Request for Concept Notes (RFCN): Annual Program Statement (APS) for Acquisition of Post-Harvest Losses Reduction Technologies through Inclusive and Innovative Business Models

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CNFA is a not-for-profit international agricultural development organization headquartered in Washington, D.C. and dedicated to increasing rural incomes by empowering farmers and rural entrepreneurs. CNFA assists smallholders in increasing household-level food security and nutrition through improved agricultural practices, introduction of new varieties, diversification of crop production, food preservation and storage, development of farmer-based organizations, and strengthened linkages to markets. CNFA has a successful track record of implementing agricultural development programs in 43 countries.

Feed the Future Rwanda Hinga Weze Activity

Annual Program Statement (APS) No: CNFA-APS -01-2018 for the period from January 30, 2018 through September 30, 2018

For Acquisition of Post-Harvest Losses Reduction Technologies through Inclusive and innovative Business Models

STEP 1: Request for Concept Notes (RFCN)

Issuance Date: January 30, 2018

Dear Applicant:

The Feed the Future Rwanda Hinga Weze Activity is releasing an Annual Program Statement (APS) to award matching grants in support of its activities. As a first step, Hinga Weze is seeking Concept Notes for potential funding of grant projects. Instructions for completing the Concept Note can be found in Annex A. The grants will be awarded and implemented in accordance with the USAID and US Government regulations governing grants and Hinga Weze internal grant management policies. 

This solicitation will target only smallholder farmers, farmers organizations and agricultural SMEs working in Rwandan high-value horticulture, maize, high iron beans, orange flesh sweet potato and Irish potato in Gatsibo, Kayonza, Bugesera, Ngoma (Eastern Province); Nyabihu, Rutsiro, Ngororero Nyamasheke, Karongi (Western Province); and Nyamagabe (Southern Province). Only potential applicants that are part of an agricultural cooperative, association or farmer groups and agricultural SMEs in these districts should submit concept notes in response to this solicitation.

IMPORTANT: Hinga Weze (HW) will hold pre-application question and answer conference February 12, 2018 at the CNFA, a Conference room located at the CNFA offices in Kimihurura, Kigali, at 3:00 pm to 4:00 pm. This conference will allow interested applicants the chance to ask questions about the RFA. Interested parties that would like to attend this workshop must confirm their attendance by sending the participant’s name and the organization’s name to grants@cnfarwanda.org. A maximum of two representatives may attend from each organization or association. No reimbursement for costs of attendance will be met. This event will start promptly.

These in-kind grants will provide financial support to agricultural cooperatives and SMEs, associations, and farmer groups with an ultimate goal of filling gaps and reducing post-harvest loss in high-value domestic market competitiveness in Hinga Weze crop value chains. Grants under this solicitation will support innovative proposals offering solutions in Post-Harvest Processing and Storage Equipment. These grants will support agribusinesses and cooperatives in accessing appropriate post-harvest handling equipment and technologies to increase value of Hinga Weze promoted value chains and create additional revenue streams. Successful applicants must demonstrate a profitable and sustainable business model, expanding access to cost effective, climate smart and and/or labor saving post-harvest losses reduction technology at a scale. The profitability and sustainability might be measured by the model’s capacity to provide incentive for upfront investment and provide a steady income to pay for maintenance and related upkeep costs over the long term.

Other grants may be awarded in instances where an applicant proposes an innovative activity and/or demonstrates the opportunity to leverage private sector investment. This includes possible grants to financial institutions, GoR legal entities, research institutions, and other organizations that can assist in the achievement of Hinga Weze targets, under its Market Access Component.

Hinga Weze grant investments can range from $5,000 - $100,000.

Applicants are encouraged to propose fully justified grants budgets. Only exceptional applications and those with the highest impact on the rural community, small agribusinesses and household farmers will be awarded maximum grant amounts.

Only interventions focused on the Hinga Weze crop value chains will be considered, which are:

  • High-Iron Beans
  • Orange Flesh Sweet Potato(OFSP)
  • Irish Potato
  • Maize
  • Horticulture (Fruits and Vegetables)

Please note that concept notes are reviewed on a rolling basis throughout the APS period of February 1, 2018 through September 30, 2018 (please refer to ‘Section III Application and Submission Information’ for more information).

