Anexa 1.1 A Model Formular Cerere de Finantare - en

POIM 2014-2020 Anexa 1.1.A Ghidul Solicitantului OS 3.2.
Format for submission of the information on a major project
MAJOR PROJECT
EUROPEAN REGIONAL DEVELOPMENT FUND / COHESION FUND
INFRASTRUCTURE/PRODUCTIVE INVESTMENT
Project title <type='S' maxlength=255 input='M'>
CCI <type='S' maxlength=15 input='S'>
EN 1 EN
A. THE BODY RESPONSIBLE FOR IMPLEMENTATION OF THE

MAJOR PROJECT, AND ITS CAPACITY
A.1. Authority responsible for project application (managing authority or
intermediate body)
A.1.1 Name: <type='S' maxlength='200' input='M'>(1)
A.1.2 Address: <type='S' maxlength='400' input='M'>
A.1.3 Name of contact person <type='S' maxlength='200' input='M'>
A.1.4 Position of contact person <type='S' maxlength='200' input='M'>
A.1.5 Telephone: <type="N" input='M'>
A.1.6 E-mail: <type='S' maxlength='100' input='M'>
(1)
Legend for the characteristics of fields:
type: N = Number, D = Date, S = String, C = Checkbox, P = Percentage
input: M = Manual, S = Selection, G = Generated by system
maxlength = Maximum number of characters including spaces
A.2. Body/-ies1 responsible for project implementation (beneficiary/-ies2)
A.2.1 Name: <type='S' maxlength='200' input='M'>
A.2.2 Address: <type='S' maxlength='400' input='M'>
A.2.3 Name of <type='S' maxlength='200' input='M'>

contact person
A.2.4 Position of <type='S' maxlength='200' input='M'>

contact person
A.2.5 Telephone: <type="N" input='M'>
A.2.6 E-mail: <type='S' maxlength='100' input='M'>
A.3. Details of the undertaking (to be filled in for productive investments only)
A.3.1 Name of the undertaking:
< type='S' maxlength='200' input='M'>
1
If more than one body is responsible for implementation, include information on the lead beneficiary (others
will be mentioned in point A.5).
2
In case of a PPP project where a private partner will be selected after approval of the operation and will be the
beneficiary in accordance with Article 63(2) of Regulation (EU) No 1303/2013, this section should contain
information on the public law body initiating the operation (i.e. the contracting authority).
EN 2 EN
A.3.2 Is the undertaking an SME1? <type='C' input=M>
Yes No
A.3.3 Turnover (value in million EUR and year):

A.3.3.1 Value in million EUR <type='N' input='M'>
A.3.3.2 Year <type="N" input='M'>
A.3.4 Total number of persons employed (value and year):

A.3.4.1 Number of persons employed <type='N' input='M'>
A.3.4.2 Year <type="N" input='M'>
A.3.5 Group structure:
Are 25% or more of the capital or voting rights of the undertaking owned by
one enterprise or a group of enterprises falling outside the definition of an
SME? <type='C' input='M'>
Yes No
Indicate the name and describe the group structure

A.4. Capacity of the body responsible for project implementation by referring to its
technical, legal, financial and administrative capacity2
A.4.1 Technical capacity (at minimum please give overview of expertise required for
project implementation and indicate the number of staff with such expertise
available within the organisation and allocated to the project)
A.4.2 Legal capacity (as minimum information, indicate the legal status of the beneficiary
allowing to implement the project, and its capacity to undertake legal action, if
necessary).
A.4.3 Financial capacity (at minimum please confirm financial standing of the body
responsible for project implementation to demonstrate that it is able to guarantee
the liquidity for adequate funding to the project to ensure its successful
implementation and future operation in addition to the other activities of the body)
1
Commission Recommendation 2003/361/EC (OJ L 124, 20.5.2003, p. 36).
2
In case of a PPP project, and if the private partner has not yet been selected, this section should contain the
minimum qualification criteria to be retained for pre-qualification in the tender and the justification for these
criteria. The application shall also describe all arrangements being put in place for the preparation, monitoring
and administration of the PPP project.
EN 3 EN
A.4.4 Administrative capacity (as minimum information, please, indicate the EU-funded
and/or comparable projects carried out in the last ten years and, in absence of such
examples, indicate if technical assistance needs have been considered; please refer
to institutional arrangements such as the existence of Project Implementation Unit
(PIU) capable to implement and operate the project and, if possible, include the
proposed organisational chart for project implementation and operation).
A.5 Provide information on all relevant institutional arrangements with third

parties for the implementation of the project and the successful operation of the
resulting facilities that have been planned and possibly concluded
A.5.1 Give details of how the infrastructure will be managed after the project is completed
(i.e. name of the operator; selection methods public management or concession;
type of contract, etc.).
B. A DESCRIPTION OF THE INVESTMENT AND ITS LOCATION;

EXPLANATION AS TO HOW IT IS CONSISTENT WITH THE RELEVANT
PRIORITY AXES OF THE OPERATIONAL PROGRAMME(S)
CONCERNED, AND ITS EXPECTED CONTRIBUTION TO ACHIEVING
THE SPECIFIC OBJECTIVES OF THOSE PRIORITY AXES AND THE
EXPECTED CONTRIBUTION TO SOCIO-ECONOMIC DEVELOPMENT
B.1 Operational programme(s) and priority axes
CCI of OP Priority axis of OP
OP1<type='S' input='S'> Priority axis of OP 1<type='S' input='S'>
B.1.1 Is the project contained in the list of major projects in the operational
programme(s)?1 <type='C' input='M'>
Yes No
1
As required by Article 102(5) of Regulation (EU) No 1303/2013.
EN 4 EN
B.2. Categorisation of project activity1
Code Amount Percentage
B.2.1. Code(s) for the intervention field <type='N' <type='N' <type='P'

dimension(s) input='S'> input='M'> input='G'>
(More than one should be used where, based
on a pro rata calculation, several <type='N' <type='N' <type='P'
intervention fields are relevant) input='S'> input='M'> input='G'>
<type='N' <type='N' <type='P'

input='S'> input='M'> input='G'>


B.2.2. Code for the form of finance <type='N' <type='N' <type='P'

dimension input='S'> input='M'> input='G'>
(More than one may be relevant in some
cases pro rata shares to be provided) <type='N' <type='N' <type='P'
B.2.3. Code for the territorial dimension <type='N' <type='N' <type='P'

(More than one may be relevant in some input='S'> input='M'> input='G'>
cases pro rata shares to be provided)
B.2.4. Code for the territorial delivery <type='N' <type='N' <type='P'

mechanism input='S'> input='M'> input='G'>
B.2.5. Code for the thematic objective <type='N' <type='N' <type='P'

dimension input='S'> input='M'> input='G'>
(More than one may be relevant in some

cases pro rata shares to be provided)
B.2.6. Code for the economic dimension <type='N' <type='N' <type='P'

(NACE Code(1)) input='S'> input='M'> input='G'>
(More than one may be relevant in some <type='N' <type='N' <type='P'

cases pro rata shares to be provided) input='S'> input='M'> input='G'>
1
Annex I to Commission Implementing Regulation (EU) No 215/2014 of 7 March 2014 laying down rules for
implementing Regulation (EU) No 1303/2013 of the European Parliament and of the Council laying down
common provisions on the European Regional Development Fund, the European Social Fund, the Cohesion
Fund, the European Agricultural Fund for Rural Development and the European Maritime and Fisheries Fund
and laying down general provisions on the European Regional Development Fund, the European Social Fund,
the Cohesion Fund and the European Maritime and Fisheries Fund with regard to methodologies for climate
change support, the determination of milestones and targets in the performance framework and the nomenclature
of categories of intervention for the European Structural and Investment Funds (OJ L 69, 8.3.2014, p. 65).
EN 5 EN
B.2.7. Code for the location dimension (s) <type='N' <type='N' <type='P'
(NUTS III)(2) input='S'> input='M'> input='G'>
(More than one may be relevant in some <type='N' <type='N' <type='P'

cases pro rata shares to be provided) input='S'> input='M'> input='G'>
B.2.8. Nature of the investment(3) (to be <type='N' <type='N' <type='P'

filled in for productive investments only) input='S'> input='M'> input='G'>
B.2.9. Product concerned(4) (to be filled in <type='N' <type='N' <type='P'

for productive investments only) input='S'> input='M'> input='G'>
(1)
NACE-Rev.2, 4 digit code: Regulation (EC) No 1893/2006 of the European Parliament and of the
Council (OJ L 393, 30.12.2006, p. 1).
(2)
Regulation (EC) No 1059/2003 of the European Parliament and of the Council (OJ L 154,
21.6.2003, p. 1) as amended. Use the most detailed and relevant NUTS III code. Where a project
affects multiple individual NUTS III level areas, consider encoding the NUTS III or higher codes.
(3)
New construction = 1; extension = 2; conversion/modernisation = 3; change of locality = 4;
creation by take over = 5.
(4)
Combined Nomenclature (CN), Council Regulation (EEC) No 2658/87 (OJ L 256, 7.9.1987, p. 1).
B.3. Project description

