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REQUEST FOR APPLICATIONS GEORGIA HAZELNUT IMPROVEMENT PROJECT (G-HIP) Request for Applications (RFA) No.003 Issuance Date: December 30, 2018 Dear Applicant: CNFA, through the G-HIP Project (the “Project”), is seeking in-kind grant applications for implementation of a competitive in-kind grant program. The grants will be awarded and implemented in accordance with the United States Agency for International Development (USAID) and US Government regulations governing grants and G-HIP’s internal grant management policies. Please note that the deadline for receiving applications is March 31, 2019. Applications will be reviewed and scored, as received, on a rolling basis until the deadline. Interested applicants have the chance to ask questions about the RFA and receive guidance on how to complete the application form given in Annex A on [email protected] or at the G-HIP office at the address: Tbilisi 47 Kostava Street, Suite 26; Tel: 0322 98 22 32 . SECTION I. PROGRAM DESCRIPTION About CNFA Cultivating New Frontiers in Agriculture (CNFA) is an international non- profit organization that specializes in designing sustainable, market-led agricultural initiatives to address the world’s growing demand for food. Established in 1985, CNFA draws on over 30 years of expertise in sustainable agriculture production, enterprise development, access to finance, market access, strengthening livelihoods, processing and post- harvest management, and input supply and farm service. CNFA has managed more than $600 million in donor-funded agriculture development programs and has worked in 45 countries throughout Africa, Eastern Europe, Latin American and the Caribbean, the Middle East, and South and Central Asia. CNFA partners with the private sector, foundations, governments, and communities to build customized local and global partnerships, and fosters inclusive development to enhance opportunities to under-served groups. 1 | Request for Applications (RFA) No.001

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Page 1: SECTION I. PROGRAM DESCRIPTION - CNFA … · Web viewThrough the in-kind grants program, G-HIP will support the establishment of up to five (5), 1000-ton capacity drying and 500-ton

REQUEST FOR APPLICATIONS

GEORGIA HAZELNUT IMPROVEMENT PROJECT (G-HIP)

Request for Applications (RFA) No.003

Issuance Date: December 30, 2018

Dear Applicant:

CNFA, through the G-HIP Project (the “Project”), is seeking in-kind grant applications for implementation of a competitive in-kind grant program. The grants will be awarded and implemented in accordance with the United States Agency for International Development (USAID) and US Government regulations governing grants and G-HIP’s internal grant management policies. Please note that the deadline for receiving applications is March 31, 2019. Applications will be reviewed and scored, as received, on a rolling basis until the deadline.

Interested applicants have the chance to ask questions about the RFA and receive guidance on how to com-plete the application form given in Annex A on [email protected] or at the G-HIP office at the address: Tbilisi 47 Kostava Street, Suite 26; Tel: 0322 98 22 32 .

SECTION I. PROGRAM DESCRIPTION

About CNFA

Cultivating New Frontiers in Agriculture (CNFA) is an international non-profit organization that specializes in designing sustainable, market-led agricultural initiatives to address the world’s growing demand for food. Established in 1985, CNFA draws on over 30 years of expertise in sustainable agriculture production, enterprise development, access to finance, market access, strengthening livelihoods, processing and post-harvest management, and input supply and farm service. CNFA has managed more than $600 million in donor-funded agriculture development programs and has worked in 45 countries throughout Africa, Eastern Europe, Latin American and the Caribbean, the Middle East, and South and Central Asia. CNFA partners with the private sector, foundations, governments, and communities to build customized local and global partnerships, and fosters inclusive development to enhance opportunities to under-served groups.

ABOUT G-HIP

CNFA is implementing the G-HIP project, a five year, USAID-funded program which utilizes market-based approaches and solutions to advance USAID’s development priorities by increasing the quality and quantity of Georgian hazelnut production, improving processing capabilities and establishing market linkages that will allow smallholder growers to reach lucrative end markets. The G-HIP Alliance will bring together and leverage the financial and technical resources of USAID, private sector partner Ferrero, and CNFA to increase the scale, efficiency and effectiveness of USAID’s development impact, while advancing private sector interests and objectives. The Alliance will transform and streamline the hazelnut value chain where mutual interests in the quality production of hazelnuts will incentivize growers and processors to produce and export high quality Georgian hazelnuts.

Due to the attractive investment opportunity for Husking, Drying, and Storage (HDS) facilities, the limited availability of HDS facilities in Georgia, and the substantial improvements in product quality, volumes, and farm revenues that result from introducing drying and storage services, it is clear that the hazelnut sector can 1 | R e q u e s t f o r A p p l i c a t i o n s ( R F A ) No.001

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benefit from a systematic approach to promoting investment in new HDS facilities. Such a systematic invest-ment promotion strategy would not only address the market needs of different value chain actors in the hazelnut sector, but would also coordinate the efforts of the Government of Georgia (GoG), the donor com-munity, and the private sector to accomplish these goals.

