1、扶輪獎(jiǎng)助金中文說明樣 (非正式表格)(此表格可由國(guó)際扶輪社網(wǎng)站下載 (141EN) Word檔)The Rotary Foundation (TRF)Major Matching Grants ApplicationFor grant requests of US$ 25,000 to US$ 150,000(適用美金$25,000-$150,000之間的申請(qǐng)表)Rotarians may use this application and attach additional pages as needed or may answer the questions below on blank p

2、aper, on the condition that the answers follow the same order as the application. Rotarians using the electronic version of the application will find that table cells expand automatically as information is added. Incomplete applications will be returned to the primary host partner with a brief expla

3、nation. See The Guide to Humanitarian Grants (144-EN) for instructions and eligibility and program requirements. (若表格空間不足, 各社可依照自己需要調(diào)整每個(gè)問題回答空間的大小, 只要不更改各項(xiàng)問題的順序, 請(qǐng)完整的填入資訊以免因?yàn)橘Y訊不足而被退件 )Note: Applications for low-cost shelter and revolving loan projects and grant requests of US$25,001 or more have addi

4、tional requirements. See The Guide to Humanitarian Grants (144-EN), , or contact TRF staff for more information.1. PROJECT DESCRIPTION計(jì)畫內(nèi)容1. What is the purpose of this project? Provide a brief description. (計(jì)畫目的為何? 簡(jiǎn)單說明)2. How will it meet the needs of the community? (如何達(dá)到社區(qū)的需要?)3. H

5、ow will the host and international partners communicate and work together to implement this project? Please provide specific examples of activities. (主辦社與國(guó)外合作的社如何執(zhí)行及溝通計(jì)畫? 請(qǐng)敘述活動(dòng)的實(shí)例)2. COOPERATING ORGANIZATIONS 合作的機(jī)構(gòu) If this project involves a co-operating organisation: (如有合作的機(jī)構(gòu): )1. Provide the name

6、of the organisation below. (提供單位名稱)2. Attach a letter of participation from that organisation that specifically states its responsibilities, how it will interact with Rotarians in this project, and the organisations agreement to cooperate in any financial review of activities connected with the proj

7、ect. (附上該機(jī)構(gòu)願(yuàn)加入計(jì)畫的責(zé)任與扶輪社的互動(dòng)及財(cái)務(wù)的介入說明 )3. Attach a letter of endorsement of the organisation from the Rotarians in the project country. (主持計(jì)畫國(guó)之社友提出該機(jī)構(gòu)的背書信)Name of organisation (機(jī)構(gòu)名稱)Is the letter of participation from the organisations attached (Yes / No)是否有附上機(jī)構(gòu)介入說明?Is the letter from the project

8、country Rotarians attached (Yes / No)是否有附上主持計(jì)畫國(guó)之社友背書信 3. RELATIONSHIP TO OTHER RI OR TRF PROJECTS (OPTIONAL) 與其他計(jì)畫的關(guān)係Is this project related to, or has it resulted from, other Rotary International or TRF projects? (Yes / No): If so, please identify those projects. (此計(jì)畫是否與其他國(guó)際扶輪或基金會(huì)的計(jì)畫相關(guān)? (是/否) 如是, 請(qǐng)

9、指出哪些計(jì)畫)Program 計(jì)畫Individuals Name and/or Project #人名/計(jì)畫號(hào)碼Program 計(jì)畫Individuals Name and/or Project # 人名/計(jì)畫號(hào)碼WCS Projects ExchangeGroup Study ExchangeIndividual GrantAmbassadorial Scholarships3-H GrantDistrict Simplified GrantMatching GrantOther:Could this project benefit from an international volunt

10、eer? (Yes / No)此計(jì)畫是否對(duì)國(guó)際義工有助益? (是/否) 4. PRIMARY HOST PARTNER IN THE PROJECT COUNTRY計(jì)畫主辦社List the club or district in the project country that assumes joint responsibility for the project.Rotary Club of社名Club ID # 社籍號(hào)碼 District 地區(qū)Country 國(guó)家 Project Committee: A committee of at least two Rotarians must

11、 be established by the primary host partner to oversee the project for its duration, even if the project continues into another Rotary Year.Primary Contact 主要聯(lián)絡(luò)人(must be a member of the above club/district)Additional Contact額外聯(lián)絡(luò)人Name 姓名NameMember ID # 社員辨識(shí)號(hào)碼Member ID #Rotary Club of 所屬社名Rotary Club