B.3.1 Please provide a concise (max. 2 pages) description of the project (presenting its
aim, existing situation, issues it will address, facilities to be constructed, etc.), a map
identifying the project area1, geo-referenced data2 and the main project components
with their individual total cost estimates (without activity cost breakdown).
In case of productive investments a detailed technical description must also be provided
including: the work involved specifying its main characteristics, the establishment, main
activities and main elements of the financial structure of the enterprise, main aspects of the
investment, the description of the production technology and equipment and the description
of the products.
B.3.2 Is this project a phase of a major project3? <type='C' input='M'>
Yes No
1
In the case of a PPP where the private partner has not yet been selected and is responsible for securing the
location, the applicant does not need to provide the map identifying the project area.
2
Please provide in Appendix 5 geo-referenced data in vector format, containing polygons, lines and/or points as
appropriate, to represent the project in preferably shape file format.
3
A major project started in the 2007-2013 programming period of which one or more phases have been
completed in that programing period, and this project represents a phase which will be carried out and
completed in the 2014-2020 programming period, or a project started in the 2014-2020 programming period of
which this project represents a phase which will be completed, while the next phase will be completed in this or
the subsequent programming period.
EN 6 EN
B.3.3 If the project is a phase of an overall project, provide a concise description of the
proposed phases of implementation and explain how they are technically and
financially independent. Explain what criteria have been used to determine the
division of the project into phases. Please provide a share (percentage) of the
overall project which this phase covers. If the project is co-financed by more than
one Operational Programme, indicate which parts fall under which Operational
Programme and their pro-rata allocation.
B.3.4 Have the Commission previously approved any part of this major project? <type='C'
input=M>
Yes No
If yes, please provide the CCI number of the major project approved.
< type='S' input='S'>
If this project is a part of the major project phased for which the first phase was carried in the
2007-2013, please provide a description of the physical and financial objectives of the
previous phase, including a description of the implementation of the first phase and confirm
that it is or will be ready to be used for its purpose.
B.3.5 Does the project form part of a Trans-European Network agreed at Union level?
<type='C' input='M'>
Yes No
If yes, please give details and give reference to the relevant EU legislation1.
B.3.6 In case of productive investments is this investment:
i) covered under Article 3(1)(a) of Regulation (EU) No 1301/2013 of the European
Parliament and of the Council2? <type='C' input='M'>
Yes No
If yes, please, explain how it contributes to creating and safeguarding jobs (notably for young
people)
1
For energy: is the project defined as project of common interest under Regulation No 347/2013 on Guidelines
for trans-European energy infrastructure and repealing Decision No 1364/2006/EC and amending Regulations
(EC) No 713/2009, (EC) No 714/2009 and (EC) No 715/2009? For transport: is the project covered under
Regulation (EU) No 1315/2013 on Union guidelines for the development of the trans-European transport
network and repealing Decision No 661/2010/EU?
2
Regulation (EU) No 1301/2013 of the European Parliament and of the Council 17 December 2013 on the
European Regional Development Fund and on specific provisions concerning the Investment for growth and
jobs goal and repealing Regulation (EC) No 1080/2006 (OJ L 347, 20.12.2013, p. 289).
EN 7 EN

ii) covered under Article 3(1)(b) of Regulation (EU) No 1301/2013? <type='C' input='M'>
Yes No
If yes, please, explain how it contributes to the investment priorities set out in Article 5(1)
and (4) Regulation (EU) No 1301/2013, and, if that investment involves cooperation between
large enterprises and SMEs, how it contributes to investment priorities in Article 5(2) of that
Regulation.
B.4. Project objectives and its consistency with the relevant priority axes of the
operational programme or operational programmes concerned, and its
expected contribution to achieving the specific objectives and results of those
priority axes and the expected contribution to socio-economic development of
the area covered by the operational programme.
B.4.1 What are the main project objectives? Please list them here and give short
explanation
B.4.2 Please give details on the project's consistency with the relevant priority axes of the
operational programme or operational programmes and its expected contribution to
achieving the result indicators under the specific objectives of those priority axes
B.4.3 Please explain how the project will contribute to socio-economic development of the
area covered by the operational programme
B.4.4 Please explain what measures have been planned/taken by the beneficiary to ensure
optimal utilisation of the infrastructure in the operation phase
C. TOTAL COST AND TOTAL ELIGIBLE COST

C.1. Please complete table below taking into account the following
(1) Ineligible costs comprise (i) expenditure outside the eligibility period, (ii)
expenditure ineligible under applicable EU and national rules, (iii) other expenditure
not presented for co-financing. NB: The starting date for eligibility of expenditure is
the date of submission of the operational programme to the Commission or
1 January 2014, whichever is the earlier1.
(2) Contingencies should not exceed 10% of total cost net of contingencies. These
contingencies may be included in the total eligible costs used to calculate the
planned contribution of the funds.
1
Unless project specific rules must apply e.g. state aid.
EN 8 EN
(3) A price adjustment may be included, where relevant, to cover expected inflation
where the eligible cost values are in constant prices.
(4) Recoverable VAT is ineligible. Where VAT is considered eligible, please give
reasons.
(5) Total cost must include all costs incurred for the project, from planning to
supervision and must include VAT regardless of whether it is recoverable or not.
(6) The purchase of land not built on and land built on in the amount exceeding 10% of
the total eligible expenditure for the operation concerned in accordance with Article
69(3)(b) of Regulation (EU) No 1303/2013. In exceptional and duly justified cases, a
higher percentage may be permitted for operations concerning environmental
conservation.
(7) Total eligible cost before taking into account of the requirements set out in Article 61
of Regulation (EU) No 1303/2013.
EUR TOTAL COST INELIGIBLE ELIGIBLE PERCENTAG

COSTS(1) COSTS E OF TOTAL
(A)
ELIGIBLE
(B) (C)=(A)-(B)
COSTS
INPUT INPUT CALCULATED CALCULATED
1 Planning/design fees <type='N' <type='N' <type='N' <type='P'

input='M'> input='M'> input='G'> input='G'>
2 Land purchase <type='N' <type='N' <type='N' <type='P'
input='M'> input='M'>( input='G'> input='G'>
6)
3 Building and <type='N' <type='N' <type='N' <type='P'

construction input='M'> input='M'> input='G'> input='G'>
4 Plant and machinery or <type='N' <type='N' <type='N' <type='P'
equipment input='M'> input='M'> input='G'> input='G'>
5 Contingencies(2) <type='N' <type='N' <type='N' <type='P'
6 Price adjustment (if <type='N' <type='N' <type='N' <type='P'
applicable)(3) input='M'> input='M'> input='G'> input='G'>
7 Publicity <type='N' <type='N' <type='N' <type='P'
8 Supervision during <type='N' <type='N' <type='N' <type='P'
construction input='M'> input='M'> input='G'> input='G'>
implementation
9 Technical assistance <type='N' <type='N' <type='N' <type='P'
EN 9 EN
10 Sub-TOTAL <type='N' <type='N' <type='N' <type='P'

input='G'> input='G'> input='G'> input='G'>
11 (VAT(4)) <type='N' <type='N' <type='N' <type='P'
12 TOTAL <type='N' <type='N' <type='N' <type='P'
(5) input='G'> input='G'> input='G'>
input='G'>
(7)
Please provide the exchange rate and the reference (where applicable)
If you have any comments regarding any of the items above (e.g. no contingencies envisaged,
eligible VAT), please note them below.
C.2. Verification of compliance with State aid rules
Do you consider that this project involves the granting of State aid? <type='C' input='M'>
Yes No
If yes, please fill in the table below1:

