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LIFE Environment and Resource Efficiency

TECHNICAL APPLICATION FORMS

Part A – administrative information

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LIFE17 ENV/

LIFE Environment and Resource Efficiency project application

Language of the proposal:

English (en)

Project title (max 120 characters):

Project acronym (max 25 characters):

The project will be implemented in the following Member State(s) and Region(s) or other countries:

Expected start date: Expected end date:

Name of the coordinating beneficiary:

Total project budget:

Total eligible project budget:

EU financial contribution requested:

Euro

Euro

Euro (= % of total eligible budget)

SECTOR

LIFE 2017 FOR ADMINISTRATION USE ONLY

LIFE17 ENV/

LIST OF BENEFICIARIES

LIST OF CO-FINANCERS

PROJECT BUDGET AND REQUESTED EU FUNDING

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LIFE17 ENV/ - A2

Coordinating Beneficiary Profile Information

Legal Name (max 200 characters)

Short Name (max 10 characters)

Legal Status

VAT No Public

body Private

commercial Private

non- commercial

Legal Registration

Registration Date

Pic Number (not compulsory)

Legal entity is SME

Employee number

Legal address of the Coordinating BeneficiaryStreet Name and No

Post Code PO Box

Town / City

Member State

Coordinating Beneficiary contact person informationTitle Function

Surname

First Name

E-mail address

Department /

Street Name and No

Post Code PO Box

Town / City

Member State

Telephone No Fax No

Website of the Coordinating BeneficiaryWebsite (max 250 characters)

Brief description of the Coordinating Beneficiary's activities and experience in the area of the

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LIFE17 ENV/ - A7

OTHER PROPOSALS SUBMITTED FOR EUROPEAN UNION FUNDING

Please answer each of the following questions:

• Have you or any of your associated beneficiaries already benefited from previous LIFE cofinancing? (please cite LIFE project reference number, title, year, amount of the co-financing, duration, name(s) of coordinating beneficiary and/or partners involved):

• Have you or any of the associated beneficiaries submitted any actions related directly or indirectly to this project to other European Union funding programmes? To whom? When and with what results?

• For those actions which fall within the eligibility criteria for financing through other European Union funding programmes, please explain in full detail why you consider that those actions are better suited to financing through LIFE and are therefore included in the current project:

• Has this proposal been submitted before? Yes No

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LIFE17 ENV/


Part B - technical summary and overall context of the project

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LIFE17 ENV/ - B1

SUMMARY DESCRIPTION OF THE PROJECT (Max. 3 pages; to be completed in English)

Project title (max 120 characters):

Project objectives (max 2500 characters):

Actions and means involved (max 2500 characters):

Expected results (outputs and quantified achievements) (max 2500 characters):

The proposal addresses the following project topic(s) (pasirenkama iš sąrašo, daugiausia 2):

Reasons why the proposal falls under the selected project topic(s):

No YesIs your project significantly climate-related?

No Is your project significantly biodiversity-related? Yes

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LIFE17 ENV/ - B2

ENVIRONMENTAL PROBLEM TARGETED (max 10,000 characters)

PROJECT PILOT / DEMONSTRATION CHARACTER OF THE PROJECT (max 10,000 characters)

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LIFE17 ENV/ - B3

EU ADDED VALUE OF THE PROJECT AND ITS ACTIONS (max 10,000 characters)

REPLICABILITY AND TRANSFERABILITY (max 10,000 characters)

SOCIO-ECONOMIC EFFECTS OF THE PROJECT (max 10,000 characters)

EFFORTS FOR REDUCING THE PROJECT'S "CARBON FOOTPRINT" (max 10,000 characters)

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LIFE17 ENV/ - B4

STAKEHOLDERS INVOLVED AND MAIN TARGET AUDIENCE OF THE PROJECT (OTHER THAN PROJECT PARTICIPANTS) (max 12,000 characters)