The introduction of additional HDS facilities would benefit the hazelnut sector in terms of preserving the quality of the hazelnut kernels in the shell from the time of harvest and in eliminating much of the post-har-vest loss due to producers not appropriately drying hazelnuts and storing them properly. By preserving the quality of the kernels, producers can yield 38-42% instead of 35% which is common in the market, which represents a 10-20% increase in sales revenue. Similarly, by utilizing HDS facilities’ services, producers will be able to reclaim the post-harvest loss of up to 35%.

G-HIP plans to use in-kind grants to facilitate the achievement of activity objectives, with a particular focus on working through Georgian institutions and ensuring sustainability. Implementation of in-kind grants will catalyze the development of hazelnut husking, drying, and storage (HDS) facilities in Georgia.

Through the in-kind grants program, G-HIP will support the establishment of up to five (5), 1000-ton capacity drying and 500-ton storage Husking Drying & Storage Facility. The cost of HDS varies from $300,000 to $350,000. G-HIP will provide in-kind grants worth up to $50,000 with potential additional leveraged funds from AgriGeorgia/Ferrero (maximum EUR 50,000). Accordingly, applicants will be expected to provide approximately $200,000 - $250,000 in matching contributions in order to be considered for grant selection. Detailed financial calculations are provided in Annex E.

Through in-kind matching grants, G-HIP will pilot model investments into postharvest infrastructure to reduce losses and improve quality. G-HIP’s investments will stimulate private and public-sector investment to develop an initial network of HDS facilities that are crucial to enhancing the competitiveness of Georgia’s hazelnut sector. Grants implementation will be supplemented by technical assistance (TA) provided by trained G-HIP staff and Ferrero. TA will include trainings on a wide range of topics such as management, operation, use and maintenance of equipment for newly established HDS Facility personnel.

REGULATORY FRAMEWORK

Grants administered under the G-HIP project must be in compliance with the relevant regulations in the US Government Code of Federal Regulations (CFR) and the USAID Automated Directive System (ADS).

● Code of Federal Regulations (CFR): A collection of regulations published by agencies of the USG, including:

o 2 CFR 200 – uniform administrative requirements, cost principles, and audit requirements for federal assistance awards to non-federal entities. For grants to non-US entities, note that only 2 CFR 200 Subpart E – the Cost Principles – applies to non-US entities.

o 2 CFR 700 – USAID’s formal adoption of 2 CFR 200. ● Automated Directive System (ADS) 303: USAID internal policy which guides the administration

of Grants and Cooperative Agreements to Non-Governmental Organizations. The ADS describes USAID’s internal guidance, policy directives, required procedures, and standards for award adminis-tration.

● ADS 303mab: A mandatory supplement to ADS 303 outlining the Standard Provisions for Non-US Non-Governmental Organizations. The Standard Provisions, and any Required as Applicable Provi-sions, will be incorporated into each applicable Grant Agreement upon award.

● ADS 303mat: A mandatory supplement to ADS 303 outlining the Standard Provisions for Fixed Amount Awards to Non-Governmental Organizations. The Standard Provisions, and any required as Applicable Provisions, will be incorporated into each applicable Grant Agreement upon award.

CNFA will be responsible for ensuring that selected grantees comply with the above regulations, updating procedures and Grant Agreements following any revisions to the regulations, and guiding Grantees in adhering to the requirements.

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SECTION II. ELIGIBILITY REQUIREMENTS

Building off CNFA’s agribusiness project successes in Georgia over more than 10 years, and to stimulate private and public sector capital to establish this critical infrastructure, G-HIP will provide grants to buy-down the risk of entrepreneurs and procure part of the necessary equipment.

To be considered eligible for an in-kind grant from G-HIP, applicants must meet the following eligibility criteria:

● Be a legally registered Georgian entity/Private for-profit enterprise, or individual tax payer;● Provide evidence of the financial capability to meet G-HIP’s matching contribution and working

capital necessary to effectively operate the HDS facility;● Demonstrate an in-depth implementation strategy for the establishment and operations of the HDS

facility;● Submit an application in response to an official G-HIP solicitation (such as this solicitation) that re -

sponds to G-HIP’s requirements and conditions;● Be committed to adhering to high ethical business standards, including transparency in business

dealings and record keeping;● Be prepared to undertake an independent financial review or audit, as requested;● Commit to the necessary matching contribution;● Demonstrate ability to maintain business, financial, and technical records, either manually or elec-

tronically;● Ensure compliance with relevant environmental protection requirements, including the Initial Envi-

ronmental Examination (IEE), and verified through an Environmental Monitoring and Mitigation Plan (EMMP) or Environmental Review Checklist (ERC);

● Complete and pass a site-visit and pre-award assessment; ● Agree to and sign the applicable certifications, such as the Certification Regarding Lobbying; Certi-

fication Regarding Terrorist Financing; Prohibition on Assistance to Drug Traffickers; and Certifica-tion of the Recipient;

● Certify that the organization/individual is not debarred, suspended, or proposed for debarment from receipt of USG funds.