Amount of Total amount of Aid intensity State aid number
aid (EUR) eligible cost (EUR) (in %) / registry number
in GGE(1) (2)
for block-
exempted aid
Approved aid scheme or <type='N' <type='N' <type='P' <type='N'
approved individual aid input='M'> input='M'> input='M'> input='M'>
Aid falling under a block <type='N' <type='N' <type='P' <type='N'
exemption regulation input='M'> input='M'> input='M'> input='M'>
Aid in line with the SGEI <type='N' <type='N' <type='P' <type='N'
decision(3) or the regulation input='M'> input='M'> input='M'> input='M'>
on public land passenger
traffic(4)
Total aid granted <type='N' Not applicable Not applicable Not applicable
input='G'>
1
This application does not replace notification to the Commission under Article 108(3) of the Treaty. A positive
decision by the Commission on the major project under Regulation (EU) No 1303/2013 does not constitute state
aid approval.
EN 10 EN
(1)
Gross grant equivalent (GGE) means the discounted value of the aid expressed as a percentage of the
discounted value of the eligible costs, as calculated at the time of award of the aid on the basis of the reference
rate applicable on that date.
(2)
State aid rules include provisions on eligible cost. In this column Member States should indicate the total
amount of eligible cost based on the State aid rules that have been applied.
(3)
Commission Decision 2012/21/EU of 20 December 2011 on the application of Article 106(2) of the Treaty on
the Functioning of the European Union to State aid in the form of public service compensation granted to certain
undertakings entrusted with the operation of services of general economic interest (OJ L 7, 11.1.2012, p. 3).
(4)
Regulation (EC) No 1370/2007 of the European Parliament and of the Council of 23 October 2007 on public
passenger transport services by rail and by road and repealing Council Regulations (EEC) 1191/69 and 1107/70
(OJ L 315, 3.12.2007, p. 1).
If no, please explain in detail the basis for establishing that the project does not involve state
aid1. Please provide this information for all groups of potential State aid recipients, for
example, in case of infrastructures, for the owner, the constructors, the operator and for the
users of an infrastructure. If applicable, please indicate whether the reason why you consider
that the project does not involve State aid is that (i) the project does not concern any
economic activity (including activities in the public remit) or that (ii) the recipient(s) of
support enjoy a legal monopoly for the relevant activities and are not active in any other
liberalised sector (or will keep separate accounts in case the recipient(s) are active in
additional sectors).
C.3. Total eligible cost calculation
The total eligible cost amount after taking into account of the requirements set out in Article
61 of Regulation (EU) No 1303/2013 should be used to verify if the project has reached the
threshold of a major project in accordance with Article 100 of Regulation (EU) No
1303/2013.
Please choose the relevant option and complete the information as required. For non-revenue-
generating operations please choose the method in Article 61(3) (b) of Regulation (EU) No
1303/2013 and set pro-rata application of discounted net revenue at 100%.
Method of calculation of the potential net Method used as chosen by the managing
revenue authority for the relevant sector, sub-sector or
type of operation(1) (Check one box only)
Calculation of the discounted net revenue <type='C' input='M'>
Flat rate method <type='C' input='M'>
Decreased co-financing rate method <type='C' input='M'>
(1)
As required by Article 61 of Regulation (EU) No 1303/2013
1
The Commission services provided guidance to Member States to facilitate the assessment when infrastructure
investments involve State aid. In particular, the Commission services have prepared analytical grids. A
Communication on the notion of aid is currently in preparation. The Commission invites Member States to make
use of the analytical grids or of other methods for explaining why it is considered that the support does not
involve the granting of State aid.
EN 11 EN
Calculation of the discounted net revenue (Article 61(3)(b) of Regulation (EU) No

1303/2013)
Value
Total eligible cost before taking into account of the requirements
set out in Article 61 of Regulation (EU) No 1303/2013 (in EUR,
1. <type='N' input='G'>
not discounted)
(Section C.1.12(C))
Pro-rata application of discounted net revenue (%) (if applicable)
2. <type='N' input='M'>
= (E.1.2.9)
Total eligible cost after taking into account of the requirements set
out in Article 61 of Regulation (EU) No 1303/2013 (in EUR, not
3. discounted) = (1)*(2) <type='N' input='M'>
The maximum public contribution must respect the State aid rules
and the amount of total aid granted reported above (if applicable)
Flat rate method or decreased co-financing rate method (Article 61(3)(a) and Article 61(5) of
Regulation (EU) No 1303/2013)
Value
Total eligible cost before taking into account of the requirements
set out in Article 61 of Regulation (EU) No 1303/2013 (in EUR,
1. <type='N' input='G'>
not discounted)
(Section C.1.12(C))
Net revenue flat rate as defined in Annex V to Regulation (EU) No
1303/2013 or delegated acts (FR) (%)
Total eligible cost after taking into account of the requirements set
out in Article 61 of Regulation (EU) No 1303/2013 (in EUR, not
discounted) = (1)*(1-FR)*
The maximum public contribution must respect the state aid rules
and the amount of total aid granted reported above (if applicable)
* In case of decreased co-financing rate method, this formula is not applicable (flat rate is reflected in co-
financing rate of the priority axis, resulting in lower ERDF/CF financing) and the total eligible cost is equal to
the amount mentioned in point (1)
D. FEASIBILITY STUDIES CARRIED OUT, INCLUDING OPTION

ANALYSIS, AND THE RESULTS
D.1. Demand analysis
Please provide a summary of the demand analysis, including the predicted demand growth
rate, in order to demonstrate the demand for the project, in accordance with the approach as
EN 12 EN
set out in Annex III (Methodology for carrying out the cost-benefit analysis) to this
Regulation. At the minimum the following information should be included:
i) methodology for projections;
ii) assumptions and baselines (e.g. traffic in the past, future assumed traffic without the
project);
iii) projections for selected options, if applicable;
iv) supply side aspects including the analysis of existing supply and expected
(infrastructure) developments;
v) network effect (if any).
In case of productive investments describe the target markets and a summary of the
demand analysis including the demand growth rate, broken down, where
appropriate, by Member State and, separately, by third countries considered as a
whole.
D.2. Option analysis
D.2.1 Please outline the alternative options considered in feasibility studies (max. 2-3
pages) in accordance with the approach as set out in Annex III (Methodology for
carrying out the cost-benefit analysis) to this Regulation. At least the following
information should be included
i) The total investment cost and operating costs for options considered;
ii) Options for scale (against technical, operational, economic, environmental and
social criteria) and options for location of the proposed infrastructure;
iii) Technological options per component and per system;
iv) Risks involved for each alternative, including risks related to climate change
impacts and weather extremes;
v) Economic indicators for options considered, if applicable1;
vi) Summary table containing all pros and cons for all options considered.
In addition, in case of productive investments give details of capacity considerations
(e.g. capacity of the firm before investment (in units per year), reference date,
capacity after investment (in units per year), estimate the capacity utilisation rate).
1
If the output and externalities are different in different options (assuming all options share the same objective)
e.g. solid waste projects, it is recommended to undertake a simplified CBA for all main options to select the best
alternative and economic parameters of a project, such as EPNV should be the key factor in the selection.
EN 13 EN
D.2.2 Please specify the criteria considered in selecting the best solution (with ranking of
their importance and method of their evaluation, reflecting the outcomes of the
climate change vulnerability and risks appraisal and of the EIA/SEA procedures as
appropriate (see: section F below)) and briefly present a justification for the option
chosen in accordance with Annex III (Methodology for carrying out the cost-benefit
analysis) to this Regulation.2
D.3. Feasibility of the option selected
Provide a short summary of the feasibility of the option selected covering the following key
dimensions: institutional, technical, environmental, and GHG emissions, climate change
impacts and risks on the project (where applicable), and other aspects taking into account
identified risks to prove feasibility of the project. Please complete the table by making
reference to the relevant documents.
D.3.1 Institutional aspect
D.3.2 Technical aspects including location, designed capacity of the main infrastructure,
justification of the project scope and size in the context of the forecasted demand,
justification of the choices made with regard to climate and natural disaster risks
assessment (where relevant), investment and operating costs estimates
D.3.3 Environmental, and climate change mitigation (GHG emissions) and adaptation
aspects (where applicable)
D.3.4 Other aspects
Please complete the reference table below
Key dimension of Reference
Feasibility Studies (or (supporting documents and chapter/section/page where the
Business Plan if specific information and details can be found)
productive investment)
Demand analysis < type='S' maxlength='1750' input='M'>
Option analysis < type='S' maxlength='1750' input='M'>
Institutional < type='S' maxlength='1750' input='M'>
Technical < type='S' maxlength='1750' input='M'>
Environmental, Climate < type='S' maxlength='1750' input='M'>
change adaptation and
mitigation and disaster
resilience (where
applicable)
Other aspects < type='S' maxlength='1750' input='M'>
2
In case of a PPP project, this section should include rationale for the selection of the procurement method,
including through a value for money analysis using reasonable public sector comparators.
EN 14 EN
In addition to the summary elements to be provided, the feasibility studies document shall be
provided in support of this application as Appendix 4.
E. A COST-BENEFIT ANALYSIS, INCLUDING A FINANCIAL AND AN

