Micro Grant Application Form

OFFICE OF PRIVATE SECTOR INITIATIVES
PEACE CORPS PARTNERSHIP PROGRAM

MICRO-GRANT APPLICATION FORM - $500 AND UNDER

PROPOSAL INFORMATION

Volunteer Name: COS Date:
Country:
PCPP Project Title:
Community Organization:
Number of Participants/Beneficiaries:

Total PCPP Request: USD $ Local Currency:
Exchange Rate Used: to $1 USD Date of Exchange Rate:

SIGNATURES

By signing below, both the Peace Corps Volunteer and Community Partner verify that the community has been informed and fully understands that Partnership Program funds are to be used only for costs associated with the project; that there will be no additional funding beyond the authorized amount on the proposal as submitted; and that funding through the Partnership Program is not guaranteed.

Additionally, both the Peace Corps Volunteer and Community Partner verify that this project is needed by the community of , who are the intended beneficiaries, and that we fully understand and will fulfill the requirements of the Peace Corps Partnership Program in implementing this project.

_ _
Community Partner’s Name (print) Community Partner’s Signature Date

By signing below, I acknowledge that I am responsible for all funds associated with this project, including the maintenance of all receipts, keeping an updated budget, and returning any unused funds at close of the project. Any funds released to me that cannot be accounted for, or are spent on non-approved costs, may be deducted from my readjustment allowance as a debt owed to the Peace Corps pursuant to MS 223.

I have also granted permission to the Partnership Program to publicize this project and my involvement/participation in the project, and for the Partnership Program to contact the referrals I listed on my behalf.

_ _
Peace Corps Volunteer’s Name (print) Peace Corps Volunteer’s Signature Date

I have reviewed this proposal and certify that it is well-planned, accurately budgeted, and the Peace Corps Volunteer has the technical skills to successfully complete the project within the timeframe of his/her service. Furthermore, this proposal meets each Peace Corps Partnership Program criterion set forth in MS 720.

_ _
Peace Corps Country Director’s Name (print) Peace Corps Country Director’s Signature Date

PROJECT TIMELINE

Approximately how long will it take to implement your proposed project? Months: _ Weeks: _ Days:

What are your planned implementation dates? Start Date: End Date:
(Month/Day/Year) (Month/Day/Year)

NARRATIVE (Boxes will expand to fit your answers. Please use as much space as needed.)

1. Summary:

Explain the project and how will the funds be used?
2. Community Information:

How is your community involved in this project? What will the community contribute to this project?
3. Project Implementation:

How will you and your community implement this project? What is the expected end result or impact of the project? How is the project sustainable?

BUDGET

How will you and your community use the PCPP funds? The PCPP Contribution amount cannot equal more than $500.00 USD on this form – for projects totaling more than $500 please use the full PCPP Application Form.
(Add rows as necessary. It is okay if your proposal expands to more than two pages.)

PCPP Contribution: USD % of PCPP Contribution: %
Community Contribution: USD % of Community Contribution %
Total Project Cost: USD (Community Contribution must equal %25 or more)

PCPP CONTRIBUTION
Item/Materials Unit Quantity Unit Cost
(LCU) Total Cost
(LCU) Total Cost
(USD)

TOTALS

COMMUNITY CONTRIBUTION
Item/Materials Unit Quantity Unit Cost
(LCU) Total Cost
(LCU) Total Cost
(USD)

TOTALS
(USD = U.S. Dollar, LCU = Local Currency)
MONITORING & EVALUATION

Knowing if your project was successful is important. How will you measure the success of your project?

REFERRALS

Identify potential donors that would be interested in supporting your proposed project –include name and e-mail address.

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