While G-HIP will consider all applicants, priority will be given to projects that impact larger numbers of beneficiaries, address under-served populations and/or create significant numbers of sustainable new jobs when selecting potential awardees.

SECTION III. APPLICATION AND SUBMISSION INFORMATION

Applications will be accepted only in the application format given (Annex A). Applications, which include completed Annexes A, B, and C, as well as all supporting documentation, may be submitted either in electronic form or the CD, in addition to the hard copy, or can be hand delivered. The electronic applications can be emailed to [email protected] and should reference RFA No.003 in the email Subject line. Hard copies of the Applications should be delivered to the G-HIP office at the address below and should reference RFA No.003 on the outside of the sealed envelope.

Tbilisi Office: 47 Kostava Street, Suite 26; Tel: 0322 98 22 32

Hand written applications will not be accepted. Incomplete applications will not be considered for evaluation. Applications along with all required certifications and supporting documentation should be submitted no later than 5 pm local time, on March 31, 2019. Late or incomplete applications will not be considered.

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Issuance of this RFA does not constitute an award or commitment on the part of G-HIP, nor does it commit G-HIP to pay for costs incurred in the preparation and submission of an application.  Further, G-HIP reserves the right to accept or reject any or all applications received. Applicants will be informed in writing of the decision made regarding their application.

SECTION IV. EVALUATION CRITERIA

All applications submitted in response to this solicitation will be evaluated against the criteria listed below:

(100 total points)1. Current activities, Corporate Capability and Ex-

perience40

Existing assets 5

Professional background of personnel 5Demonstrated ability to conduct similar activities 5

Experience managing donor funds (if applicable) 5Financial status, management and record-keeping capabilities, matching contribution ability

20

2. Project Goals and Business Strategy 30

Market Analysis 10Operational Plan 15

Project budget 53. Project Impacts 30

Beneficiaries 20Projected impact 10

Total 100

1. Current activities, Corporate Capability and Experience

Existing assets: Description of existing facilities, equipment, buildings and other assets of the enterprise (owned and leased)

Professional background: includes information about organization’s governance and key personnel, their qualifications and professional backgrounds related to the project.

Demonstrated ability to conduct similar activities: the extent to which the applicant has ex-perience conducting activities similar to those proposed in the grant application (Registration as an official business entity; Length of registration as a legal entity; Preference for enter -prises with a long track record of profitable operation).

Experience managing donor funds (if applicable): Information about company’s experience of participation in the donor funded projects (received funding, technical assistance, etc.)

Financial status, management and record-keeping capabilities, matching contribution ability: Financial management and record-keeping capabilities: ability to manage finances and keep accurate records including but not limited to timesheets, employment agreements, account-ing documents, and other expenditures related to the organization’s operation. Information about existence of financial resources (likely sources: incomes from current activities, owner's savings, bank credit); demonstrated ability to make the required matching contribu-tion.

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2. Project Goals and Business Strategy

Market Analysis: A realistic and detailed description of the targeted clients, market, ex-pected costs and methods for operating in the market.

Operational plan: A clear & detailed description of implementation schedule for two (2) years is presented, including all key operations.

Project Budget: Budget calculations for necessary materials, inventory or equipment are re-alistic and match existing requirements & trends. Grant funds requested in budget are rele -vant to the project goals, as described in business strategy & operation plan.

3. Project Impacts Beneficiaries. Number of created jobs, level of wages, and projections of numbers of farm-

ers who will benefit during the implementation of this project. To achieve the maximum score in this category, applications must demonstrate the engagement of women as owners, leaders, employees or clients.

Projected Impact/Pro-forma Financial Projections. The compliance of the projected financial results and profitability with the existing target indicators will be evaluated. In addition, a fair and detailed description of potential risks and assumptions of their project is presented. The quality and completeness of financial projections will be evaluated.

For those successful applicants that receive a consensus score above the 70% threshold and passed the pre-award eligibility screening, G-HIP will use site visits to verify information provided in the application, evaluate the proposed project location, conduct an initial pre-award assessment, and perform an initial environmental assessment. Applicants who successfully pass the site visit, pre-award assessment, and environmental assessment are anticipated to be accepted for the next stage of grant award.

ANNEXES

Annex A – Grant Application Form Annex B – Applicant Self-Assessment Form Annex C – Required Certifications PackageAnnex D – Mandatory Standard Provisions and Required as Applicable Standard Provisions for Non-U.S. Non-Governmental Organizations Annex E – HDS Establishment Financial calculationsAnnex F – HDS images

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ANNEX A. APPLICATION FORM

Submission of this grant application is FREE OF CHARGE. Applicants are solely responsible for submitting applications. CNFA will not reimburse expenses associated with preparation and submission of application materials. CNFA and USAID reserve the right to decline any application received.