ECONOMIC ANALYSIS, AND A RISK ASSESSMENT
This section should be based on Annex III (Methodology for carrying out the cost-benefit
analysis) to this Regulation. In addition to the summary elements to be provided, the full
cost-benefit analysis document shall be provided in support of this application as Appendix 4.
E.1. Financial analysis
E.1.1. Please provide a short (max. 2-3 pages) description of methodology (description of
compliance with Annex III (Methodology for carrying out the cost-benefit analysis)
to this Regulation and Section III (Method for calculating the discounted net
revenue of operations generating net revenue) of Commission Delegated Regulation
(EU) No 480/20141 and exceptions to the application of the methodologies; all key
assumptions made concerning operating costs, capital replacement costs, revenues
and residual value, macroeconomic parameters used, steps considered in the
calculations, data used to perform the analysis) and the main findings of the
financial analysis including the results of financial sustainability analysis to
demonstrate that the project will not run out of cash in the future (please confirm
commitment from project beneficiary, its owners and/or public authorities to finance
the investment, operating and replacement costs, and where possible provide
financial sustainability tables presenting cash flows projections for the reference
period):
E.1.2. Main elements and parameters used in the CBA for financial analysis (all values in
euro)2
Main elements and Value
parameters
Reference period <type='N'
1 input='M'>
(years)
<type='P'
Financial discount input='M'>
2
rate (%)(1)
Value Value Reference to CBA

Main elements and Not Discounted (Net document
parameters discounted Present Value) (chapter/section/page)
1
Commission Delegated Regulation (EU) No 480/2014 of 3 March 2014 supplementing Regulation (EU) No
1303/2013 of the European Parliament and of the Council laying down common provisions on the European
Regional Development Fund, the European Social Fund, the Cohesion Fund, the European Agricultural Fund for
Rural Development and the European Maritime and Fisheries Fund and laying down general provisions on the
European Regional Development Fund, the European Social Fund, the Cohesion Fund and the European
Maritime and Fisheries Fund (OJ L 138, 13.5.2014, p. 5).
2
All figures must correspond to CBA document. CBA should be drafted in Euro or local currency with the
exchange rate clearly indicated.
EN 15 EN
Total investment cost <type='N' <type='N' < type='S'

3 excluding input='M'> input='M'> maxlength='500'
contingencies input='M'>
<type='N' <type='N' < type='S'
4 Residual value input='M'> input='M'> maxlength='500'
input='M'>
<type='N'
< type='S'
5 Revenues input='M'>
maxlength='500'
input='M'>
Operating and <type='N'

< type='S'
6 maxlength='500'
replacement costs(2) input='M'>
input='M'>
Pro-rata application
of discounted net
revenue(3)
Net revenue = < type='S'
revenues operating maxlength='500'
and replacement <type='N' input='M'>
7
costs + residual input='G'>
value = (5) (6) +
(4)
Total investment cost < type='S'
<type='N'
8 net revenue = (3) input='G'>
maxlength='500'
(7) input='M'>
Pro-rata application <type='P' input='G'> < type='S'
of discounted net maxlength='500'
9 input='M'>
revenue (%) =
(8) / (3)
* Where VAT is recoverable, the costs and revenues should be based on figures excluding VAT.
(1)
Preferably in real terms.
(2)
In the meaning of Article 17 of Commission Delegated Regulation (EU) No 480/2014.
(3)
This does not apply: 1) for projects subject to the rules on State aids in the meaning of Article 107 of the
Treaty (see point G1), pursuant to Article 61(8) of Regulation (EU) No 1303/2013; 2) if flat rate (Article
61(3)(a) of Regulation (EU) No 1303/2013) or decreased co financing rate (Article 61(5) of Regulation
(EU) No 1303/2013) is used; and 3) if the sum of the present values of operating and replacement costs are
higher than the present value of revenues the project is not considered as revenue generating, in which case
items 7 and 8 can be ignored and pro-rata application of discounted net revenue should be set at 100%.
E.1.3. Main indicators of the financial analysis in accordance with the CBA document
without Union support with Union Reference to CBA

A support document
B (chapter/section
/page)
1. Financial rate of (%) <type='P' FRR(C)(1) <type='P' FRR(K)(2) < type='S'
return input='M' input='M' maxlength='500'
> > input='M'>
2. Net present value (euro) <type='N' FNPV(C) <type='N' FNPV(K) < type='S'
EN 16 EN
input='M' input='M' maxlength='500'

> > input='M'>
(1)
FRR(C) stands for the financial profitability of an investment.
(2)
FRR(K) stands for the financial profitability of national capital.
If a major project shows high financial profitability, i.e. FRR(C) is substantially higher than
the financial discount rate, please justify Union contribution in accordance with Annex III to
this Regulation
In case of productive investments provide results of FRR(Kp)1 calculation and its comparison
with national benchmarks on expected profitability in the given sector.
E.1.4. Tariff strategy and affordability (if applicable)
E.1.4.1. If the project is expected to generate revenues through tariffs or charges borne
by users, please give details of the charging system (types and level of charges, principle or
Union legislation on the basis of which the charges have been established).
E.1.4.2 Do the charges cover the operational costs including maintenance and
replacement costs of the project2? <type='C' input='M'>
Yes No
Please provide details with reference to the tariff strategy. If the answer is no, indicate the
proportion in which operating costs will be covered and sources of financing of costs not
covered. If operating aid is provided, please give details. If no charges are envisaged, explain
how operating costs will be covered.
E.1.4.3. If the charges differ between various users, are they proportional to the
different use of the project/real consumption? (Please provide details in text box) <type='C'
input='M'>
Yes No

E.1.4.4 Are the charges proportional to the pollution generated by users? (Please
provide details in text box) <type='C' input='M'>
Yes No
1
FRR(Kp) stands for the financial profitability of project promoter's capital.
2
Including increased costs over economic lifetime of the project due to climate change impacts and other
natural disasters (where relevant).
EN 17 EN

E.1.4.5 Has affordability of the charges for users been taken into account? (Please
provide details in text box) <type='C' input='M'>
Yes No

E.2. Economic analysis
E.2.1. Please provide a short (max. 2-3 pages) description of methodology (description of
compliance with the Implementing Act on methodology for cost benefit analysis and
exceptions to the application of the methodology, key assumptions made in valuing
costs (including relevant cost components considered investment costs,
replacement costs, operating costs), economic benefits and externalities including
those related to environment, climate change mitigation (including, where relevant,
incremental greenhouse gas emissions in CO2 equivalent) and climate change
resilience and disaster resilience, and the main findings of the socio-economic
analysis and explain the relationship with the Analysis of the Environmental Impact
(see: section F below) as appropriate:
E.2.2. Give details of economic benefits and costs identified in the analysis together with
values assigned to them:
Total value
Unit value (where
Benefit (in euro, % of total benefits
applicable)
discounted) (1)
< type='S' < type='S'
maxlength='200' maxlength='50' <type='N' input='M'> <type='P' input='M'>
input='M'> input='M'>

Total CALCULATED 100%
Total value
Unit value (where
Cost (in euro, % of total costs
applicable)
discounted)
< type='S' < type='S'
maxlength='200' maxlength='50' <type='N' input='M'> <type='P' input='M'>

Total CALCULATED 100%
(1)
The sum of discounted amounts of costs and benefits presented in the table should add up to the ENPV value.
E.2.3. Main indicators of the economic analysis in accordance with the CBA document
Main parameters and indicators Values Reference to CBA
EN 18 EN
document
(chapter/section/page)
1. Social discount rate (%) <type='P' input='M'> <type='S' maxlength='500'
input='M'>
2. Economic rate of return ERR (%) <type='P' input='M'> <type='S' maxlength='500'
input='M'>
3. Economic net present value ENPV (in <type='N' input='G'> < type='S' maxlength='500'
euro) input='M'>
4. Benefit-cost ratio <type='N' input='G'> <type='S' maxlength='500'

input='M'>
E.2.4. Employment effects of project

Provide an indication of the number of jobs to be created (expressed in terms of full-time
equivalents (FTE)).
Number of jobs directly created: No (FTE) Average duration of these jobs
(A) (months) (1)
(B)
During implementation phase <type='N' input='M'> <type='N' input='M'>
During operational phase <type='N' input='M'> <type='N' input='M'>
Number of jobs indirectly created: No (FTE) Average duration of these jobs

(productive investments only): (A) (months)
(B)
During operational phase <type='N' input='M'> <type='N' input='M'>
Number of jobs safeguarded <type='N' input='M'> n.a.

