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DISBURSEMENT DECISION-MAKING FORM
Legend: Compulsory If applicable Sub-Saharan Africa: Southern Africa Fund Portfolio Manager

Portfolio Cluster

1 - GENERAL GRANT AND DISBURSEMENT INFORMATION
Country: Disease: Principal Recipient: Grant Number: Grant Start Date: Grant End Date: Total Committed: Currency: Grant Phase: 01-Nov-2005 31-Oct-2007 Disbursement Request Number: FPM Disbursement Amount Decision: Beginning Date: Period Covered by End Date: Progress Update: Period Covered by Beginning Date: Disbursement Request*: End Date:
* Includes buffer quarter

.00

Date of Previous Disbursement: Amount of Previous Disbursement:

15-Mar-2007 4,186,625.90

2 - PERFORMANCE EVALUATION
PERFORMANCE RATING LEGEND

PERFORMANCE RATING Overall evaluation of performance

Select

LFA Rating

Select

New Scale Old Scale (LFA)

A - Expected or exceeding expectations (5 or 4) - (Exceptional or Expected)

B1 - Adequate (3) - (Minor adjustments needed)

B2 - Inadequate but potential demonstrated (2 or 1) - (Major adjustments needed or Little progress made)

C - Unacceptable (0) - (Major program issues)

Do the LFA comments on program progress indicate any cause for concern?

If yes:

I have considered causes of concern raised by the LFA regarding program progress in my overall evaluation of performance (rating and comments)

I have provided full justification for any difference between my overall progress rating and the LFA's rating I have considered LFA comments on data quality and reporting, if any

3 - FINANCIAL CONSIDERATIONS
Comments on disbursements to date, expenditures and cash balance, if any

Do the LFA comments on program expenditure indicate any cause for concern?

If yes:

I have considered causes of concern raised by the LFA regarding program expenditures in the comment box above

I have provided clear explanation in the comment box above in cases where cumulative expenditures significantly deviate from budget (eg. +/- 15%)

4 - CONTEXTUAL INFORMATION CRITICAL TO DISBURSEMENT DECISION
Governance(CCM, Civil Society, Donor and Partner Relations, GF Related - LFA, Secretariat, etc.-, etc.) General Management (PR and Project Management, SR, Procurement, HR, Health Systems, M&E, etc.) External Factors (Political Environment, Currency Fluctuations, Natural Disaster, etc.) Other (National Programs, SWAPS, Corruptive Environment, etc.)

Select

Select

Select

Select

11/8/2009

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5 - FUTURE AND OUTSTANDING REQUIREMENTS
REQUIRED DOCUMENTATION Attachment to Annex A (covering disbursement period) Audit Report Annual Review
OUTSTANDING?

COMMENTS (if Outstanding)

Select Select Select

CONDITIONS PRECEDENT APPLICABLE TO THIS DISBURSEMENT

FULFILLED? Select Select Select Select

COMMENTS (if Outstanding)

I confirm that the LFA and the PR have provided sufficient comments on all applicable conditions precedent to this disbursement(s) I have reviewed and assessed LFA comments in relation to satisfaction of all applicable CPs and have ensured that they are consistent with CPs provided in the Grant Agreement
####

6 - LFA RECOMMENDATION(S)
I have provided decisions for each LFA Recommendation (on the “LFA On-going Progress Review and Disbursement Recommendation” Form)

7 - DISBURSEMENT DECISION
Amount ( ) Cash Request (from the PR) LFA Recommended 0.00 0.00

%
#DIV/0! #DIV/0!

Period Covered by Disbursement Request (as above) Beginning Date: End Date: Total Committed Less: Actual Disbursed to Date
Undisbursed Grant Amount

Amount ( )

%
#VALUE!

10,698,938.62 #VALUE! #VALUE!

#VALUE! #VALUE! #VALUE!

FPM DISBURSEMENT AMOUNT DECISION Rationale and Performance Basis for Disbursement Decision

0.00

#DIV/0!

Amount in Words

0

Undisbursed after this disbursement

Has the LFA concluded that the forecasts included in the disbursement calculation are reasonable?