About CNFA

Cultivating New Frontiers in Agriculture (CNFA) is an international non-profit organization that specializes in designing sustainable, market-led agricultural initiatives to address the world’s growing demand for food. Established in 1985, CNFA draws on over 30 years of expertise in sustainable agriculture production, enterprise development, access to finance, market access, strengthening livelihoods, processing and post-harvest management, and input supply and farm service. CNFA has managed more than $600 million in donor-funded agriculture development programs and has worked in 45 countries throughout Africa, Eastern Europe, Latin American and the Caribbean, the Middle East, and South and Central Asia. CNFA partners with the private sector, foundations, governments, and communities to build customized local and global partnerships, and fosters inclusive development to enhance opportunities to under-served groups.

The Georgia Hazelnut Improvement Project (GHIP) in Georgia provides in-kind grants to private existing agribusinesses and start-up enterprises with the goal of developing commercially sustainable and competitive hazelnut Hasking and Draying facilities that will result in increased profitability, income generation and employment in rural areas.

Completed applications with all required annexes may be delivered to the project office or emailed to [email protected]. Hand written applications will not be accepted. Incomplete applications or applications submitted after the submission deadline will not be considered for evaluation.

Date of Submissiondate/month/year

Name of company:

Company’s legal form: Ltd Sole Proprietorship JSC Cooperative OtherIf Other, indicate here ______________________________________

Date of registrationand TAX ID Number:

List of shareholders and their respective shares/stakes:

Contact Information:

Contact person (At

least 1)Position Address,

(town, village) Tel. E-mail

1. 2. 3.

1.2.3.

1.2.3.

1. 2. 3.

1.2.3.

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Requested grant amount (USD):

Company matching contribution (USD):

1. Current Activities

1A. Describe facilities, equipment, buildings and other assets of the enterprise (owned and leased)

1B. Provide information about the company’s history of operations, experience directly related to the proposed project and planned activities, qualification and professional backgrounds of organization’s owners and key personnel. Provide information about your company’s experience of participation in the donor funded projects (received funding, technical assistance, etc.)

1C. Using the table below provide information about quantities of sales and profits and exact place of salesduring last 2 years (in GEL):

Products/services Volume Sales revenues

Cost of Goods Sold

Gross profit Place of sale

Total

1D. Provide a narrative description of the financial status of the enterprise, based on the figures. Also describing any reserves, savings, investment or financing that may be brought to the project and is not shown in Attachment 1.

2. Project Goal and business strategy

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2A. Describe the details of agricultural production and services in the proposed market area. Specify: a) what varieties of hazelnuts are cultivated or services provided for produces; b) how many potential clients exist; and c) competitive environment, including prevailing market prices for goods and complementary services.

2B. Specify stages of project implementation and define periods /stages. Also indicate milestones - planned activities, works to be conducted for each stage.

Preliminary schedule and milestones of project implementation:

Milestone Period/date Matching Contribution amount GEL

123

2C. Project Budget

Complete the table, provide project budget in USD.

Description

Grantee contribution

G-HIP funds

Total proje

ct investment

Company’s own funds

External Financing (i.e.

Ferrero/Agrigeorgia, bank loan etc.)

Total matching

contribution Equipment and/or Supplies (machinery, office equipment, cash register, shelving and furniture, etc.)

              USD 50,000      

 Marketing, advertisement, product promotion, etc.

                         

 New working capital (labor, etc.) and inventory needed for the project

                         

                          

Construction, remodelling, reconstruction, environmental mitigation measures

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Construction, remodelling, reconstruction, environmental mitigation measures1

 Other                          

 TOTAL                          

2D. Specify the source of amounts intended for matching contribution:

Fill the information in this section in case you intend to apply for a bank loan. If your matching contribution will not be secured from outside financing, skip this section and go to Section 4 - Expected Results.

2E. Have you ever applied for a bank loan: Yes No

2F. Describe the collateral you may use to secure a bank loan for the matching contribution.

2G. Do you have commercial finance in place to cover the capital requirements of the proposed project? If so, specify the financial institution and terms of the bank loan.

3. Project Impacts

3A. Provide information about the planned activity of the proposed project. Specify: a) how many and what type of clients are expected to be served; b) what specific advantages in technology, service quality, marketing or pricing the proposed enterprise will have/need.

1USAID funds are not used to cover construction costs. Please be informed that grant funds will be disbursed through the direct procurement by the implementing organization (CNFA) to a vendor for the procurement of assets for a grantee and CNFA will maintain the title/ownership rights to the procured assets during the lifetime of the project. Thus, while developing the budget envision all operational costs as a part of the on matching contribution.