(productive investments only)
(1)
In case of permanent jobs, instead of duration in months, type "permanent"
In addition, for productive investments please give details of the expected impact of the
project on employment in other regions of the Union, and define whether the financial
contribution from the Funds does not result in a substantial loss of jobs in existing locations
within the Union, taking into account recital 92 of the CPR as well as the rules on regional
State Aid.
E.2.5. Identify the main non-quantifiable / non-monetisable benefits and costs:
E.3. Risk assessment and sensitivity analysis
E.3.1. Please provide short description of the methodology and summary results including
main risks identified
EN 19 EN
E.3.2. Sensitivity analysis

State the percentage change applied to the variables tested:
Present the estimated effect (as a percentage change) on results of financial and economic
performance indexes.
Variable tested Financial Net Financial Net Economic Net

Present Value Present Value Present Value
(FNPV(K)) (FNPV(C)) variation
variation (%) variation (%) (ENPV) (%)
<type='S' <type='P' <type='P' <type='P'

maxlength='500' input='M'> input='M'> input='M'>
input='M'>
Which variables have been identified as critical? State which criterion has been applied and
mention the impact of the key variables on the main indicators FNPV, ENPV.
What are the switching values of the critical variables? Please provide an estimated
percentage change for FNPV or ENPV to become zero for each of the critical variables
identified.
E.3.3. Risk assessment
Please present a short summary of the risk assessment including a list of risks to which the
project is exposed, the risk matrix1 and interpretation and proposed risk mitigation strategy
and the body responsible for mitigating the main risks such as cost overruns, time delays,
demand shortfalls; special attention should be given to environmental risks, climate change
related risks, and other natural disasters related risks.
E.3.4. Additional assessments carried out, if applicable
If probability distributions for critical variables, quantitative risk analysis or options to assess
climate risk and measures have been carried out, please provide details below.
1
In case of a PPP project it should include the risk matrix as allocated under the PPP arrangements (if the
operation has already been tendered) or the intended risk allocation under the PPP arrangements (if the operation
has not yet been tendered).
EN 20 EN
F. AN ANALYSIS OF THE ENVIRONMENTAL IMPACT, TAKING INTO

ACCOUNT CLIMATE CHANGE ADAPTATION AND MITIGATION NEEDS,
AND DISASTER RESILIENCE
F.1. Consistency of the project with environmental policy
F.1.1 Describe how the project contributes and takes into account the environmental
policy objectives including climate change (as guidance, please consider the
following: resource efficiency, preservation of biodiversity and ecosystem services,
reduction of GHG emissions, resilience to climate change impacts etc.).
F.1.2 Describe how the project respects the precautionary principle, the principle of
preventive action, the principle that environmental damage should as a priority be
rectified at source and the "polluter pays" principle.
F.2. Application of Directive 2001/42/EC of the European Parliament and of the
Council1 (the 'SEA Directive')
F.2.1 Is the project implemented as a result of a plan or programme, other than
Operational Programme? <type='C' input='M'>
Yes No
F.2.2. If the reply to question F.2.1 is Yes, please specify if the plan or programme was
made subject to a strategic environmental assessment in accordance with the SEA
Directive <type='C' input='M'>
Yes No
If the reply is 'No', please provide a short explanation:

If the reply is 'Yes', please provide the non-technical summary 2 of the
Environmental Report and the information required by Article 9(1)(b) of that
Directive (either an internet link or an electronic copy).
1
Directive 2001/42/EC of the European Parliament and of the Council of 27 June 2001 on the assessment of the
effects of certain plans and programmes on the environment (OJ L 197, 21.7.2001, p. 30).
2
Prepared pursuant to Article 5 and Annex I to Directive 2001/42/EC.
EN 21 EN
F.3. Application of Directive 2011/92/EU of the European Parliament and of the

Council 1 (the 'EIA Directive')
F.3.1 In case of non-fulfilment of the ex-ante conditionality on environmental legislation
(Directive 2011/92/EU and Directive 2001/42/EC), as per Article 19 of Regulation
(EU) No 1303/2013 demonstrate link to the agreed action plan
F.3.2 Is the project listed in EIA Directive annexes2:
Annex I to the EIA Directive (go to question F.3.3)
Annex II to the EIA Directive (go to question F.3.4)
Neither of the two Annexes (go to question F.4) please explain below
F.3.3 When covered by Annex I to the EIA Directive, include the following documents (as
Appendix 6) and use a text box below for additional information and explanations3:
(a) The non-technical summary of the EIA Report4.
(b) Information on consultations with environmental authorities, the public and if
applicable, consultations with other Member States, carried out in accordance
with Articles 6 and 7 of the EIA Directive.
(c) The decision of the competent authority issued in accordance with Articles 8
and 9 of the EIA Directive 5, including information on how it was made
available to the public.
F.3.4 When covered by Annex II to that Directive, has an EIA been carried out? <type='C'
input='M'>
Yes No
If the reply is 'Yes', please include the necessary documents listed under point
F.3.3
If the reply is 'No', please include the following information:
1
Directive 2011/92/EU of the European Parliament and of the Council of 13 December 2011 on the assessment
of the effects of certain public and private projects on the environment (OJ L 26, 28.1.2012, p. 1).
2
If a project consists of several works/activities/services that are classified into different groups, the information
should be completed separately for each investment tasks.
3
The additional information should focus on selected elements of the EIA procedure important for the project
(e.g. data analysis, studies and assessments, additional consultations with the competent authorities and the
public, determination of additional compensation/mitigation measures, additional screening decision etc.,
when changes in the project are likely to be identified) that needs to be carried out, in particular as part of multi-
stage development consent processes.
4
Prepared pursuant to Article 5 and Annex IV to Directive 2011/92/EU.
5
In the cases where the EIA procedure has been completed with a legally binding decision, pending the issuing
of development consent in accordance with Articles 8 and 9 of Directive 2011/92/EU, the availability of a
written commitment by the Member States for timely action to ensure that the development consent would be
issued at latest before the start of works.
EN 22 EN
(a) The determination required in Article 4(4) of the EIA Directive (known
as 'screening decision').
(b) The thresholds, criteria or case by case examination carried out to reach
the conclusion that an EIA was not required (this information is not
needed, if it is already included in the decision mentioned under point (a)
above).
(c) An explanation of the reasons why the project has no significant
environmental effects, taking into account the relevant selection criteria
listed in Annex III to the EIA Directive (this information is not needed, if
it is already included in the decision mentioned under point (a) above).
F.3.5 Development consent/construction permit (as applicable)
F.3.5.1. Is the project already in the construction phase (at least one works contract)?
Yes * No
F.3.5.2. Has the development consent/construction permit already been given to this project
(for at least one works contract)? <type='C' input='M'>
Yes No *
* Projects in construction phase (Yes answer to question F.3.5.1.) and without development
consent/construction permit for at least one works contract at the time of their submission to the European
Commission are not admissible by the Commission
F.3.5.3.If 'Yes' (to F 3.5.2.), on which date
<type='D' input='M'>
F.3.5.4.If 'No' (to F 3.5.2.), when was the formal request for the development consent
introduced:
F.3.5.5.If 'No' (to F 3.5.2.), specify the administrative steps accomplished so far and describe
those remaining:
F.3.5.6.By which date is the final decision (or decisions) expected?
F.3.5.7.Specify the competent authority (or authorities), which has issued or will issue the
development consent:
EN 23 EN
F.4. Application of the Directive 92/43/EEC on the conservation of natural habitats

and of wild fauna and flora 1 (Habitats Directive); assessment of effects on
Natura 2000 sites
F.4.1. Is the project likely to have significant negative effects, either individually or in
combination with other projects, on sites included or intended to be included in the
Natura 2000 network? <type='C' input='M'>
Yes No
F.4.2 If the reply to question F.4.1 is 'Yes', please provide:

(1) the decision of the competent authority and the appropriate assessment carried out
according to Article 6(3) of the Habitats Directive;
(2) if the competent authority has determined that the project has significant negative
effects on one or more sites included or intended to be included in the Natura 2000
network, please provide:
(a) a copy of the standard notification form Information to the European
Commission according to Article 6(4) of the Habitats Directive2, as notified to
the Commission (DG Environment) and/or;
(b) an opinion of the Commission under Article 6(4) of the Habitats Directive in
case of projects having significant impacts on the priority habitats and/or
species and justified by imperative reasons of overriding public interest other
than human health and public safety or beneficial consequences of primary
importance for the environment.
F.4.3 If the reply to question F.4.1 is 'No', please attach a completed Appendix 1
declaration filled in by the competent authority and the map indicating the location
of the project and Natura 2000 sites. For a non-infrastructure major project (e.g.
purchase of equipment), this should be duly explained below and, in that case, it is
not obligatory to attach such a declaration.
type='S' maxlength='1750' input='M'>
F.5. Application of Directive 2000/60/EC of the European Parliament and of the