This Request for Concept Notes contains the following documents:

  • Annex A – Concept Note Instructions and Template
  • Annex B – Applicant Self-Assessment Form

SECTION I. PROGRAM DESCRIPTION

IA. ABOUT HINGA WEZE

Feed the Future Rwanda Hinga Weze is a five (5) year Activity of USAID that started in June 2017.The activity is implemented by CNFA. The primary objective of the Feed the Future Rwanda Hinga Weze activity is to sustainably increase smallholder farmers’ income, improve the nutritional status of Rwandan women and children, and increase the resilience of the agriculture and food systems to the changing climate. This is envisioned to be achieved through sustainable increase of agriculture productivity, improving farmers’ access to market and improving nutrition outcomes of agriculture interventions.  Hinga Weze will achieve results by combining capacity building with in-kind matching grants and technical support to strengthen agriculture extension, improve agricultural mechanized infrastructure, and facilitate linkages between value chain actors.

IB. COMPETITIVE MATCHING GRANT PROGRAM DESCRIPTION

The Hinga Weze grant application process is a two-step, competitive process: Step 1 is the Concept Note; and Step 2 is the Full Proposal. Grants under Hinga Weze will be used to competitively support innovative proposals offering solutions in Post-Harvest Processing and Storage Equipment. Concept notes will support agribusinesses and cooperatives in accessing appropriate post-harvest handling equipment and technologies to increase value of Hinga Weze promoted value chains and create additional revenue streams.

Hinga Weze will ensure that each grant project leverages a matching contribution from the grantee, and that it is supported by the technical assistance required for sustainability. Applicants will contribute a minimum of approximately 25% of the total value of the grant project. Applications that will contribute more than the required 25% will receive special consideration. Grant evaluation criteria will incentivize innovative solutions, benefits to women, and the use of agriculture technology and Information Communications Technology (ICT). Approximately 20% of the grant fund will be set aside for women entrepreneurs to ensure inclusivity of women in the marketplace. This policy will be provided to the applicants upon successfully completing the concept note phase of the grant process and should be incorporated into the full application that will be submitted at a later date.

IC.       AUTHORITY/GOVERNING REGULATIONS

Hinga Weze grant awards are made under the authority of the U.S. Foreign Affairs Act, Code of Federal Regulations (CFR) 2 CFR 200, and USAID’s Advanced Directive System (ADS) Chapter 303, “Grants and Cooperative Agreements to Non-Governmental Organizations.” Grants administered under Hinga Weze will adhere to the terms of the USAID Standard Provisions for Non-U.S. Non-Governmental Recipients, as well as the HINGA WEZE grants procedures.

Hinga Weze is required to ensure that all organizations receiving USAID grant funds comply with the guidance found in these regulations, as applicable to the respective terms and conditions of their grant awards.  Under the Hinga Weze grant program, USAID retains the right at all times to terminate, in whole or in part, Hinga Weze grant-making authorities or any grants in progress.

SECTION II. ELIGIBILITY

IIA.      Eligible Recipients

Applicants that submit Concept Notes in response to this solicitation must be legally registered entities, and must submit registration documents as a pre-requisite for receiving grant resources.  If the applicant is not registered, they must demonstrate a commitment to formally register the business with the submission of their Concept Note (Step 1) in the form of a written statement to that effect.

Formal Hinga Weze grant support under this solicitation may be extended to the following actors working in the Hinga Weze crop value chains:

  • Cooperatives
  • Women’s Groups
  • Smallholder Farmers
  • Post-Harvest Machinery Manufacturers and Suppliers
  • Grains, Tubers, horticulture and Nutrient-Rich Producers
  • Youth associations/network/enterprises
  • Aggregators and Agro-processing enterprises
  • Local NGOs
  • Financial institutions

IIB.      Additional Conditions of Eligibility

All applicants must show proof of their ability to meet matching contribution requirement. Capital investments are preferred; however, in some cases, existing assets can be used to meet matching contribution requirements as long as they are directly relevant to the proposed grant activity. In general, the Grantee’s Matching Contributions should adhere to the following criteria:

Are verifiable from the Grantee’s records; are not included as contributions for any other US Government-assisted program; are necessary and reasonable for proper and efficient accomplishment of this grant’s objectives; are allowable under the Standard Provision, “Allowable Costs; are not paid by the US Government under another grant or agreement and are included in the approved grant agreement budget.