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3B. Provide narrative information about the projected impact the proposed enterprise will have, both for the applicant enterprise and for clients (farmers). Specify: a) increased sales and net income for the applicant firm; b) new jobs created and salaries paid to employees; c) increased incomes for clients and farmers as a result of gaining access to goods and services through the enterprise and; d) direct/indirect impact on women consumers or clients in the community.

3C. Number of people employed currently and number of new jobs anticipated to be created as a result of project implementation:

Existing jobs

Position Average Monthly Wages in GEL

Total Number of Employees

Men Women

Management Level Positions

Finance & Administrative (non-managerial) Positions

Technical Specialist Level Positions2

Workers, Laborers

Other

New jobs

Note: Please refer here only jobs anticipated to be created in addition to existing jobs, please do not include here existing jobs

Position Average Monthly Wages in GEL

Total Number of Employees

Men Women

Management Level Positions

Finance & Administrative (non-

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managerial) Positions

Technical Specialist Level Positions3

Workers, Laborers

Other

3D. Provide information about training required for current and/or new employees.

4. Pro forma Financial Projections

4A. Complete the tables below. Specify financial results of the planned activities (in GEL):

Project year 1Exchange rate

Sales types Sales volumes Income from sales Cost of goods sold Gross profit

Total

Project year 2Exchange rate

Sales types Sales volumes Income from sales

Cost of Goods Sold Gross profit

Total

Additional explanations: detailed information about service volumes and client; a fair and detailed description of potential risks and assumptions

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5. Environmental Measures

5A. Describe the site of the enterprise. Specify: a) the distance from the nearest water resources (well, river, spring, lake, potable water, irrigation water etc.), forests, natural reserve territory, agricultural lands, monuments of cultural heritage, populated areas, public buildings such as schools, hospitals; b) availability of running water, sewerage, electricity and gas supply to the site; c) road access to the proposed site; d) proximity to fields/clients to be served by the project.

5B. If applicable, provide information on the disposal of waste through the project. Specify: a) storage and handling of diesel fuel, lubricants and engine fluids; b) fire prevention and worker safety measures planned for the project; c) mitigation of noise, air and water pollution for any surrounding agricultural land, wildlife or human settlements.

5C. Describe your past experience in applying environment, health, and safety procedures. Provide information on: a) planned safeguarding and mitigation measures to reduce possible environmental impact as a result of the proposed activity; b) capacity and resources to implement these measures.

I ______________________________________, certify that the information presented in the application and attachments is true and accurate.

______________________Signature

ATTACHMENT 1Provide pro-forma projections of the expected financial performance of the enterprise after award. Projections should be forecasted at least for 24 months of operations.

ATTACHMENT 2Certification from applicant

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Official financial statements for the last declaration period Any other additional information related to your objectives description or project implementation.

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CHECKLIST AND SIGNATURE PAGE

G-HIP requests that your organization submit a number of documents along with this completed questionnaire (Attachment A). Complete this page to ensure that all requested information has been included.

Please complete the checklist below, then sign and return the questionnaire and any other requested documents to G-HIP.

1. Complete the checklist:

__ Incorporation papers or certificate of registration and statute have been provided to G-HIP.

__ Organizational chart, if available, has been provided to G-HIP.

__ Copy of your organization's most recent audit has been provided to G-HIP (Alternatively, if there has been no recent audit, then a "Balance Sheet" and "Revenue & Expense Statement" for the prior fiscal year must be provided to G-HIP).

__ All questions on this questionnaire have been fully answered.

__ The organization’s authorized agent has signed and dated this page.

The accounting questionnaire must be signed and dated by the organization’s authorized Agent who has either completed or reviewed the form.

Submitted by:

__________________________Print Name Signature

__________________________Title Date

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ATTACHMENT 1: Pro-forma financial projections (values in GEL)

PROFIT AND LOSS STATEMENT Project Year 1 (period) Project Year 2 (period)

1 Sales Revenues    2 Cost of Goods Sold    3 Gross Profit (1-2)    4 Gross Profit Margin % (3/1)    5 Administrative Costs    6 Sales and Marketing Costs    7 Operational Profit (3-5-6)    8 Grants Received (no in-kind, only in cash)    9 Other Non-Operational Income/Expense +/-    

10 EBITDA (7+8+9)    11 Depreciation and Amortization    12 Interest    13 EBT (10-11-12)    14 Profit Tax    15 Net Profit (Loss) (13-14)    

BALANCE SHEETEnd of Project Year 1 (as

of)End of Project Year2 (as

of)ASSETS:

Cash    Accounts Receivable    Inventory    Other Short-Term Assets    Total Short-Term Assets    Net Fixed Assets (Land, Buildings, Machinery)    Other Long-Term Assets    Total Long-Term Assets    TOTAL ASSETS    LIABILITIES AND CAPITAL:Accounts Payable    Other Short-Term Liabilities    Total Short-Term Liabilities    Bank Loan    Other Long-Term Liabilities    Total Long-Term Liabilities    Paid-in Capital    Retained Earnings    Other Capital    Total Capital    TOTAL LIABILITIES AND CAPITAL    

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ATTACHMENT 2: G-HIP Program Certification

I understand that the G-HIP Activity is an open and transparent program and submission of a grant application is absolutely free of charge.