Council3 (the 'Water Framework Directive'); assessment of effects on water bodies
F.5.1 In case of non-fulfilment of the corresponding ex-ante conditionality, as per Article
19 of Regulation (EU) No 1303/2013, demonstrate link to the agreed action plan
1
Council Directive 92/43/EEC of 21 May 1992 on the conservation of natural habitats and of wild fauna and
flora (OJ L 206, 22.7.1992, p. 7).
2
Revised version adopted by the Habitats Committee on 26.4.2012.
http://ec.europa.eu/environment/nature/natura2000/management/guidance_en.htm#art6
3
Directive 2000/60/EC of the European Parliament and of the Council of 23 October 2000 establishing a
framework for Community action in the field of water policy (OJ L 327, 22.12.2000, p. 1).
EN 24 EN
F.5.2 Does the project involve a new modification to the physical characteristics of a
surface water body or alterations to the level of bodies of groundwater which
deteriorate the status of a water body or cause failure to achieve good water
status/potential? <type='C' input='M'>
Yes No
F.5.2.1. If the reply is 'Yes', please provide the assessment of the impacts on the water body
and a detailed explanation of how all the conditions under Article 4.7 of the Water
Framework Directive were/are to be fulfilled.
Indicate also whether the project results from a national/regional strategy in relation to the
relevant sector and/or from a river basin management plan, which takes into account all
relevant factors (e.g. a better environmental option, cumulative effects, etc.)? If so, please
provide full details.
F.5.2.2. If the reply is 'No", please attach a completed Appendix 2 declaration filled in by the
competent authority. For a non-infrastructure major project (e.g. purchase of equipment), this
should be duly explained below and, in that case, it is not obligatory to attach such a
declaration.
type='S' maxlength='1750' input='M'>
F.5.3 Please explain how the project fits with the River Basin Management Plan's
objectives which have been established for the relevant water bodies.
F.6. Where applicable, information on compliance with other environmental directives
F.6.1 Application of Council Directive 91/271/EEC1 (the 'UWWT Directive') projects in
urban waste water sector
(1) Please fill-in Appendix 3 to the Application Form (table concerning
compliance with the UWWT Directive).
(2) Please explain how the project is consistent with the plan or programme
associated with the implementation of the UWWT Directive.
F.6.2 Application of Directive 2008/98/EC of the European Parliament and of the
Council 2 (the 'Waste Framework Directive') - projects in waste management sector
F.6.2.1. In case of non-fulfilment of the corresponding ex-ante conditionality, as per Article
19 of Regulation (EU) No 1303/2013, demonstrate link to the agreed action plan.
1
Council Directive 91/271/EEC of 21 May 1991 concerning urban waste-water treatment (OJ L 135, 30.5.1991,
p. 40).
2
Directive 2008/98/EC of the European Parliament and of the Council of 19 November 2008 on waste and
repealing certain Directives (OJ L 312, 22.11.2008, p. 3).
EN 25 EN
F.6.2.2. Please explain how the project meets the objectives laid down in Article 1 of the
Waste Framework Directive. In particular, how the project is consistent with the
relevant waste management plan (Article 28), the waste hierarchy (Article 4), and
how the project contributes to the achievement of the 2020 recycling targets (Article
11 (2)).
F.6.3 Application of Directive 2010/75/EU of the European Parliament and of the
Council1 (the 'Industrial Emissions Directive') - Projects requiring the granting of a
permit under that Directive
Please explain how the project complies with the requirements of Directive 2010/75/EU, in
particular with the obligation to operate in accordance with an integrated permit based on the
Best Available Techniques (BAT) and, where applicable, with the emission limit values set
out in that Directive.
F.6.4 Any other relevant environmental directives (please explain below)
F.7. Cost of measures taken to mitigate and/or compensate negative environmental

impacts, in particular resulting from the EIA procedure or other assessment
procedures (such as the Habitats Directive, the Water Framework Directive, the
Industrial Emissions Directive) or national/regional requirements
F.7.1. In case of such costs, were these included in the Cost Benefit Analysis? <type='C'
input='M'>
Yes No
F.7.2. If these costs are included in the total costs, please estimate the proportion of the
cost of measures taken to reduce and/or to compensate for negative environmental
impacts.
% <type='P'
input='M'>
Please explain briefly the measures

1
Directive 2010/75/EU of the European Parliament and of the Council of 24 November 2010 on industrial
emissions (integrated pollution prevention and control) (OJ L 334, 17.12.2010, p. 17).
EN 26 EN
F.8. CLIMATE CHANGE ADAPTATION AND MITIGATION, AND DISASTER RESILIENCE

F.8.1. Explain how the project contributes to climate change targets in accordance with
EU 2020 strategy, including information on climate change-related expenditure in
line with Annex I to the Commission Implementing Regulation (EU) No 215/2014
F.8.2. Explain how climate change related risks, adaptation and mitigation considerations,
and disaster resilience have been taken into account.
(As a guidance, please consider the following questions: How were the volume of
the Greenhouse Gas (GHG) externality and the external cost of carbon assessed?
What is the shadow cost of GHG and how has it been integrated into the economic
analysis? Was a less carbon intense or based on renewable sources alternative been
considered? Has a climate risk assessment or vulnerability screening been carried
out during the preparation of the project? Have climate change issues been taken
into account as part of SEA and EIA and have been checked by the relevant national
authorities? How did the analysis and ranking of relevant options take into account
climate issues? How does the project relate to the national and/or regional strategy
for adaptation to climate change? Will the project in combination with climate
change have any positive and/or negative impacts on the surroundings? Did climate
change influence the location of the project?)1
F.8.3. Explain what measures have been adopted to ensure resilience to current climate
variability and future climate change within the project
(As a guidance, please consider the following questions: how was climate change
taken into consideration when designing the project and its components, for example
with regard to external forces (e.g. wind load, snow load, temperature differences) and
impacts (e.g. heat waves, drainage, risk of flooding as well as prolonged dry periods
affecting e.g. soil characteristics))
G. THE FINANCING PLAN SHOWING THE TOTAL PLANNED FINANCING

RESOURCES AND THE PLANNED SUPPORT FROM THE FUNDS, THE EIB,
AND ALL OTHER SOURCES OF FINANCING, TOGETHER WITH PHYSICAL
AND FINANCIAL INDICATORS FOR MONITORING PROGRESS, TAKING
ACCOUNT OF THE IDENTIFIED RISKS
G.1. Total planned financial resources and planned support from the Funds, the
EIB, and all other sources of financing
G.1.1. Sources of co-financing
The total investment costs of the project shall be met from the following sources:
1
For additional guidance on climate adaptation/resilience please refer to DG CLIMA project managers
guidelines:
http://ec.europa.eu/clima/policies/adaptation/what/docs/non_paper_guidelines_project_managers_en.pdf and the
and the EIA/SEA guidance documents: http://ec.europa.eu/environment/eia/home.htm
EN 27 EN
Of which (for
Source of financing total investment cost ()
Information)
Total cost Union support(1) National National Other sources EIB/EIF loans:
[C.1.12.(A)] public (or private (specify)
equivalent)
(a)= (b)+(c)+
(b) (c) (d) (e) (f)
(d)+(e)
<type='N' <type='N' <type='N' <type='N' <type='N' <type='N'
input='G'> input='M'> input='M' input='M' input='M' input='M'>
> > >
(1)
The Union support should correspond to the amount specified in the agreement mentioned in Article 125
paragraph 3 c).
G.1.2. Annual plan of total eligible expenditure to be declared to the Commission

(financial indicator for monitoring progress)
The total eligible expenditure to be declared to the Commission shall be presented below in
terms of the annual share in EUR (indicative). In case of major project co-financed by more
than one Operational Programme, the annual plan shall be presented separately for each
Operational Programme. In case of major project co-financed by more than one priority axis,
the annual plan should be presented separately for each priority axis.
EN 28 EN
(in 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 Total
EUR) eligible
expenditure
Priority <type='N' <type='N' <type='N' <type='N' <type='N' <type='N' <type='N' <type='N' <type='N' <type='N' <type='N'
input='M' input='M' input='M' input='M' input='M' input='M' input='M' input='M' input='M' input='M' input='G'>
axis of > > > > > > > > > >
OP1
Priority
axis of
OP1
Priority
axis of
OP2
Priority
axis of
OP2
EN 29 EN
G.1.3. Other Union financing sources
G.1.3.1 Has an application been made for assistance from any other Union source (TEN-T
Budget, CEF, LIFE+, Horizon 2020, other sources of Union finance) for this project?
Yes No
If yes, please give details (EU programme concerned, reference number, date,
amount requested, amount granted, etc.):
G.1.3.2 Is this project complementary to any project already financed or to be financed by the ERDF, the ESF,
the Cohesion Fund, the CEF, other source of Union finance? <type='C' input='M'>
Yes No
If yes, please give details (source of the EU contribution, reference number, date,
amount requested, amount granted, etc.):
G.1.3.3 Has an application been made for loan or equity support from the EIB or the EIF for this project?
Yes No
If yes, please give details (financial instrument concerned, reference number, date, amount
requested, amount granted, etc.):
G.1.3.4 Has an application been made for assistance from any other Union source
(including the ERDF, the ESF, the Cohesion Fund, the EIB, the EIF, or other sources of
Union finance) for an earlier phase of this project (including feasibility and preparatory
phases)? <type='C' input='M'>
Yes No
If yes, please give details (source of the EU contribution, reference number, date, amount
requested, amount granted, etc.):
G.1.4. Will the construction of the infrastructure be delivered through a public-private
partnership (PPP)1? <type='C' input='M'>
Yes No
1
In the meaning of Article 62 of Regulation (EU) No 1303/2013.
EN 30 EN
If yes, please describe the form of PPP (i.e. selection process for private partner, structure of
PPP, infrastructure ownership arrangements including upon termination of the PPP
arrangements at maturity or otherwise, risk allocation arrangements, etc.). In addition provide
results of FRR(Kp) calculation and its comparison with national benchmarks on expected
profitability in the given sector.
G.1.5. If financial instruments1 are to be used for financing the project, please describe the
form of financial instruments (equity or debt instruments):
G.1.6 Impact of Union assistance on project implementation
Will Union assistance:
a) accelerate implementation of the project? <type='C' input='M'>
Yes No
If yes, please specify how and to what extent it will accelerate implementation.
If no, please explain
b) be essential to implementation of the project? <type='C' input='M'>
Yes No
If yes, please specify how much it will contribute to implementation. If no,

