome indicators (disaggregated by gender) which the proposal seeks to affect for all activitieslisted. The reporting plan must include a quarterly progress report and a project completionreport. If the project proposal is accepted the sub-grantee will be required to finalize thereporting indicators and timelines with the Monitoring and Evaluation section of GEP.Section 5: Proposal Process5.1 Who should applyThe following types of organizations should apply for the sub-grants in this solicitation:Private Shelters, Helplines, NGOs, CBOs, civil society organizations, traininginstitutions, and media production organizations.5.2 Eligibility Criteria1. The organization shall be registered in Pakistan2. The organization shall have a track record in the sector3. The organization should be based in the target area or have a strong capacity for outreachin the target area and target sector4. The organization shall demonstrate financial accountability, preferably audited accounts.5.3 How to applyProspective sub-grantees should submit a completed application package; the proposal form andbudget template available in this document. A complete application should include:1. GEP Proposal Application Form (Section 5.4)2. Work Plan (Annex 2)3. Proposal Budget (Annex 3)4. Reporting plan including a proposal for a baseline study to define key indicators5. CV‟s of 3 key staff members6. Financial audit report for the past 3 fiscal years if available7. Copy of Registration9

8. Signed and stamped certifications (Available in Annexes)a. Certification Regarding Terrorist Financingb. Narcotics offenses and drug trafficking- key individualcertification c. Narcotics offenses and drug trafficking - participantcertificationd. Certification regarding debarment, suspension, ineligibility andvoluntary exclusion lower tier covered transactionse. Voluntary Population Planningactivities f. Initial EnvironmentalExaminationApplications should be submitted in hardcopy. Incomplete applications may be rejected.Applications sent after the last date may also be rejected.Please address your applicationsto: Grants ManagementCommitteeGender Equity Program (GEP)House 12, Street 12, F-7/2,Islamabadprocurement.gep@af.org.pk5.4 Sub-Grant Application FormatInstructions:1. Please copy sections A-C below and complete in a new Word document. Section D-Etemplates are available in the annexes2. Application forms (Sections A-C) may NOT exceed 10 pages in length. Please use TimesNew Roman, Font size123. In Sections D and E, please add rows as necessary depending on your proposed activities.Section A: Introductory Information (Cover Sheet)1. Name and Contact Information of Organization2. Sub-Grant Title/Number3. Estimated Start/End Dates of the Project4. Total Project CostSection B: Organizational Profile10

1. Full legal name and acronym:2.3.Legal status (type of registration e.g. government body, non-governmentalorganization, limited liability company, partnership, etc, registration number) &date of registration of organization:Type of organization (e.g. service delivery, advocacy, research, educational,other):4.5.6.7.8.9.10.Organization‟s outreach (local, provincial, national, and whether urban and/orrural):Number of offices and appropriate staff strength:Publications:Previous Donors (i.e. names of organizations or bodies from which the applicanthas received any type of funding):Previous similar donor-funded projects undertaken in the past 3 years:Project Name & Location:Project Description (2-3 lines):Donor Name:Project Duration, i.e. start/end date:Contact Person/Designation:Email address:Contact Number:Note: Please provide above details for all previous projects.Members of organizations Board (if any):Other partners (organizations with which the applicant has collaborated over thelast three years. Please indicate nature of links e.g. program implementation,information sharing, technical training etc):11. Official street address, telephone, fax and email:Section C: About the Grant1. Grant title:2. Grant goals/objectives:3. Grant rationale (description of why the project has been proposed, and a shortanalysis of the problem it is tackling):11