Applicants are encouraged to meet the minimum 25% and will be considered more favorably.

Other eligibility conditions include:

  • Applicants must have the ability to impact a significant number of beneficiaries in their immediate market area, leading to increased employment and rural incomes.
  • Applicants must be legally-registered NGOs, associations, or similar groups or willing to become legally-registered in the first year of operations.
  • Applicants must be committed to adherence to high ethical business standards, including transparency in business dealings and record keeping.
  • All grant recipients must be prepared to undertake an independent financial review or audit as requested.
  • Applicants must agree to abide to acceptable environmental standards and to present information regarding potential environmental risks and mitigation measures; however a negative environmental assessment can be a condition for disqualification for the applicant.
  • Applicants may not engage in alcohol and tobacco production and activities that support this will not be accepted.
  • Applicants must not engage in any activities related to Trafficking in Persons.
  • Applicants must not engage, transact with, or provide resources to individuals or organizations associated with terrorism.
  • By submitting an application, the Applicant certifies that it and its principal officers are not debarred, suspended, or otherwise considered ineligible for an award by the U.S. Government. CNFA will not award a grant to any entity that is debarred, suspended, or considered to be ineligible by the U.S. Government.

IIC. Ineligible Activities and Unallowable Costs

Hinga Weze Grant funds cannot be utilized for the following:

  • Private ceremonies, parties, celebrations, or "representation" expenses.
  • In accordance with the Mandatory Standard Provision regarding “USAID Eligibility Rules for Procurement of Commodities and Services,” as well as ADS 312.3.3.5 (“Pesticides”), and ADS 312.3.3.7 (“Fertilizer”), grant funds cannot be used to fund purchases of restricted goods such as agricultural commodities, motor vehicles, pharmaceuticals, pesticides, used equipment, or fertilizers, without the prior approvals or waivers required by the applicable regulations. Additionally, in accordance with the Hinga Weze Initial Environmental Examination, procurement of seeds or seedlings of non-native or invasive species will require additional approval from USAID/BEO. As such, grantees are strongly discouraged from requesting project funding for these restricted goods and are encouraged to finance the purchase of any such goods from the grantee share of the grant program, as these limitations on restricted goods only apply to goods purchased with the project share of grant funds (see ADS 303.3.10.3 – Meeting Cost Share Requirements).
  • Prohibited goods under USAID regulations, including but not limited to: military equipment, surveillance equipment, police or law enforcement equipment, abortion equipment and services, weather modification equipment, luxury goods, and gambling equipment.
  • Any purchases or activities deemed unnecessary to accomplish grant purposes as determined by Hinga Weze, including any grantee headquarters expenses that are not directly linked to the implementation of the proposed project.
  • Previous obligations and/or bad debts.
  • Fines and/or penalties.
  • Creation of endowments.
  • Other costs unallowable under USAID and/or federal regulations, such as alcoholic beverages. Refer to 2 CFR 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards.
  • Indirect costs such as but not limited to overhead or indirect fringe (unless the applicant has documented proof of such rates through audits or USAID-issued NICRA).

SECTION III. APPLICATION SUBMISSION AND EVALUATION INFORMATION

Concept notes will be accepted only in the application format given in Annex A. Concept Notes, Annexes, and supporting documentation should be delivered by hand or express mail as a hard copy OR as a soft copy via email. All submissions should be written in English and/or French. Hard copies of the Concept Notes can be delivered to the Hinga Weze offices at KG 28 AV, 7.Kimihurura-Gasabo District, Post Office Box 1270, Kigali.

Email submissions of the Concept Notes and other supporting documentation (e.g. Rwandan registration certificate, Organizational chart, Balance Sheet" and "Revenue & Expense Statement" for the prior fiscal year) should be sent to grants@cnfarwanda.org.  Applicants should be sure to request a confirmation of receipt from Hinga Weze when emailing the Concept Note and follow-up with Hinga Weze to be sure that their submission was received. The complete RFCN Package includes the following documents:

  • Annex A – Concept Note Instructions and Template
  • Annex B – Applicant Self-Assessment Form

Any Concept Note submitted under this APS should propose a grant project that is responsive to the following criteria and considerations, which will be used to review and evaluate concept notes submitted under this APS.