I further understand that my application, to which this Certification is attached, (the “Application”) will be reviewed for possible funding based only on the potential of the proposed project to offer innovative and sustainable ideas that address the goals of G-HIP. I have not and will not make any payments or gifts or any offers or promises of payments or gifts of any kind, directly or indirectly, to any person in connection with the Application. I understand that the making of any such act shall entail the disqualification of the Application.

I undertake to promptly and fully disclose to CNFA any information about the situations listed above should they occur in connection with the Application.

I confirm that neither I, nor my immediate family (or other owners) are related to any employees of CNFA or USAID. If a potential conflict of interest or appearance of impropriety exists, I undertake to discuss with CNFA the situation and how it can be resolved.

Name of Applicant: _____________________________

Name of Applicant Representative: _____________________________

Title: _____________________________

Signature: _____________________________

Date: _____________________________

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ANNEX B. APPLICANT SELF ASSESSMENT FORM

This form is required to be completed by the applicant and submitted to G-HIP, along with the grant application. It is used as part of G-HIP’s assessment of an applicant’s adherence to eligibility requirements as well as capacity to adequately handle grant funds. It may be used in lieu of or in conjunction with other pre-award responsibility determination tools.

------------------------------------------------------------------------------------------------------------------------G-HIP Applicant Self-Assessment Form

Accepting a grant from G-HIP creates a legal duty for the Grantee to use the funds according to the grant agreement and to United States federal regulations. Before awarding a grant, G-HIP must assess the adequacy of the financial and accounting systems of a prospective grantee to ensure accountability.

To complete this form, answer each question as completely as possible, using extra pages if necessary.

APPLICANT INFORMATION

Name of Organization:Activity Title:Name, Title, Contact Information of Individual Completing Questionnaire:

SECTION A: INTERNAL CONTROLS

Internal controls are procedures that ensure: a. Financial transactions are approved by an authorized individual and follow laws, regulations, and the or-

ganization's policies, b. Assets are kept safely, c. Accounting records are complete, accurate, and kept on a regular basis.

Please complete the following concerning your organization's internal controls:

1. The name, position/title, and telephone number for the individuals responsible for verifying allowability of expenditures.

Name:Title:Telephone number:

2. The name, position/title, and telephone number for the individual responsible for maintaining accounting records:

Name:Title:Telephone number:

3. List the name, position/title, and telephone number for the individual responsible for preparing financial reports:

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4. List the name, position/title, and telephone number for the individual responsible for preparing narrative reports:

Name:Title:Telephone number:

5. Does the organization keep timesheets for each paid employee?

Yes: __ No: __

6. Is your organization familiar with U.S. Government regulations concerning costs which can be charged to U.S. grants (2 CFR 200 Subpart E, Cost Principles for Nonprofit Organizations)?

Yes: __ No: __

SECTION B: ACCOUNTING SYSTEM

The purpose of an accounting system is to (1) accurately record all financial transactions; and (2) ensure that all financial transactions are supported by invoices, timesheets and other documentation.

The type of accounting system often depends on the size of the organization. Some organizations may have computerized accounting systems, while others use a manual system to record each transaction in a ledger. In either case, G-HIP Grant funds must be properly authorized, used for the intended purpose, and recorded in an organized and regular manner.

1. Briefly describe your organization's accounting system including: (A) any manual ledgers used to record transactions (general ledger, cash disbursements ledger, suppliers ledger etc.); (B) any computerized accounting system used (please indicate the name); and (C) how transactions are summarized in financial reports, (by the period, project, cost categories).______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Does your organization have written accounting policies and procedures? Yes: __ No: __

3. Are your financial reports prepared on a:

Cash basis: __ Accrual basis: __ (Accrual = bill for costs before they are incurred)

4. Can your accounting records separate the receipts and payments of the G-HIP grant from the receipts and payments of your organization's other activities? Yes: __ No: __

5. Can your accounting records summarize expenditures from the G-HIP grant according to different budget categories such as salaries, rent, supplies, and equipment? Yes: __ No: __

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6. How do you allocate costs that are “shared” by different funding sources, such as rent, utilities, etc.? __________________________________________________________________________________________________________________________________________________

7. How often are financial reports prepared?Monthly: __ Quarterly: __ Annually: __ If financial reports are not prepared, then briefly explain why they are not: _________________________________________________________________________________________________________________________________________________

8. How often do you input entries into the financial system?a. Daily __ b. Weekly __ c. Monthly __ d. Ad hoc/as needed __ 9. How often do you do a cash reconciliation?a. Daily __ b. Weekly __ c. Monthly __ d. By accountants decision __ 10. Do you keep invoices, vouchers and timesheets for all payments made from grant funds? Yes:__ No: __

SECTION C: AUDIT

G-HIP may require an audit of your organization's accounting records. An audit is a review of your accounting records by an independent accountant who works for an accounting firm. An audit report contains your financial statements as well as an opinion by the accountant that your financial statements are correct. Please provide the following information on prior audits of your organization.