4. Expected impact of the grant:5. Target group (number and description of direct and indirect beneficiaries, howthey will benefit from the grant and be involved in the project cycle):6. Grant location and duration:7. Methodology (description of the approach, tools and techniques forimplementing the activity):8. Key activities and description, including outputs/deliverables and indicatorsbeing used:9. Implementation plan and schedule (please attach):10. Personnel (details of proposed roles and responsibilities of key staff):Name:Proposed designation/responsibilities:Previous relevant experience:11.Linkages (with existing or previous work done, indicating the impact of thatactivity and details of any other opportunities for developing local or nationallinkages:12. Grant partners (other organizations that will be involved in the grant and theirrole:13. Other donors (donors who are either currently funding work related to this grantapplication or who have been approached for funding for the same grant:14. Monitoring & Evaluation Plan and reporting schedule (please attach):15. Publicity (plans for highlighting the interventions planned for the grant):16. Sustainability (attach your plans for sustainability of grant outputs:17. Total grant funding requested in Pak Rupees (attach a breakdown of thisamount, indicating which costs, if any, will be covered by the applicant and/orother identified sources):Section D: Project Work PlanA sample work plan is available in Annex 2.12

Section E: Grant BudgetThe detailed budget is available in Annex 3.5.5 Evaluation CriteriaAll proposals will go through a stringent review process. The first will ensure that allapplications are complete with:1. Completed application form with the relevant signatures/stamps2. The completed package is sent before the final deadline3. All supporting documents are presentProposals meeting the eligibility criteria will undergo reviews by the Grants ManagementCommittee (GMC). Sub-grants will be made with a view to those projects deemed most likely tomeet GEP objectives.5.6 Award CriteriaAll applications will be reviewed under the following standardized criteria:1. Previous Relevant Experience (30)2. Technical Proposal (30)3. Financial Proposal (20)4. CVs of core staff proposed on the project (20)5.7 NotificationAll applicants will receive notifications regarding the status of their proposals. Letters of regretwill be sent out for all proposals that GEP will not be able to assist in this cycle. Notificationswill include reasons for regret, encouragement to re-apply in future cycles, and/or referrals toGEP‟s capacity building workshops.Finalized applicants will be notified in writing as well as by telephone. The notification willmake clear that the sub-grant is pending on adequate results of the pre-award evaluation and finalapproval by USAID.13

Section 6: CertificationsThe following certifications must be signed, stamped and submitted along with your application.1. Certification Regarding Terrorist Financing2. Narcotics offenses and drug trafficking- key individual certification3. Narcotics offenses and drug trafficking - participant certification4. Certification regarding debarment, suspension, ineligibility and voluntary exclusionlower tier covered transactions5. Voluntary Population Planning activities6. Environmental Impact AssessmentAll certifications are available in Annex 114

ANNEX 1: Required Certifications(1)Certification Regarding Terrorist Financing Implementing E.O. 13224USAID requires that recipients sign the certification below as a prerequisite to receiving a grant from a U.S.Government source.CERTIFICATION REGARDING TERRORIST FINANCING IMPLEMENTING E.O. 13224By signing and submitting this application, the prospective recipient provides the certification set out below:1. The Recipient has not provided, and will take all reasonable steps to ensure that it does not and willnot knowingly provide, material support or resources to any individual or entity that commits,attempts to commit, advocates, facilitates, or participates in terrorist acts, or has committed, attemptedto commit, facilitated, or participated in terrorist acts.2. Specifically, in order to comply with its obligations under paragraph 1, the Recipient will take thefollowing steps:a. Before providing any material support or resources to an individual or entity, the Recipientwill verify that the individual or entity does not appear on the master list of SpeciallyDesignated Nationals and Blocked Persons, which list is maintained by the U.S. Treasury‟sOffice of Foreign Assets Control (OFAC) and is available online at OFAC‟s website :http://www.treas.gov/offices/eotffc/ofac/sdn/t11sdn.pdf , or (ii) on any supplementary list ofprohibited individuals or entities that may be provided by USAID to the Recipient. TheRecipient also will verify that the individual or entity has not been designated by the UnitedNations Security (UNSC) sanctions committee established under UNSC Resolution 1267(1999) (the ì1267 Committeeî) [individuals and entities linked to the Taliban, Osama binLaden, or the Al Qaida Organization]. To determine whether there has been a publisheddesignation of an individual or entity by the 1267 Committee, the Recipient should refer tothe consolidated list available online at the Committee‟s website:http://www.un.org/Docs/sc/committees/1267/1267ListEng.htm .b. Before providing any material support or resources to an individual or entity, the Recipientwill consider all information about that individual or entity of which it is aware or that isavailable to the public.c. The Recipient will implement reasonable monitoring and oversight procedures to safeguardagainst assistance being diverted to support terrorist activity.3. For purposes of this Certificationa.ìMaterial support and resourcesî means currency or monetary instruments or financialsecurities, financial services, lodging, training, expert advice or assistance, safe houses, falsedocumentation or identification, communications equipment, facilities, weapons, lethalsubstances, explosives, personnel, transportation, and other physical assets, except medicineor religious materials.b. ìTerrorist actî meansi.an act prohibited pursuant to one of the 12 United Nations Conventions andProtocols related to terrorism (see UN terrorism conventions Internet site:http://untreaty.un.org/English/Terrorism.asp ); or15

