Lifelong Learning Programme 2007-2013

Leonardo da Vinci

TRANSFER OF INNOVATION
Model: Grant Agreement Amendment Request Form

Note: The electronic version of the form is available at: www.mobilnost.hr

Grant Agreement number: 	Grant agreement period:	
Starting Year:	Country:	Project duration:                  (months)  	
Title:	
Beneficiary:	
Beneficiary's legal representative:	
Previous amendments	No:		Yes:		How many:		

DECLARATION OF CONFORMITY

I, the undersigned, hereby declare that the attached information is accurate and in accordance with the facts. This information has been approved by the authorities representing the partners involved in the project detailed within this request.

...........................................................................................................………………………………………………………
(Original signature of the person legally authorised to act on
behalf of the beneficiary organisation and who signed the agreement)

Name of beneficiary's legal representative: …………………………………….…………..……………………

Position within the beneficiary organisation: …………….................…………………………..………………
Place & Date: ………………………………………………………………………......…………………….

Form to be returned to the following address: 
Agencija za mobilnost i programme EU
Gajeva 22
10000 Zagreb

AMENDMENT SUMMARY

Amendments to the grant agreement are subject to written requests, dated and signed by the beneficiary's legal representative. These amendments are also subject to formal endorsement by the National Agency. 

Please note that an amendment only takes effect following signature by the National Agency (this will be in the form of an official, signed amendment to the grant agreement)

Following the on-line completion of the appropriate section(s) of this form, please print, sign, date and send by ordinary mail, together with an accompanying letter and all appropriate annexes, to the National Agency.

The present request for amendment, to the initial agreement (including previous amendments), concerns one or more of the following items (please, tick the box(es), as appropriate):

 	A - Change of the beneficiary organisation 
 	B - Partner(s) withdrawal
 	C - New / Replacement partner(s) joining the project1
 	D - Changes to the work programme2
 	E - Change of bank account
 	F - Changes to the project duration
 	G - Changes to the reporting schedule
 	H - Changes to the budget
 	I - Other

A.	Change of the beneficiary organisation	

New Beneficiary
Name of the new beneficiary organisation in national language (full and abbreviated if applicable)	(full)	
	(abbreviated)	
Name of the organisation in EN, FR or DE		
Organisation type code 		
Organisation size code 		
Economic sector code 		
Head Office
Street		
Number		
Post code		
Town/city		
Country code		
Region code		
Contact Person
Name	Mr□   Ms□		
Position		
Street		
Number		
Post code		
Town/city		
Telephone	++	/	
Fax	++	/	
E-mail		

Authorised signatory
Name	Mr□   Ms□		
Position		

Reasons for withdrawal of existing beneficiary organisation (max 1/2 page)	

	

General description of the new beneficiary organisation: size, scope of work, areas of specific expertise and competence in relation to the project proposal (max 1/2 page)	

	

Skills and expertise of key staff involved in the project in the new beneficiary organisation (limit 5 lines per person)	

	

Tasks taken over by the new beneficiary organisation and/or (re)distribution of related tasks amongst the partners (max 1/2 page)	

	

Previous projects: If the new beneficiary organisation has already obtained financial support for a project related to this proposal within the Leonardo da Vinci Programme or under other Community programmes / initiatives in the last five years, please, fill in the table below.	
Start year 	Programme or initiative 	Type of action 	Identification number 	Contracting organisation 	Title 	Website 	

							

List of annexes to be sent with this amendment request (mail delivery):
a)	Copy of the report from the withdrawing beneficiary to the new beneficiary detailing both activities undertaken and related expenditure (plus all supporting documents)
b)	Original letter from the new beneficiary organisation approving this report and undertaking to act as the new beneficiary and to pursue the remaining project activities
c)	Copy of the draft take-over protocol
d)	Original letters of acceptance by all partners
e)	Copy of the legal statutes of the organisation and copies of the financial accounts for the most recent financial year (required for financial assessment of the organisation, except for "public bodies" as defined in the relevant call for proposals)
f)	Legal Entity form;
available for downloading at:  http://ec.europa.eu/budget/execution/legal_entities_en.htm
g)	A revised table with the list of partners and budget by partner:

NB: Please note that replacement of the beneficiary organisation will not only imply changes of bank account (section E) but would normally also imply changes to the initial budget. Revised financial tables will therefore need to be considered (section H)

B.	Partner(s) withdrawal	

Please provide detail on the partner(s) that have withdrawn and explain why

Name of the partner organisation that has withdrawn	
1		
2		
3		
…		

Reasons for withdrawal (max 1/2 page)	
1		
2		
3		
…		

Where no new partner is joining, please comment upon the (re)distribution of the tasks amongst the existing partners.(max 1/2 page)	

	

Where new / replacement partner(s) are joining the project, please also complete section C.