1. Does your organization contract and pay for regular independent audits?Yes: __ (please provide the most recent copy) No audits performed: __

2. If regular independent audits are performed, who performs the audit?

Name:Company:Telephone number:

3. How often are audits performed?Quarterly: __ Yearly: __ Every two years: __

Other: __(explain)

4. If your organization does not have a current audit of its financial statements, please provide a copy of the following financial information, if available:

a. "Balance Sheet" for your prior fiscal or calendar year; and b. "Revenue and Expense Statement" for your prior fiscal or calendar year

5. Are there any reasons (local conditions, laws, or institutional circumstances) that would prevent an independent accountant from performing an audit of your organization? Yes: __ No: __

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If yes, please explain:

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ANNEX C. Required Certifications Package

Certification Regarding LobbyingThe undersigned certifies, to the best of his or her knowledge and belief, that:(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal Cooperative Agreement, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned must complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,” in accordance with its instructions.

(3) The undersigned must require that the language of this certification be included in the award documents for all subawards at all tiers (including contracts, subawards, and contracts under grants, loans, and cooperative agreements) and that all subrecipients must certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, United States Code. Any person who fails to file the required certification will be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance

“The undersigned states, to the best of his or her knowledge and belief, that: If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned must complete and submit Standard Form-LLL, “Disclosure of Lobbying Activities,” in accordance with its instructions. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, United States Code. Any person who fails to file the required certification will be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.”

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Prohibition on Assistance to Drug Traffickers for Covered Countries and Individuals

USAID reserves the right to terminate this Agreement, to demand a refund or take other appropriate measures if the Grantee is found to have been convicted of a narcotics offense or to have been engaged in drug trafficking as defined in 22 CFR Part 140. The undersigned must review USAID ADS 206 to determine if any certifications are required for Key Individuals or Covered Participants.

If there are COVERED PARTICIPANTS: USAID reserves the right to terminate assistance to or take other appropriate measures with respect to, any participant approved by USAID who is found to have been convicted of a narcotics offense or to have been engaged in drug trafficking as defined in 22 CFR Part 140.

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Certification Regarding Terrorist Financing

By signing and submitting this application, the prospective recipient provides the certification set out below:

1. The Recipient, to the best of its current knowledge, did not provide, within the previous ten years, and will take all reasonable steps to ensure that it does not and will not 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, attempted to commit, facilitated, or participated in terrorist acts, as that term is defined in paragraph 3. The Certification in the preceding sentence will not be deemed applicable to material support or resources provided by the Recipient pursuant to an authorization contained in one or more applicable licenses issued by the U.S. Treasury’s Office of Foreign Assets Control (OFAC).

2. The following steps may enable the Recipient to comply with its obligations under paragraph 1:

a. Before providing any material support or resources to an individual or entity, the Recipient will ver-ify that the individual or entity does not (i) appear on the master list of Specially Designated Nation-als and Blocked Persons, which is maintained by OFAC, or (ii) is not included in any supplementary information concerning prohibited individuals or entities that may be provided by USAID to the Re-cipient.

b. Before providing any material support to an individual or entity, the Recipient will also verify that the individual or entity has not been designated by the United Nations Security (UNSC) sanctions committee established under UNSC Resolution 1267 (1999) (the “1267 Committee”) [individuals and entities linked to the Taliban, Usama bin Laden, or the Al-Qaida Organization]. To determine whether there has been a published designation of an individual or entity by the 1267 Committee, the Recipient should refer to the consolidated list available online at the Committee’s website: http://www.un.org/Docs/sc/committees/1267/1267ListEng/htm.

c. Before providing any material support or resources to an individual or entity, the Recipient will con-sider all information about that individual or entity of which it is aware and all public information that is reasonably available to it or of which it should be aware.

d. The Recipient also will implement reasonable monitoring and oversight procedures to safeguard against assistance being diverted to support terrorist activity.