ii.iii.an act of premeditated, politically motivated violence perpetrated againstnoncombatant targets by sub national groups or clandestine agents; orany other act intended to cause death or serious bodily injury to a civilian, or to anyother person not taking an active part in hostilities in a situation of armed conflict,when the purpose of such act, by its nature or context, is to intimidate a population,or to compel a government or an international organization to do or to abstain fromdoing any act.c. ìEntityî means a partnership, association, corporation, or other organization, group orsubgroup.This Certification is an express term and condition of any agreement issued as a result of this application, andany violation of it shall be grounds for unilateral termination of the agreement by USAID prior to the end of itsterm.APPLICANT:Name:Signature:Title:Date:16

I hereby certify that within the last ten years:(2)KEY INDIVIDUAL CERTIFICATION NARCOTICSOFFENSES AND DRUG TRAFFICKING1. I have not been convicted of a violation of, or a conspiracy to violate, any law or regulation of theUnited States or any other country concerning narcotic or psychotropic drugs or other controlledsubstances.2. I am not and have not been an illicit trafficker in any such drug or controlled substance.3. I am not and have not been a knowing assistor, abettor, conspirator, or colluder with others in theillicit trafficking in any such drug or substance.Signature:Date:Name:Title/Position:Organization:Address:Date of Birth:NOTICE:1. You are required to sign this Certification under the provisions of 22 CFR Part 140, Prohibition onAssistance to Drug Traffickers. These regulations were issued by the Department of State and requirethat certain key individuals of organizations must sign this Certification.2. If you make a false Certification you are subject to U.S. criminal prosecution under 18 U.S.C. 1001.17

1. I hereby certify that within the last ten years:(3)PARTICIPANT CERTIFICATION NARCOTICSOFFENSES AND DRUG TRAFFICKINGa. I have not been convicted of a violation of, or a conspiracy to violate, any law or regulation ofthe United States or any other country concerning narcotic or psychotropic drugs or othercontrolled substances.b. I am not and have not been an illicit trafficker in any such drug or controlled substance.c. I am not or have not been a knowing assistor, abettor, conspirator, or colluder with others inthe illicit trafficking in any such drug or substance.2. I understand that USAID may terminate my sub-grant if it is determined that I engaged in the aboveconduct during the last ten years or during my USAID training.Signature:Name:Date:Address:Date of Birth:NOTICE:1. You are required to sign this Certification under the provisions of 22 CFR Part 140, Prohibition onAssistance to Drug Traffickers. These regulations were issued by the Department of State and requirethat certain participants must sign this Certification.2. If you make a false Certification you are subject to U.S. criminal prosecution under 18 U.S.C. 1001.18