List of annexes to be sent with this amendment request (mail delivery):
a) Original letter, dated and signed by the legal representative, of the withdrawing partner
b) Report on the status of the work carried out by the withdrawing partner, the rights acquired relating to individual products and results, the procedure for termination (including an end date), the funds already received by the partner, a breakdown of existing expenditure and the amount to be paid back (if any)
c) A revised table with the list of partners and budget by partner

NB: Please note that partner(s) withdrawal would normally imply changes to the initial budget. Revised financial tables will therefore need to be considered (refer to section H)

C.	New / Replacement partner(s) joining the project	

Please provide detail on the partner(s) that have joined and explain why

C.1 - Information sheet on the new partner
Name of the organisation/institution in national language 		
Name of the organisation in EN, FR or DE		
Organisation type code 		
Organisation size code 		
Economic sector code 		
Head Office
Street		
Number		
Post code		
Town/city		
Country code		
Region code 		
Contact Person
Name	Mr□   Ms□		
Position		
Street		
Number		
Post code		
Town/city		
Telephone	++	/	
Fax	++	/	
E-mail		

Authorised signatory
Name	Mr□   Ms□		
Position		

C.2 - Reasons for joining

If this partner replaces a partner that has withdrawn, please indicate the name of the withdrawing partner	

General description of the new / replacement partner(s) joining the project: size, scope of work, areas of specific expertise and competence in relation to the project proposal (max 1/2 page per partner)	

Reasons for joining (max 1/2 page)	

	

Skills and expertise of key staff involved in the project at the new / replacement partner(s) joining the project (limit 5 lines per person)	

	

Tasks taken over by the new partner and/or (re)distribution of the tasks amongst all partners (max 1/2 page)	

	

Please add extra sheets if necessary.

List of annexes to be sent with this amendment request (mail delivery):
a) Original of the commitment letter, including the partners own financial contribution, dated and signed by the legal representative of the organisation wishing to join the project
b) A revised table with the list of partners and budget by partner:

NB: Please note that new / replacement partner(s) joining the project would normally imply changes to the initial budget. Revised financial tables will therefore need to be considered (refer to section H)

D.	Changes to the work programme	

Please list work packages and clearly and briefly describe the proposed changes to the work programme 

Work packages5	Institutions/Organisations involved 	
N°	Title of Work package	Start date (d/m/y)	End date (d/m/y)		
WP 1					
WP 2					
WP 3					
…					

Work packages	Proposed changes to the work programme, including any justification6 (1/2 page maximum)	
WP 1		
WP 2		
WP 3		
…		

E.	Change of bank account 	

BANKING SHEET OF THE BENEFICIARY ORGANISATION

Financial identification form to be downloaded, completed and signed by the relevant parties and further submitted with this Grant Agreement Amendment Request Form.

Available for downloading at: 
http://ec.europa.eu/budget/execution/ftiers_en.htm 

Reasons for the change of the bank account: (max 1/2 page)	

	

This annex to be sent with this amendment request (mail delivery):
a)	A copy of the agreement concluded with the bank on establishment of the project’s bank account

F. 	Changes to the project duration	

Project commencement date (dd/mm/yyyy):		
Previous termination date (dd/mm/yyyy):		
Change requested (months)7		
New termination date (dd/mm/yyyy):		

Reasons for changes to the project duration (max 1/2 page)	

	

G.	Changes to the reporting schedule	

Interim Report 	Final Report 

Previous deadline (dd/mm/yyyy):		
Extension requested (days and/or months):		
New deadline (dd/mm/yyyy):		

Reasons for changes to the reporting schedule (max 1/2 page)	

	

H.	Changes to the budget 	

NB: Please note that neither the total amount of the Leonardo da Vinci grant nor the amount of the indirect costs can be increased and that the financial provisions of the relevant call and the grant agreement should be respected.

Table H.1 - Breakdown of the total proposed budget

	Total	Budget  (EURO)	Grant LDV	(EURO)	
	Initial	With the requested modifications	Initial	With the requested modifications
	
DIRECT COSTS 					
Heading A – Staff costs					
Staff costs 					
Heading B – Operational costs					
Travel and subsistence					
Equipment
(up to 10% of direct costs)					
Sub-contracting
(up to 30% of direct costs)					
Other costs 					
Total Heading B					
TOTAL DIRECT COSTS (A+B)					

INDIRECT COSTS
(up to 7% of direct costs)					

TOTAL PROJECT EXPENDITURE					

Table H.2. Breakdown of the proposed budget / Leonardo grant by partner (Euro)

	Total proposed budget	P1	P2	P3	P4	P…	
DIRECT COSTS							
Heading A – Staff costs						
Staff costs							
Heading B – Operational costs							
Travel and subsistence 							
Equipment							
Sub-contracting							
Other costs							
Total Heading B							
TOTAL DIRECT COSTS (A+B)							

INDIRECT COSTS
(up to 7% of direct costs)							

TOTAL PROJECT EXPENDITURE							

Leonardo da Vinci Grant							

Please justify any proposed changes to the agreed project budget (maximum 1 page)

	

List of annexes to be sent with this amendment request (mail delivery):
a) Agreement by all funded project partners, relating to the proposed budget changes
b) Original letters of acceptance by all partners which have direct changes to their budget (global and / or Leonardo da Vinci contribution)

I.	Other	

Please detail any other proposed changes to your project (maximum 1 page)

	

 

Receipt Acknowledgement
Grant Agreement Amendment Request Form	

This page will be returned to you when we have received your Grant Agreement Amendment Request Form. Please therefore complete the information below.
Title of project:

Name of beneficiary organisation:		
Name of legal representative:		
Street Number:			Street		
Country code - Post code - Town/City:		
Fax number:		
			
Date you sent in your request:	…….... / ..…….. / ..……..	

Reserved for National Agency:

Documents received:
Grant Agreement Amendment Request Form	Original + copy + electronic copy	
Annexes		

Missing data, to be submitted as soon as possible (not later than two weeks):

	

We acknowledge receipt of your Grant Agreement Amendment Request Form:
	
Country	Year	Project type	Project number	
			Use the LLPlink code!	

Please use this number in all communication with the National Agency .	

Yours sincerely

Date: _________	Signature: ____________________________________________
Name: __________________________________________________________________
Position: __________________________________