ANNEX 1

PROGRAMME TITLE
SUBPROGRAMME CODE/PROJECT :
IMPLEMENTING AGENCY:
IMPLEMENTING AGENCY:

REQUEST OF FUNDS
Instalment no.3
Prepared by1

_______________

/2004

Preventive financial
control visa(s)

Programme Authorising Officer (PAO)

_____________

Endorsed by
National Fund
General Director
______________
(name)

Comments attached2

Approved by
NAO

/2004

________________
(signature)

/_/

yes

_______________
(name)

Comments attached2

/_/

/_/

_________________
(signature)
yes

The Request of Funds should be prepared by a senior official in the IA

Comments in each case attached on separate page

2
2

____/____/___
(date)

no

____/____/____
(date)
/_/

no

BASIC DATA OF THE SUBPROGRAMME(S)/PROJECT

Subprogramme(s)/Project title& code:

F.M. signed on:
F.A. signed on:
Amendments to the FM/FA
Cost estimates:
FM -Phare Initial cost estimates
FM - Phare Reallocated cost estimates
PF Co-financing (national/other sources) Initial cost estimates (as in the FM and/or Project Fiche)
PF - Co-financing (national/other sources) Reallocated cost estimates (as as in the FM and/or Project Fiche)
Sub-programmes/Projects/Sub-projects3
Code
Title

FM

PHARE contribution
FM
Budget
managed
by HQ

Budget
managed
locally

National Public Funds

PF
PF

(MEUR)
Other sources
PF

PF

Expiry data for

Commitment

Disbursement

Implementing
Authority/Beneficiary

10

11

12

13

Note: National public funds shall be considered the state budget funds (under the National Preaccession Fund budgetary line and the ministries/agencies budgets),
local budgets funds and the funds of other institutions asimilated as public bodies.Other sources shall be considered the private and /or IFI/or bilateral funding,
according to the project fiche.

Management:
3

Total shall be provided for each sub-programme, project, subproject level. The breakdown shall be made taking into account the Implementing Authority level.

Implementing Agency
Address:
PAO:
Delegate 1:
Delegate 2:
Contact person
Address:
Email address:
TRANSFER OF FUNDS
(EUR)

AMOUNT

DATE

Funds RECEIVED from the National Fund

1st Instalment
2st Instalment
Total received from the National Fund

Phare Funds PAID by the IA4:

BALANCE AT THE IA5
INTEREST GENERATED
Subprogramme/Project

Bank sub-account number

Bank Interest
Received

Bank Charges
EUR

EUR
Code
1

Title
2

3
TOTAL

Net of bank interest received and bank charges

Difference between total funds received from the NF and total paid by the IA
6
Interest net of bank charges
5

Bank Net
interest
received6
EUR

Interest
allocated

EUR

DOCUMENTS ATTACHED (tick the appropriate box):

1
2
3
4
5
6
7
8
9

Declaration of expenditure
Bank reconciliation and Local Status of Contracts
Bank Statements
Progress Report
Implementing Agreements with Implementing
Authorities*
Nominations of PAO, SAO, SPO and their delegation
of responsibilities**
Modification of the project fiche (since the last
request of funds)
Status of conditionalities fulfilment
Cofinancing contribution

Note:

YES
X
X
X
X

Not Applicable

COMMENTS

*) for the projects/components where IA is not the Implementing Authority

**) internal documents confirming PAO, SAO, SPO nominations and their delegates shall be attached to the
first request of funds and whenever modified

PERSEUS:
Last reporting done (date):

IA : 30/07/2004

DECLARATION OF EXPENDITURE

The undersigned, Maria Crivineanu PAO of the Programme . hereby7 declares that the total eligible expenditure paid by the IA in accordance with
the progress of the programme amounts to ..The payments made out of the EC contribution represent % of the PHARE local budget in force of the Programme,
with respect to which the statement of expenditure is as follows :
(Cumulative amounts in EURO)
Subprogramme/
/Project/Sub-project8

FM9 - Local budget allocation

Local amounts contracted

Local amounts paid by the IA/

Beneficiary

Balance Due on Local Amount Contracted

Codes

PHARE
Contribution

National Public
Funds

PHARE
Contribution

National Public
Funds10

PHARE
Contribution11

National Public
Funds12

PHARE
Contribution

National Public Funds

8=4-6

9=5-7

I also declare that the aggregate of the funds in IA bank sub-accounts. is % not exceeding 10% of the local budget in force of all the project .
managed by the IA and that the data here certified is consistent with the Perseus reporting..

Subprogramme/ Bank sub-account

Project Code
Number
1

Funds
received
EUR

Net Bank
Interest
EUR

Local
Disbursement
EUR

Closing
Balance
EUR13

Date of Bank
Statement14

Equal to the amount indicated in column 4 of the table shown below

This table must be presented in the same way as in the Financing Memorandum budget /detailed cost breakdown (add as many rows as necessary)
9
Financing Memorandum in force including reallocation of funds
10
The Euro equivalent of the contracted amounts in ROL at the Infoeuro exchange rate applicable on the month of the contract signature
11
Local amounts paid by the IA/ beneficiaries, without bank charge
12
The Euro equivalent of the paid amounts in ROL at the Infoeuro exchange rate applicable on the month of the payment
13
At the end of the previous month. The differences between the ABN AMRO Bank exchange rate and InforEuro exchange rate affected this amount.
14
Date of the closing balance
8

In accordance with the financing plan in force, I hereby request payment of the amount corresponding to the instalment / balance (less the interest generated) amounting to
EUR and determined as follows:
Amount per subaccount
TOTAL
1
2
3
4

(+) updated cash-flow forecast for the

current month
(+) cash-flow forecast for the next month
(+) estimated bank charges16
(+) bank net interest 17

(-) total of the closing balance18

(=) Instalment Requested

I also declare that the project RO 2002/000-628 is progressing at a satisfactory rate in accordance with the objectives laid down in the Financing Memorandum and in
the Project fiches.

PAO ___________________________________

date:

SAO ___________________________________

date:

16

0.15% applicable to (1+2) amounts

Interest net of bank charges; to be considered for calculation only if it is a positive amount
18
Total of the column 6 closing balance - in the table above.
17