please justify the need for Union support
<type='S' maxlength='1750' input='M'>
G.2. Output indicators2 and physical indicators for monitoring progress
Please list in the table provided output indicators, including common indicators as specified
in the operational programme(s) and other physical indicators for monitoring progress.
Volume of information will depend on complexity of projects, but only main indicators
should be presented.
OP (CCI) Priority Name of Measurement Target value Target year

axis indicator unit for the major
project
<type='S' <type='S' Common: Common: <type='S' <type='N'

input='S'> input='S'> <type='S' <type='S' input='M'> input='M'>
input='S'> input='S'>
Other: Other:
<type='S' <type='S'
1
In the meaning of Article 37 of Regulation (EU) No 1303/2013.
2
As required in Article 101(1)(h) of Regulation (EU) No 1303/2013.
EN 31 EN
G.3. Risk assessment
Please present a short summary of the main risks to the successful physical and financial
implementation of the project and the proposed risk mitigation measures
<type='S' maxlength='3500' input='M'>
H. THE TIMETABLE FOR IMPLEMENTING THE MAJOR PROJECT

Where the implementation period is expected to be longer than the programming
period, the timetable for the phases, for which support from the funds is requested
during the 2014-2020 period, must be provided.
H.1. Project timetable
Please give below the timetable for the development and implementation of the
overall project and attach a summary schedule of the main categories of works (i.e. a
Gantt chart, where available). Where the application concerns a project stage, clearly
indicate in the table the elements of the overall project for which assistance is being
sought by this application:
Start date Completion date

(A) (1) (B) (1)
1. Feasibility studies (or business plan if <type='D' input='M'> <type='D' input='M'>

productive investment):
2. Cost-benefit analysis: <type='D' input='M'> <type='D' input='M'>
3. Environmental impact assessment: <type='D' input='M'> <type='D' input='M'>
4. Design studies: <type='D' input='M'> <type='D' input='M'>
5. Preparation of tender <type='D' input='M'> <type='D' input='M'>

documentation(s):
6. Tender procedure(s): <type='D' input='M'> <type='D' input='M'>
7. Land acquisition: <type='D' input='M'> <type='D' input='M'>
8. Development consent : <type='D' input='M'> <type='D' input='M'>
9. Construction phase / contract: <type='D' input='M'> <type='D' input='M'>
10. Operational phase: <type='D' input='M'> <type='D' input='M'>

(1)
If already complete - please give exact date, if only planned please give at least month and year
EN 32 EN
H.2. Project maturity
Please describe the project timetable (J.1) in terms of the technical and financial
progress and current maturity of the project under the following headings:
H.2.1. Technical (feasibility studies, project design etc.):
H.2.2. Administrative with a minimum reference to necessary authorisations such as EIA,
development consent, territorial/planning decisions, land purchase (if relevant),
public procurement etc.:
H.2.3 Public procurement:
Please fill in the information in the table below
Contrac Value Body Date of Ref.
Date of
t type (actual or responsible Date of completin (Official
signature
(works/ expected for the publishin g Journal of
Contrac of
supplies/ ) contract g tender evaluation the EU
t name contract
services) (actual or of tenders etc.) if
(actual or
planned) (actual or relevant
planned)
planned)
<type='S' <type='S' <type='N' type='S' <type='D' <type='D' <type='D' type='S'
input='M'> input='S'> input='M'> maxlength='300 input='M'> input='M'> input='M'> maxlength='00
' input='M' ' input='M'
H.2.4. Financial (commitment decisions in respect of national public expenditure, loans

requested or granted, etc. - give references):
H.2.5. If the project has already started, indicate the current state of implementation:
I. IS THE PROJECT SUBJECT TO A LEGAL PROCEDURE FOR NON-

COMPLIANCE WITH UNION LAW? <TYPE='C' INPUT='M'>
Yes No
If yes, please give details and justify the proposed contribution from the Union
budget in this respect:
EN 33 EN
J. HAS THE UNDERTAKING PREVIOUSLY BEEN, OR IS IT CURRENTLY,

SUBJECT OF A PROCEDURE 1 TO RECOVER UNION SUPPORT
FOLLOWING THE RELOCATION OF A PRODUCTIVE ACTIVITY
OUTSIDE THE PROGRAMME AREA? <type='C' input='M'>
Yes No
If yes, please give details and justify the proposed contribution from the Union budget to the
project in this respect:
K. INVOLVEMENT OF JASPERS IN PROJECT PREPARATION

K.1. Has Jaspers contributed to any part of the preparation of this project? <type='C'
input='M'>
Yes No
K.2. Describe the elements of the project where Jaspers had an input (e.g.
environmental compliance, procurement, review of technical description, cost-
benefit analysis).
L. STATUS OF THE PROJECT IN RELATION TO ARTICLE 102 OF REGULATION

(EU) NO 1303/2013
L.1. In case the project is submitted in line with the procedure pursuant to article
102(2), has the project been subject to the quality review by independent
experts? <type='C' input='M'>
Yes No
If yes, please give details and justify the change of the procedure for submission of
the project to the EC:
M. SUMMARY OF REVISIONS TO THE APPLICATION FORM IN CASE THE

MAJOR PROJECT IS SUBJECT TO MODIFICATION
1
Under Article 71(2) of Regulation (EU) No 1303/2013.
EN 34 EN
N. ENDORSEMENT OF COMPETENT NATIONAL AUTHORITY
I confirm that the information presented in this form is accurate and correct.
Name <type='S' maxlength=255 input='M'>
Signature (Electronically signed via <type='S' input='G'>

SFC2014)
Organisation (Managing Authority(-ies) <type='S' maxlength=1000 input='M'>
Date <type='D' input='G'>
EN 35 EN
Appendix 11
DECLARATION BY AUTHORITY RESPONSIBLE FOR MONITORING
OF NATURA 2000 SITES
Responsible Authority _____________________
Having examined the project application _____________________
For the project to be located at _____________________
Declares that the project is not likely to have significant effects on a NATURA 2000 site on
the following grounds:
TEXT BOX
Therefore an appropriate assessment required by Article 6(3) of Council Directive
92/43/EEC2 was not deemed necessary.
A map at scale of 1:100.000 (or the nearest possible scale) is attached, indicating the location
of the project as well as the NATURA 2000 sites concerned, if any.
Date (dd/mm/yyyy): ____________________
Signed: ____________________
Name: ____________________
Position: ____________________
Organisation: ____________________
(Authority responsible for monitoring NATURA 2000 sites)
Official Seal:
1
The Appendix 1declaration shall provide the name of the relevant site(s), reference number, the distance of the
project to the nearest Natura 2000 site(s), its conservation objectives, and justification that project (either
individually or in combination with other projects) is not likely to have significant negative effects on Natura
2000 site(s) included or intended to be included in the Natura 2000 network, and, if relevant, an administrative
decision.
2
Council Directive 92/43/EEC of 21 May 1992 on the conservation of natural habitats and of wild fauna and
flora (OJ L 206, 22.7.1992, p. 7).
EN 36 EN
Appendix 2
DECLARATION BY COMPETENT AUTHORITY RESPONSIBLE FOR WATER
MANAGEMENT1
Responsible Authority _____________________

Having examined the project application _____________________
For the project to be located at _____________________
Declares that the project does not deteriorate the status of the water body or cause failure to
achieve good water status/potential on the following grounds:
TEXT BOX
Date (dd/mm/yyyy): ____________________

Signed: ____________________
Name: ____________________
Position: ____________________
Organisation: ____________________
(Competent Authority identified in accordance with Article 3(2) of the Water Framework
Directive)
Official Seal:
1
In accordance with Article 3(2) of Directive 2000/60/EC of the European Parliament and of the Council of 23
October 2000 establishing a framework for Community action in the field of water policy (OJ L 327,
22.12.2000, p. 1).
EN 37 EN
Appendix 3
TABLE CONCERNING COMPLIANCE OF THE AGGLOMERATIONS SUBJECT TO THE APPLICATION FORM, WITH THE
URBAN WASTEWATER TREATMENT DIRECTIVE1
Status before implementation (based on the application form) Status after implementation (based on the application form)
Capacity of UWWTP(s) serving the agglomeration
Capacity of UWWTP(s) serving the agglomeration