12、ofDistrict 地區(qū)DistrictPosition/title 職稱Position/titleE-mail 電子郵件信箱E-mailStreet address 住址Street addressCity / state /postal code 城市 區(qū)域號(hào)碼City / state /postal codeCountry 國(guó)家CountryTelephone 電話Home 家TelephoneHomeOffice 公OfficeFax 傳真FaxCellular 手機(jī)Cellular5. PRIMARY INTERNATIONAL PARTNER OUTSIDE THE PROJE

13、CT COUNTRY 國(guó)外社List the club or district outside the project country that assumes joint responsibility for the project.Rotary Club of社名Club ID # 社籍號(hào)碼 District 地區(qū)Country 國(guó)家 Primary Contact 主要聯(lián)絡(luò)人(must be a member of the above club/district)Additional Contact額外聯(lián)絡(luò)人Name 姓名NameMember ID # 社員辨識(shí)號(hào)碼Member ID #

14、Rotary Club of 所屬社名Rotary Club ofDistrict 地區(qū)DistrictPosition/title 職稱Position/titleE-mail 電子郵件信箱E-mailStreet address 住址Street addressCity / state /postal code 城市 區(qū)域號(hào)碼City / state /postal codeCountry 國(guó)家CountryTelephone 電話Home 家TelephoneHomeOffice 公OfficeFax 傳真FaxCellular 手機(jī)CellularProject Committee:

15、A committee of at least two Rotarians must be established by the primary host partner to oversee the project for its duration, even if the project continues into another Rotary Year.6. PROJECT BUDGET 計(jì)畫預(yù)算Include a complete itemised budget for the project and indicate which currency is used. Please a

16、nswer the questions provided about purchase of equipment, materials, or supplies. Use separate pages if necessary. Pro forma invoices, supplier price quotes, and/or other cost documentation may be required upon request.(列出計(jì)畫各項(xiàng)目之預(yù)算及貨幣單位, 包括購(gòu)滿器具, 材料 可用其他表格附上)Item to be purchased 購(gòu)買物品Name of supplier 廠

17、商名稱Cost 價(jià)錢總價(jià)(請(qǐng)聲明貨幣)Total (identify currency)$ 0.00換算美金匯率Exchange rate used相等於美金US$ EquivalentNote: To calculate the total automatically, place your cursor on the cell, click on Table, then Formula, then OK.7. PURCHASE OF EQUIPMENT 購(gòu)買設(shè)備1. Who will own equipment and maintain, operate, and secure items

18、 purchased with grant funds? (Equipment cannot be owned by a Rotary Club or Rotarian) (誰(shuí)將擁有,保養(yǎng),使用及購(gòu)買設(shè)備?) (社友及社不得擁有此設(shè)備)2. Is software necessary to operate any budget items? If so, has software been provided? (預(yù)算中購(gòu)買的設(shè)備是否包括軟體的使用? 如是, 是否已有提供軟體?)3. Will training in use and maintenance of technical equipm

19、ent be provided? (是否提供設(shè)備維護(hù)及使用的訓(xùn)練?)4. If budget items will be shipped, have arrangements been made for customs clearance? (如是進(jìn)口品,是否有報(bào)關(guān)的安排?)8. PROPOSED FINANCING 財(cái)務(wù)建議If SHARE District Designated Funds (DDF) are part of the funding for this Major Matching Grant, either attach a letter(s) from the distr

20、ict Rotary Foundation committee (DRFC) chair(s) authorizing the use of those funds and specifying the amount or have the DRFC chair(s) authorize the use of the SHARE funds by signing below. Only the chair, on behalf of the DRFC, can authorize the use of SHARE DDF. Please list all financing and indic

21、ate cash or SHARE (DDF) amounts.Rotary Club / DistrictAmountContributing(US$) 捐款Cash /DDF 現(xiàn)金/DDFDRFC Chair Authorization 基金會(huì)主委簽字Rotary Club of 社名$0 CashDistrict # 地區(qū)$0 DDFRotary Club of 社名$0District # 地區(qū)$0DDFSub-total 合計(jì)$0.00Amount requested from TRF 基金會(huì)請(qǐng)款$0Additional funding from other sources其他來源$

22、0TOTAL 總計(jì)$0.00(Must be equal to budget cost) 必須與預(yù)算相同Note: To calculate the subtotal and total automatically, place your cursor in the correct cell, click on Table, then Formula, then OK.9. COMMUNITY NEEDS ASSESSMENT (FOR GRANT REQUESTSOF US$25 001 TO US$ 150 000) 社區(qū)需求評(píng)估(要求USD$25,000至USD$150,000)If y

23、our grant request is for US$ 25 001 or more, a community needs assessment must be included. This assessment should demonstrate how the proposed project: (如果您申請(qǐng)的金額超過USD$25,001 必附上需求評(píng)估及符合以下條件: )· Is viable and can be maintained by the benefiting community after grant funding has been fully expend