(4)Certification Regarding Debarment, Suspension, Ineligibility and Voluntary ExclusionLower Tier Covered Transactions(a) Instructions for Certification1. By signing and submitting this proposal, the prospective lower tier participant is providing thecertification set out below.2. The certification in this clause is a material representation of fact upon which reliance was placedwhen this transaction was entered into. If it is later determined that the prospective lower tierparticipant knowingly rendered an erroneous certification, in addition to other remedies available tothe Federal Government, the department or agency with which this transaction originated may pursueavailable remedies, including suspension and/or debarment.3. The prospective lower tier participant shall provide immediate written notice to the person to whomthis proposal is submitted if at any time the prospective lower tier participant learns that itscertification was erroneous when submitted or has become erroneous by reason of changedcircumstances.4. The terms "covered transaction," "debarred," "suspended," ineligible, "lower tier covered transaction,""participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarilyexcluded," as used in this clause, has the meanings set out in the Definitions and Coverage sections ofrules implementing Executive Order 12549. 1/ You may contact the person to which this proposal issubmitted for assistance in obtaining a copy of those regulations.5. The prospective lower tier participant agrees by submitting this proposal that, should the proposedcovered transaction be entered into, it shall not knowingly enter into any lower tier coveredtransaction with a person who is debarred, suspended, declared ineligible, or voluntarily excludedfrom participation in this covered transaction, unless authorized by the department or agency withwhich this transaction originated.6. The prospective lower tier participant further agrees by submitting this proposal that it will includethis clause titled "Certification Regarding Debarment, Suspension, Ineligibility and VoluntaryExclusion--Lower Tier covered Transaction," 2/ without modification, in all lower tier coveredtransactions and in all solicitations for lower tier covered transactions.7. A participant in a covered transaction may rely upon a certification of a prospective participant in alower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excludedfrom the covered transaction, unless it knows that the certification is erroneous. A participant maydecide the method and frequency by which it determines the eligibility of its principals. Eachparticipant may, but is not required to, check the Non procurement List.8. Nothing contained in the foregoing shall be construed to require establishment of a system of recordsin order to render in good faith the certification required by this clause. The knowledge andinformation of a participant is not required to exceed that which is normally possessed by a prudentperson in the ordinary course of business dealings.9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a coveredtransaction knowingly enters into a lower tier covered transaction with a person who is suspended,debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other19

emedies available to the Federal Government, the department or agency with which this transactionoriginated may pursue available remedies, including suspension and/or debarment.1/ See ADS Chapter 303, 22 CFR 208.2/ For USAID, this clause is entitled "Debarment, Suspension, Ineligibility, and Voluntary Exclusion(March 1989)" and is set forth in the USAID grant standard provision for U.S. nongovernmentalorganizations entitled "Debarment, Suspension, and Related Matters" (see ADS Chapter 303), or inthe USAID grant standard provision for non-U.S. nongovernmental organizations entitled"Debarment, Suspension, and Other Responsibility Matters" (see ADS Chapter 303).(b) Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower TierCovered Transactions1. The prospective lower tier participant certifies, by submission of this proposal, that neither it nor itsprincipals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarilyexcluded from participation in this transaction by any Federal department or agency.2. Where the prospective lower tier participant is unable to certify to any of the statements in thiscertification, such prospective participant shall attach an explanation to this proposal.Application Title:Date of Application/Proposal:Name of Recipient:Typed Name and Title:Signature/Date20

(5)752,7101 VOLUNTARY POPULATION PLANNING ACTIVITIES. (JUNE 2008)(a) Requirements for voluntary sterilization programNone of the funds made available under this contract shall be used to pay for the performance ofinvoluntary sterilizations as a method of family planning or to coerce or provide and financialincentive to any individual to practice sterilization.(b) Prohibition on abortion-related activities1. No funds made available under this contract will be used to finance, support, or be attributed tothe following activities:a. Procurement or distribution of equipment intended to be used for the purpose of inducingabortions as a method of family planningb. Special fees or incentives to any person to coerce or motivate them to have abortionsc. Payments to persons to perform abortions or to solicit persons to undergo abortionsd. Information, education, training, or communication programs that seek to promoteabortions as a method of family planning; ande. Lobbying for or against abortion. The term Ñmotivate‟ as it relates to family planningassistance, shall not be construed to prohibit the provision, consistent with local law, ofinformation or counseling about all pregnancy options.2. No funds made available under this contract will be used to pay for any biomedical researchwhich relates, in whole or in part, to methods of, or the performance of, abortion or involuntarysterilizations as a means of family planning. Epidemiologic or descriptive research to assess theincidence, extent or consequences of abortions is not precluded.Name & TitleSignatureDate21