Criteria

Maximum Points

Proposed activity is feasible to implement

20 points

Proposed activity supports goals of Hinga Weze laid out in Section I (i.e. How well the applicant defines the Business Model or Post-Harvest Handling Technology upgrade, relevance to the existing business and cost benefit analysis)

30 points

Applicant has the organizational and financial capacity to meet the demands of implementing a grant, including the ability to meet or exceed the cost sharing requirements

15 points

Activity proposed will close existing gaps within the selected value chain detailed on page 2

25 points

Activities proposed integrates women and youth as owners, managers, employees, clients and/or consumers

10 points

Total Points Possible

100 points

Concept Note Review Process

Once a Concept Note has been submitted under this APS, members of the Hinga Weze Technical Committee will initially review the Concept Notes. The Hinga Weze Grant Manager will then notify the applicant within 30 calendar days after receipt of the Concept Note as to whether Hinga Weze wishes to engage in more in-depth and specific discussions aimed at understanding the grant project in greater detail.

The initial review and communication will result in one of three Outcomes:

  1. A decision to refer the Concept Note to the Hinga Weze Concept Note Evaluation Committee
  2. A decision to forego further consideration of the grant project proposed in the Concept Note
  3. A decision to provide the applicant an opportunity to submit a revised Concept Note within 15 calendar days after have been notified

The Hinga Weze Concept Note Evaluation Committee will meet to evaluate the Concept Notes, using the individual and aggregated score sheets, that attained Outcome 1 or Outcome 3 – i.e. submitted a revised Concept Note – status based on the above criteria.  Applicants that score below 70 points will not be eligible to submit a Full Proposal application and receive grant funding.  All applicants that submit a Concept Note will be notified within 30 calendar days after the Concept Note Evaluation Committee meeting whether they were successful or not.

A decision to engage in more in-depth and specific discussions is NOT a commitment to funding. It is simply a decision to move forward in the collaborative and joint effort to develop an impactful grant project. If the in-depth and specific discussions do not result in the identification and development of a grant activity worthy of further pursuit, then Hinga Weze will not request a Full Proposal application and will instead inform the applicant that Hinga Weze is no longer interested in advancing their grant project. On the other hand, if the more in-depth discussions result in a promising design and concept, and Hinga Weze decides a Full Proposal application is warranted, then the Hinga Weze Grant Manager will inform the applicant of that determination and decision.

Applicants with successful concept notes (that scored at least 70 and above) will be subject to a site visit from Hinga Weze staff for an applicant assessment to verify the accuracy of their submission, perform a admin & financial review, and conduct environmental due diligence. If the site visit assessment uncovers no major issues, then the Grants Manager will provide the necessary additional instructions, technical requirements and specific evaluation criteria for a full application. Hinga Weze technical staff members will continue to communicate with the applicant regarding the substance of the grant project.

Issuance of this RFCN and assistance with application development do not constitute an award or commitment on the part of Hinga Weze, nor does it commit Hinga Weze to pay for costs incurred in the preparation and submission of an application. Further, Hinga Weze reserves the right to accept or reject any or all applications received, as well as issue amendments revising the terms of this solicitation before or after receipt of applications. In submitting an application, Applicants understand that USAID is not a party to this solicitation and the Applicant agrees that any communications regarding this solicitation will be conducted with Hinga Weze and not USAID. Applicants will be informed in writing of the decision made regarding their application.

ANNEX A.    CONCEPT NOTE INSTRUCTIONS AND TEMPLATE

Purpose:

The Grant Concept Note serves as a first-screening test for grant activities. The form is designed to gather essential basic information about the Applicant and what it is proposing to do. Concept Notes shall be submitted in English with a maximum of 5 pages (annexes are not counted in this limitation).

Instructions by Section:

Items 1-3:        Applicant’s name, address, telephone, fax and e-mail—self-explanatory.

Item 4:             Key contact person & title—The contact person (agent) is responsible for communications between Hinga Weze and the Applicant. This applies to all aspects of the grant, from initial summary through completion. The agent must have full authority and responsibility to act on behalf of the Applicant. The agent should be someone who will be directly involved with the grant activity and has a proven, established relationship with the Applicant.

Item 5:             Briefly describe organization and its activities—should introduce the Applicant and its background: How it was formed, its mission or purpose, major accomplishments in the area of the targeted activity, current activities, and clients.