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LIFE17 ENV/ - B5

EXPECTED CONSTRAINTS AND RISKS RELATED TO THE PROJECT IMPLEMENTATION AND MITIGATION STRATEGY (max 12,000 characters)

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LIFE17 ENV/ - B6

CONTINUATION / VALORISATION AND LONG TERM SUSTAINABILITY OF THE PROJECT'S RESULTS AFTER THE END OF THE PROJECT

Which actions will have to be carried out or continued after the end of the project? (max 5,000 characters)

How will this be achieved? What resources will be necessary to carry out these actions? (max 5,000 characters)

To what extent will the results and lessons of the project be actively disseminated after the end of the project to those persons and/or organisations that could best make use of them (please identify these persons/organisations)? (max 5,000 characters)

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LIFE17 ENV/


Part C – detailed technical description of the proposed actions

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LIFE17 ENV/ - C0

LIST OF ALL PROPOSED ACTIONSA. Preparatory actions (if needed)

B. Implementation actions (obligatory)

C. Monitoring of the impact of the project actions (obligatory)

D. Public awareness and dissemination of results (obligatory)

E. Project management (obligatory)

For each action, the applicant should provide the following information: Name of the action (max 200 characters): Beneficiary responsible for implementation (pasirenkama iš sąrašo, jei daugiau partnerių atsakingų už

vieną veiklą - aprašymui daugiausia 500 ženklų): Description (what, how, where, when and why) (max 7,000 characters): Assumptions related to major costs of the action (max 2,000 characters):

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LIFE17 ENV/ - C2

DELIVERABLE PRODUCTS OF THE PROJECT

Name of the Deliverable Number of the associated action Deadline

MILESTONES OF THE PROJECT

Name of the Milestone Number of the associated action Deadline

ACTIVITY REPORTS FORESEENPlease indicate the deadlines for the following reports:• Progress Reports n°1, n°2 etc. (if any; to ensure that the delay between consecutive reports does not exceed 18 months)

• Mid term report payment request (for project longer than 24 months or with Eu contribution of more than EUR300,000)

• Final Report with payment request (to be delivered within 3 months after the end of the project)

DeadlineType of report

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LIFE17 ENV/

FINANCIAL APPLICATION FORMS

Part F – financial information

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LIFE17 ENV/ R1 - Budget

Budget breakdown cost categories Total cost in € Eligible Cost in € % of total eligible costs

1. Personnel 0 0 0.00%2. Travel and subsistence 0 0 0.00%3. External assistance 0 0 0.00%4. Durable goods

Infrastructure 0 0 0.00%Equipment 0 0 0.00%Prototype 0 0 0.00%

5. Land Not applicable

6. Consumables 0 0 0.00%7. Other costs 0 0 0.00%8. Overheads 0 0 0.00%Total 0 0 100.00%

Contribution breakdown In € % of total % of total eligible costs

EU contribution requested 0 0.00% 0.00%Coordinating Beneficiary's contribution 0 0.00%Associated Beneficiaries' contribution 0 0.00%Co-financers contribution 0 0.00%Total 0 0.00%

LIFE17 ENV/ - R2 - Costs per Action

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Cost category in Euro

LIFE17 ENV/ - R2a

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Costs per Beneficiary

LIFE17 ENV/ - FC

Coordinating Beneficiary's contributionCountry code Beneficiary short name Total costs of the

actions in € (including

overheads)

Beneficiary's own contribution in €

Amount of EU contribution

requested in €

LT 0 0 0

Associated Beneficiaries' contributionCountry code Beneficiary short name Total costs of the

actions in € (including

overheads)

Associated beneficiary's own contribution in €

Amount of EU contribution

requested in €

TOTAL Associated Beneficiaries 0 0 0

TOTAL All Beneficiaries 0 0 0

Co-financers contribution

Co-financer's nameAmount of cofinancing in €

TOTAL 0

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