IAS - individual appropriate systems
IAS - individual appropriate systems
Treatment performances
Treatment performances
Deadlines
Treatment level in place

Treatment level in place
Agglomeration load
Agglomeration load
and
Connection rate
Connection rate
Planned
Collection rate
Collection rate
transitional
Agglomeration Receiving date of the
periods in
name waters project
the
completion
Accession
Treaty
(in % of (in % of (in % of (in % of (in % of (in % of

SA / NA / (mm/yyyy
(mm/yyyy) (in p.e.) the the the (in p.e.) (in p.e.) the the the (in p.e.)
LSA/BW/ )
load) load) load) load) load) load)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1
Council Directive 91/271/EEC of 21 May 1991 concerning urban waste-water treatment (OJ L 135, 30.5.1991, p. 40).
EN 38 EN
EN 39 EN
Explanatory notes (number corresponds to the number of the column):
1. Name of the agglomeration(s) included in the application for EU co-financing. Note that
the indicators and calculations related to wastewater should refer to the agglomerations, not
to municipalities, as an agglomeration may include several administrative municipalities or
one municipality could be divided into several agglomerations. When an agglomeration is
only partially covered by a project, i.e., there is still part of the load to be addressed, ask for
information on the future plans to cover the remaining load of the agglomeration (which is
necessary for the agglomeration as a whole to reach compliance with the Directive).
2. Information on the receiving waters and their catchments: "normal" or "sensitive" (Article
5 of the UWWT Directive), "drinking water abstraction", "bathing waters", "shellfish waters
Please indicate the criterion, see Annex II to the Directive, use the following terms: SA
Sensitive area NA Normal area, LSA Less Sensitive area, BW designated bathing waters, O
other directives to be fulfilled (SA).
3. Only if applicable - the compliance deadlines under the Accession Treaty for each
agglomeration covered by the project for wastewater collection and treatment (refer to both
interim and final targets if applicable). Please indicate date and relevant Articles of the
Directive.
4. Planned date by when the project included in the application for the EU co-financing will
be implemented and completed.
Columns 5-11 refer to the description of the agglomeration at the stage when the application
for the EU co-financing is submitted.
5. The load of the agglomeration expressed in p.e. (population-equivalent).
6. Collection rate coverage of the collecting sewage systems (IAS not included) i.e. load
collected by the collecting system in relation to the total load of agglomeration concerned in
%.
7. Connection rate - the load collected by the collecting system which is connected to the
WWTP serving the agglomeration in %.
8. IAS the ratio of the load collected/treated by individual appropriate systems according to
Article 3(1) of the Directive in % of the load (system which achieves the same level of
environmental protection and is established in the case where the collecting system is not
justified either because it would produce no environmental benefit or because it would
involve excessive cost). If IAS is envisaged, a brief description of the type(s) of the IAS and
the treatment level which is reached should be provided. NB: the objective of the Directive
for the agglomerations above 2.000 p.e.: the collection rate plus IAS should cover 100% of
the load of the agglomeration.
9. Capacity of the Urban Wastewater Treatment Plant(s) in p.e.
10. Treatment level the treatment provided by the Urban Wastewater Treatment Plant(s) for
the discharges from the agglomeration(s) i.e. primary, secondary, more stringent (N, P
removal, disinfection etc.).
11. Treatment performance compliance with the treatment requirements laid down in the
Annex to I table 1 and 2 (if applicable).
EN 40 EN
Columns 12-18 refer to the description of the agglomeration envisaged after the
implementation of the project included in the application for the co-financing. Columns 13
and 14 In addition to total rates, please indicate the rates which correspond to rehabilitation
of the existing collecting system, and the rate which corresponds to newly constructed
collecting system. In case the connection rate will be below collection rate after the
implementation of the project, the reasons for such difference and investment plans for the
future to reduce the difference should be provided (including the cases where users do not
want to connect to the collector).
15. If relevant please indicate any improvements (rehabilitation, new, upgrade) to the IAS
included in the project.
16. Please also indicate if the plant(s) are totally new, rehabilitated or upgraded. The capacity
of the plants should be sufficient to treat the whole load generated by the agglomeration. In
case total capacity of the UWWTP(s) is below the total load of the agglomeration, an
explanation of the reasons should be provided (e.g.: forecasted increase, etc.). In addition, it
should be explained how proper functioning of the plants will be ensured to overcome the
plant overloading. In case the plant(s) are (largely) over-dimensioned, an explanation of the
reasons should be provided (ex: forecasted increase of the incoming load, extension of the
collecting systems, further connections of other agglomerations etc.).
EN 41 EN
Appendix 4 Feasibility Studies (or Business Plan if productive investment)
and Cost-Benefit Analysis (as required in D and E)
Appendix 5 - Map identifying the project area and geo-referenced data (as
required in B.3.1)
Appendix 6 Documentation required in F.3.3
EN 42 EN

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POIM 2014-2020 Anexa 1.1.A Ghidul Solicitantului OS 3.2.

Format for submission of the information on a major project

Project title <type='S' maxlength=255 input='M'>

CCI <type='S' maxlength=15 input='S'>

A. THE BODY RESPONSIBLE FOR IMPLEMENTATION OF THE

A.1.1 Name: <type='S' maxlength='200' input='M'>(1)

A.1.2 Address: <type='S' maxlength='400' input='M'>

A.1.3 Name of contact person <type='S' maxlength='200' input='M'>

A.1.4 Position of contact person <type='S' maxlength='200' input='M'>

A.1.5 Telephone: <type="N" input='M'>

A.1.6 E-mail: <type='S' maxlength='100' input='M'>

A.2. Body/-ies1 responsible for project implementation (beneficiary/-ies2)

A.2.1 Name: <type='S' maxlength='200' input='M'>

A.2.2 Address: <type='S' maxlength='400' input='M'>

A.2.3 Name of <type='S' maxlength='200' input='M'>

A.2.4 Position of <type='S' maxlength='200' input='M'>

A.2.5 Telephone: <type="N" input='M'>

A.2.6 E-mail: <type='S' maxlength='100' input='M'>

A.3.2 Is the undertaking an SME1? <type='C' input=M>

A.3.3 Turnover (value in million EUR and year):

A.3.4 Total number of persons employed (value and year):

Indicate the name and describe the group structure

A.5 Provide information on all relevant institutional arrangements with third

B. A DESCRIPTION OF THE INVESTMENT AND ITS LOCATION;

CCI of OP Priority axis of OP

OP1<type='S' input='S'> Priority axis of OP 1<type='S' input='S'>

OP1<type='S' input='S'> Priority axis of OP 1<type='S' input='S'>

OP2<type='S' input='S'> Priority axis of OP 2<type='S' input='S'>

OP2<type='S' input='S'> Priority axis of OP 2<type='S' input='S'>

B.2. Categorisation of project activity1

Code Amount Percentage

B.2.1. Code(s) for the intervention field <type='N' <type='N' <type='P'

<type='N' <type='N' <type='P'

<type='N' <type='N' <type='P'

<type='N' <type='N' <type='P'

B.2.2. Code for the form of finance <type='N' <type='N' <type='P'

B.2.3. Code for the territorial dimension <type='N' <type='N' <type='P'

B.2.4. Code for the territorial delivery <type='N' <type='N' <type='P'

B.2.5. Code for the thematic objective <type='N' <type='N' <type='P'

(More than one may be relevant in some

B.2.6. Code for the economic dimension <type='N' <type='N' <type='P'

(More than one may be relevant in some <type='N' <type='N' <type='P'

(More than one may be relevant in some <type='N' <type='N' <type='P'

B.2.8. Nature of the investment(3) (to be <type='N' <type='N' <type='P'

B.2.9. Product concerned(4) (to be filled in <type='N' <type='N' <type='P'

B.3. Project description

< type='S' maxlength='1750' input='M'>

C. TOTAL COST AND TOTAL ELIGIBLE COST

EUR TOTAL COST INELIGIBLE ELIGIBLE PERCENTAG

INPUT INPUT CALCULATED CALCULATED

1 Planning/design fees <type='N' <type='N' <type='N' <type='P'

3 Building and <type='N' <type='N' <type='N' <type='P'

10 Sub-TOTAL <type='N' <type='N' <type='N' <type='P'

If yes, please fill in the table below1:

Calculation of the discounted net revenue <type='C' input='M'>

Flat rate method <type='C' input='M'>

Decreased co-financing rate method <type='C' input='M'>

Calculation of the discounted net revenue (Article 61(3)(b) of Regulation (EU) No