If no:

I have concluded that the disbursement amount is still appropriate based on the rationale outlined in the comment box above.

I have provided full justification for any difference between my disbursement decision and the LFA's Recommendation and/or PR Request I have provided full justification for disbursement in case of under-performance of the program (e.g., B2 or C Rating)

8 - DOCUMENTATION SUPPORTING THE DISBURSEMENT
Supporting Documentation PR Disbursement Request LFA On-going Progress Review and Disbursement Recommendation Other: Other: PR has provided an authorized signature and date on the report PR Request Report period dates are correct and follow exactly sequentially from PR's previous report The expenditure and program progress is reported to a date not more than six months ago Date:
11/8/2009

Date Signed

Calculation of Disbursement Request is correct (from Cash Reconciliation and supporting statements)

PR Request

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Periods for which cash is requested are reasonable and follow directly after report period LFA Report LFA report has been properly signed and dated LFA has properly verified the PR's bank / bank account details (LFA has referenced the grant agreement face page containing the correct PR bank details for this disbursement) LFA report period dates are correct and follow directly after the report period in the previous report LFA has properly conducted all required verifications (Section 4.C. or 1.B) I have updated the Grant Performance Report (GPR) Other An LFA implementation work order is currently in place for this grant agreement and will expire not later than one month from today Expiry date:

The required procurement information for the previous disbursement has been entered into the Global Fund's Price Reporting Mechanism: yes/no Beneficiary Details Owner of Bank Account: Bank Account Name: Bank Account Number: Beneficiary Bank Name: Bank Address: Bank SWIFT Code: Bank Code (Other): PR Name: PR Type: Address: PR Additional Representative: PR Tel. Number: PR Fax. Number: PR e-mail: Principal Recipient Details

0

Routing Instructions:

9 - RECOMMENDATION OF DISBURSEMENT
Particular attention is drawn to the following matters: >> Grant agreement has expired or will expire within one month Grant Disbursement Number Grant Amount Disbursement Amount Undisbursed After Disbursement Global Fund Rating Grant End Date Grant Phase
Statement by Fund Portfolio Manager I have carefully reviewed the PR disbursement request and the associated LFA report and have taken account of all contextual information in my knowledge as portfolio manager for this grant as the basis for my answers and comments on this form and the accompanying file note. All matters that should be brought to the attention of the Cluster Leader are set out above or in the accompanying file note. Based on this review and knowledge of the grant I recommend payment of this disbursement.

0.00 #VALUE! Select 31-Oct-2007

jkj

--------------------------------------------------Signature Statement by Cluster Leader

-----------/------------------/ 200 Date

--------------------------------------------------------Printed Name and Title of Signatory

I have reviewed this disbursement worksheet and the supporting documentation as listed above and have taken account of any matters brought to my attention therein. Based on my review, I recommend payment of this disbursement.

--------------------------------------------------Signature

-----------/------------------/ 200 Date

--------------------------------------------------------Printed Name and Title of Signatory

Statement by Additional Reviewer (for disbursements in excess of 2,000,000 USD) I have reviewed this disbursement worksheet and the supporting documentation as listed above and have taken account of any matters brought to my attention therein. Based on my review, I recommend payment of this disbursement.

--------------------------------------------------Signature

-----------/------------------/ 200 Date

--------------------------------------------------------Printed Name and Title of Signatory

10 - FINANCE REVIEW
Statement by Finance Officer This disbursement is within committed funds
11/8/2009

Statement by Chief Financial Officer

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Undisbursed grant amount: #VALUE! The supporting documents are in order The above has been verified by:

% funds disbursed:

96.46%

I recommend payment instructions to the Trustee for the above disburseement.
Barry Greene, Chief Financial Officer / Ian Carter, Financial Controller

Eric Godfrey, Finance Officer

-------------------------------------------------------------- -----------/------------------/ 200 Signature Date

--------------------------------------------------------Printed Name and Title of Signatory

--------------------------------------------------------------------------------/------------------/ 200 Signature Date

--------------------------------------------------------Printed Name and Title of Signatory

To be completed by Signatory of Bank Order

Payment instruction signed by:
WBT Reference Number

Date:

Initials

11/8/2009


				
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