24、ed (可實(shí)行的,在獎(jiǎng)助金使用完後受益社區(qū)還能夠繼續(xù)維持此申請(qǐng)計(jì)畫)· Involves the benefiting community, including its ownership of the project(受益社區(qū)及計(jì)畫擁有者必須參與計(jì)畫)Please refer to The Guide to Humanitarian Grants (144-EN) for additional information.Community needs assessment attached (Yes / No) 否有附上社區(qū)需求評(píng)估 (是/否)10. PARTNERSHIP AUTH

25、ORIZATION 合作的國(guó)外社授權(quán)All Rotary Clubs or districts involved in this project are responsible to The Rotary Foundation (TRF) for the conduct of the project and reporting on it. The partners signatures confirm that they understand and accept responsibility for the project. Partners may either sign this pa

26、ge or submit a separate letter of commitment.By signing below, we are agreeing to the following:· All information contained in this application is true and accurate, to the best of our knowledge.· This application meets all Matching Grant criteria as stated in The Guide to Humanitarian Gra

27、nts (144-EN).· We will ensure all cash contributions (as detailed in item 8) will be forwarded to TRF after Trustee approval of a Matching Grant.· We understand that if our club/district or our partner club/ district has overdue progress or final reports for any previously awarded Matching

28、 Grants, this application will be returned to the host partner.HOST PARTNER 主辦社INTERNATIONAL PARTNER 國(guó)外社Club President (if club-sponsored)社長(zhǎng)Club President (if club-sponsored)社長(zhǎng)District Grants Subcommittee Chair (if district-sponsored) 主委District Grants Subcommittee Chair (if district-sponsored)主委Nam

29、e姓名NameTitle職稱TitleRotary Club of 社名Rotary Club ofDistrict # 地區(qū)DistrictSignature簽名SignatureDate日期Date11. DISTRICT GRANTS SUBCOMMITTEE CHAIR CERTIFICATION 地區(qū)獎(jiǎng)助金主委證明The Trustees strongly suggest that the district grants subcommittee chair from either the host or international district certify the appl

30、ication as complete. If the application is not complete or eligible, it will be returned to the host partner with a brief explanation.“On behalf of the committee, I hereby certify that to the best of my knowledge and ability this grant application is complete and meets all TRF guidelines.”District G

31、rants Sub-Committee Chair Signature主委簽名District 地區(qū)12. REPORTS 報(bào)告Although both partners are responsible for completing progress and final reports, the Trustees require that one partner take primary responsibility for submitting the reports to TRF.“By signing below, our club/district accepts primary r

32、eporting responsibility.”Signature簽名Rotary Club of 社名District地區(qū)13. COMPLETION CHECKLIST 核對(duì)主件Before submitting your Major Matching Grants Application, please take a moment to review this checklist. If you have any questions or concerns, please contact TRF staff (see below).¨ Are there written sp

33、onsorship confirmations from the club president(s)/district leadership who will be in office during the year of the funding request? (計(jì)畫是否獲社長(zhǎng)及地區(qū)領(lǐng)導(dǎo)人支持?)¨ Does the project meet all grant policies and guidelines (see The Guide to Humanitarian Grants (144-EN) or the RI Web site at )?

34、 Does the project description clearly state how the project will assist those in need? (是否符合基金會(huì)申請(qǐng)條件?)¨ Have both the host and the international partner created committees to oversee the project? Are these individuals correctly listed on the application? (雙方是否設(shè)立主委委員會(huì)管理及監(jiān)督計(jì)畫?是否正確在申請(qǐng)表格上列出?)¨

35、Have the responsibilities of the project country partner and international partner been outlined? Do they meet the requirements of a Matching Grant project? (雙方之責(zé)任是否清楚劃分?)¨ Are there written commitments (or signatures on section 10 of the application) from each primary project partner? If SHARE

36、 District Designated Funds (DDF) are used, the current district Rotary Foundation committee chair must provide a written confirmation authorizing use of DDF (or signature on section 8 of the application). (相關(guān)人士是否都簽字?)¨ Is a co-operating organization involved? If so, are there letters from 1) th

37、e organization, specifically stating its responsibilities, how it will work with Rotarians, and its agreement to co-operate with any financial review of the project; and 2) the primary host partner, indicating that it has knowledge of the organization and endorses the co-operative effort? (有合作機(jī)構(gòu)時(shí), 是否文件齊全?)¨ Is your project to build low-cost shelters? If yes, is a Low-Cost Shelter Agreement a