Item 6:             Grant activity title—The title given to the activity should relate to the grant objective.

Item 7:             Problem analysis and statement—Identify the problem that the grant activities           proposes to address.

Items 8-9:        Activity objective, results to be achieved, linkage to grant objective, and verifiable indicators of achievement——Must be linked to Hinga Weze' objectives.

Item 10:           Identify beneficiaries, disaggregated by gender and age if possible, number, location, and how they will benefit from the grant activities and how they will be involved.

Item 11:           Anticipated duration should be stated with a degree of accuracy of plus or minus two weeks as well as the target location of implementation.

Item 12:           How the organization is planning for the long-term commercial viability of the activity

Item 13:           How will the grant activity will be gender sensitive and make sure to be achieve gender equality and equity.

Item 14:           Main task phases of the activity—Activity Plan Timeline.

Item 15:           Approximate cost of this activity (cash, in-kind, and third-party sources)—Applicant must submit a rough estimate of the cost of the proposed activity and sources of funds, specifying how much will come from Hinga Weze, the Applicant’s contribution, and any third-party contributions. A detailed budget is not necessary at this point, only a plausible estimate, which should be within 15 percent  (+/-) of the final approved budget.

Template of Grant Concept Note:

 

  1. Organization’s name:
  2. Address:
  3. Telephone: Fax:E-mail:
  4. Key contact person and title:
  5. Briefly describe organization, purpose, and past related experience:
  6. Grant activity title:
  7. Problem analysis and statement:
  8. Grant objective:
  9. Results to be achieved, linkage to grant objective, and verifiable indicators of achievement:
  10. Identify beneficiaries, disaggregated by gender if possible, number, and how they will benefit from grant and their participation in the grant activities:
  11. Anticipated duration of activity from start to finish as well as the target location of implementation:
  12. Sustainability plan
  13. Gender sensitivity of the grant activities
  14. Main task phases of the activity: [Activity Plan Timeline.]
  15. Approximate cost of this activity (cash, in-kind, and third-party sources):

 

            Applicant Cost Share contribution     =          RWF_________________

            Third-party resources (e.g. third party

loan, investment partners)                  =          RFW _________________ (identify source)

            Hinga Weze contribution                  =          RWF _________________

            Total Estimated Cost                          =          RWF _________________

Submitted by: _________________________      Date   ______________________

ANNEX B. Applicant Self Assessment Form

This form is required to be completed by the applicant and submitted to the Feed the Future Rwanda Hinga Weze activity, along with the grant application. It is used as part of Hinga Weze’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.

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Hinga Weze Applicant Self-Assessment Form

Accepting a grant from Hinga Weze 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, Hinga Weze 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:

  • Financial transactions are approved by an authorized individual and follow laws, regulations, and the organization's policies,
  • Assets are kept safely,
  • 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:

Name: 

Title:

Telephone number:

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)?

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, Hinga Weze 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 Hinga Weze grant from the receipts and payments of your organization's other activities?  

Yes: __                        No: __

5. Can your accounting records summarize expenditures from the Hinga Weze grant according to different budget categories such as salaries, rent, supplies, and equipment?

Yes: __                        No: __

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:  FUNDS CONTROL

Hinga Weze will reimburse its simplified grant recipients by bank transfer in local currency to the Grantee organization’s bank account based on the submission of receipts. Access to the bank account must be limited to authorized individuals.

1. Do you have a bank account registered in the name of your organization?

Yes: __                        No: __

2. Are the bank account and its signatories authorized by the organization's Board of Directors, Trustees, or other authorized persons?

Yes:  __           No:  __

SECTION D:  AUDIT

Hinga Weze 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: __

If yes, please explain:                                                                                                                                                                                                                                                                                                                                                                         

CHECKLIST AND SIGNATURE PAGE

Hinga Weze requests that your organization submit a number of documents along with this completed questionnaire.  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 Hinga Weze.

1.  Complete the checklist:

__ Incorporation papers or certificate of registration and statute have been provided to Hinga Weze.

__ Organizational chart, if available, has been provided to Hinga Weze.

__ 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 representative who has either completed or reviewed the form.

Approved by:                         

                                                            __________________________

Print Name                               Signature

 

                                                            __________________________

Title                                         Date