3. For the purposes of this Certification –

a. “Material support and resources” means currency or monetary instruments or financial securities, fi-nancial services, lodging, training, expert advice or assistance, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, person-nel, transportation, and other physical assets, except medicine or religious materials.

i. “Training” means instruction or teaching designed to impart a specific skill, as opposed to general knowledge.

ii. “Expert advice or assistance” means advice or assistance derived from scientific, technical, or other specialized knowledge.

b. “Terrorist act” means –

i. An act prohibited pursuant to one of the 12 United Nations Conventions and Protocols re -lated to terrorism (see UN terrorism conventions Internet site: http://untreaty.un.org/English/Terrorism.asp); or

ii. An act of premeditated, political motivated violence perpetrated against noncombatant tar-gets by subnational groups or clandestine agents; or

iii. Any other act intended to cause death or serious bodily injury to a civilian, or to any other person not taking an active part in hostilities in a situation of armed conflict, when the pur-

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pose of such act, by its nature or context, is to intimidate a population, or to compel a gov-ernment or an international organization to do or to abstain from doing any act.

c. “Entity” means a partnership, association, corporation, or other organization, group or subgroup.d. References in this Certification to the provision of material support and resources must not be

deemed to include the furnishing of USAID funds or USAID-financed commodities to the ultimate beneficiaries of USAID assistance, such as recipients of food, medical care, micro-enterprise loans, shelter, etc., unless the Recipient has reason to believe that one or more of these beneficiaries com-mits, attempts to commit, advocates, facilitates, or participates in terrorist acts, or has committed, at-tempted to commit, facilitated or participated in terrorist acts.

e. The Recipient’s obligations under paragraph 1 are not applicable to the procurement of goods and/or services by the Recipient that are acquired in the ordinary course of business through contract or pur-chase, e.g., utilities, rents, office supplies, gasoline, etc., unless the Recipient has reason to believe that a vendor or supplier of such goods and services commits, attempts to commit, advocates, facili -tates, or participates in terrorist acts, or has committed, attempted to commit, facilitated, or partici -pated in terrorist acts.

This Certification is an express term and condition of any agreement issued as a result of this application, and any violation of it will be grounds for unilateral termination of the agreement by USAID prior to the end of its term.

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Certification of the Recipient

By signing below, the recipient provides certifications and assurances for (1) the Certification Regarding Lobbying, (2) the Prohibition on Assistance to Drug Traffickers for Covered Countries and Individuals (ADS 206), and (3) the Certification Regarding Terrorist Financing Implementing Executive Order 13224 above.

These certifications and assurances are given in consideration of and for the purpose of obtaining any and all Federal grants, loans, contracts, property, discounts, or other Federal financial assistance extended after the date hereof to the recipient by the Agency, including installment payments after such date on account of applications for Federal financial assistance which was approved before such date. The recipient recognizes and agrees that such Federal financial assistance will be extended in reliance on the representations and agreements made in these assurances, and that the United States will have the right to seek judicial enforcement of these assurances. These assurances are binding on the recipient, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign these assurances on behalf of the recipient.

Name of Recipient___________________________________________________________________

Type Name and Title_________________________________________________________________

Signature______________________________________________________________________

Date ________________________________________________________________________

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ANNEX D. MANDATORY STANDARD PROVISIONS FOR NON-U.S. NONGOVERNMENTAL ORGANIZATIONS

If selected for award, grantees will be required to comply with all mandatory and any required as applicable Standard Provisions, the full text of which can be accessed online at https://www.usaid.gov/sites/default/files/documents/1868/303mab.pdf . These provisions will be incorporated into the execution of any grant agreement upon signature.

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ANNEX E – ILLUSTRATIVE EXAMPLE OF HDS CONSTRUCTION AND ESTABLISHMENT COST BREAKDOWN

CapEx USD GELBuilding Construction/Renov 211,200 528,000 Dryers 80,000 200,000 Aeration fans 2,000 5,000 Laboratory 3,000 7,500 Forklift 15,000 37,500 Jute Bags 25,000 62,500 Pallets 5,000 12,500 IT System 1,500 3,750

0Required Rate of Return 10.0%IRR, 10-Year 17.2%IRR, 20-Year 24.1%NPV, 10-Year 82,553

INPUT REQUIRED General Assumptions Desc.Agricultural Cooperative No Grant from APMA Yes Preferential Agro Credits Yes Other Grant Yes

50,000 3.60 4.10

Operating Assumptions USDPermanent Staff 2

Size of Other Grant (USD)Price of Low-Quality In-Shell Nuts (GEL/KG)Price of High-Quality In-Shell Nuts (GEL/KG)

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INPUT REQUIRED General Assumptions Desc.Agricultural Cooperative No Grant from APMA Yes

INPUT REQUIRED General Assumptions Desc.Agricultural Cooperative No

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ANNEX F – EXAMPLES OF HDS FACILITIES

HDS facilities represent the greatest potential for value chain improvements and overall rural development in Georgia’s hazelnut production areas and provide the greatest potential for improvements in producer’s in-comes and livelihoods.

Equipment:

Storage:

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