(6)Initial Environmental Examination FormGender Equity ProgramGrant # , (Grant Title)A. Applicant informationContractor/grantee(organization)Individual contactand titleActivity (briefdescription)Address, phoneand email(if available)AmountLocation of activityStart and end dateof activityB. Activities, screening results, and recommended determinationTABLE 1Proposed Sub-activitiesScreening result(Step 3 of instructions)Very Low RiskModerate RiskHigh RiskRecommended Determinations(Step 6 of instructions. Completefor all moderate and high-riskactivities)No significantadverse impactWith specifiedmitigation, nosignificantadverse impact,SignificantAdverseimpact22

C. Summary of recommended determinationsThe activity contains. . .Very low risk sub-activitiesAfter environmental review, sub-activities determined tohave no significant adverse impactsAfter environmental review, sub-activities determined tohave no significant adverse impacts, given appropriatemitigation and monitoringAfter environmental review, sub-activities determined to have significant adverse impactsD. Certification:I, the undersigned, certify that:1. The information on this form is correct and complete(equivalent regulation 216 terminology)categorical exclusion(s)negative determination(s)negative determination(s) with conditionspositive determination(s)2. The following actions have been and will be taken to assure that the activity complies with environmentalrequirements for the (Project name) under the Code of Federal Regulations 22 CFR 216: These design elements and best practices will be followed in implementing this activity, except with theapproval of USAID.Any specific mitigation or monitoring measures described in the attached information will be implementedin their entirety.Compliance with these conditions will be regularly confirmed and documented by on-site inspectionsduring the activity and at its completion.SignatureDateBELOW THIS LINE FOR USAID USE ONLYApprovalUSAID Project Officer Approved Rejected(print name)(signature)USAID MEO or DMEO Approved Rejected(print name)(signature)USAID comments: (if documentation is rejected, comments must be provided to applicant23

ANNEX 2: Sample Work plan1 Project name2 Organization3 Grant NoQuarter 1 Quarter 2 Quarter 3 Quarter4ID Task Activity QTY Time Jan Feb Mar Apr May Jun Jul1 (no.) (days)2345678910111235

ANNEX 3: Sample BudgetName of Organization:ProjectName:Sub-grantNo:

Line ItemsDescriptionUnitCostRs.Numberof UnitsUnitAnticipated InstallmentsQuarter 1 Quarter 2 *1.0 Personnel Cost1.1 e.g. Program Coordinator(Rs. 15,000 x 1 person x 61 Monthmonths) 15,00045,000 45,000 901.2 e.g. Social Mobilizer(Rs. 10,000 x 2 persons x 62 Monthmonths) 10,00060,000 60,000 121.3 - -Subtotal 105,000 105,0002.0 Program Activities Cost2.1 e.g. Activity 1 Base line Survey (Rs. 45,000 x 1)2.2 e.g. Activity 2 Field Monitoring (Rs. 1,000 x 60 visits)e.g. Activity 3 Other ProgramActivities45,0001,000(Activity cost x Number ofActivities) 500,0001 Event60 Visit45,000 - 4530,000 30,000 602.32 Activity500,000 500,000 1,2.4 - -3.0 Administrative Cost (If any)3.1 e.g. Communication(e.g. Courier charges, Telephoneand Internet) 1,0001 MonthSubtotal 575,000 530,000 13,000 3,000 6,3.2 e.g. Stationery (e.g. Project Documentation) 500 1 Month 1,500 1,5003.3 - -Subtotal 4,500 4,500GRAND TOTAL 684,500 639,500 1*Increase columns as necessary to addquarters and rows to add programactivitiesNote: The above is a sample budget and only for guidance. The abovefigures are not actual for any budgeting purposes.