Pro Poor Results-Based Financing ProgrammeApplication Form(Version dated: 22.11.2019)

The application form for the Pro Poor Results-Based Financing (RBF) Programme should be completed and submitted by a representative of the applying company. The application should be submitted electronically as an MS Word document (.doc or .docx) to Urwego Bank Plc. The application will be signed together with the contract. Therefore, there is no need to print and sign the form beforehand.

1. Contact details

Company Name [Insert company name here]

Date of application DD/MM/YYYY

Address in Rwanda

City / Town: Click or tap here to enter text.

Street: Click or tap here to enter text.

P.O. Box: Click or tap here to enter text.

Website: Click or tap here to enter text.

Contact person

Name: Click or tap here to enter text.

Position within company: Click or tap here to enter text.

Phone: Click or tap here to enter text.

Email: Click or tap here to enter text.

Bank detailsName of bank: Click or tap here to enter text.

Account holder: Click or tap here to enter text.

Account number: Click or tap here to enter text.

2. Company information

2.1. Company descriptionPlease describe your company and the products you currently offer. What is the focus of your business? How are you organised? What was your turnover for 2018? (Max. 1 page)

[Insert text]

Please indicate the number of full- and part-time staff in the table below.

Men Women

Part-time [Insert number] [Insert number]

Full-time [Insert number] [Insert number]

Please specify which products you are selling, the average price of each product and the average number of systems sold or distributed per month in the table below.

Product model Average number sold per month Average price in RWF

[Insert model name] [Insert number] [Insert number]

[Insert model name] [Insert number] [Insert number]

[Insert model name] [Insert number] [Insert number]

[Insert model name] [Insert number] [Insert number]

[Insert model name] [Insert number] [Insert number]

2.2. Support received from other organisations

Have you received (up to one year ago) or are you currently receiving financial support from another organisation or programme? Please tick all appropriate boxes.

☐ No, we do not receive support currently.

☐ No, we have not received support in the last year.

☐ Yes, we are currently receiving support.

☐ Yes, we have received support in the last year.

If you have received support in the last year or are receiving support currently, please provide further details. Please include information on the purpose of the support / subsidy, the amount of funding provided, the funder, funding period, and products sold during this period.

Donor / Programme providing support

[Insert donor or programme name]

Grant period DD/MM/YYYY – DD/MM/YYYY

Grant amount provided

Click or tap here to enter text.

Purpose of the grant Click or tap here to enter text.

Description Click or tap here to enter text.

Products supported Click or tap here to enter text.

Number of products supported

Click or tap here to enter text.

Donor / Programme providing support

[Insert donor or programme name]

Grant period DD/MM/YYYY – DD/MM/YYYY

Grant amount provided

Click or tap here to enter text.

Purpose of the grant Click or tap here to enter text.

Description Click or tap here to enter text.

Products supported Click or tap here to enter text.

Number of products supported

Click or tap here to enter text.

Donor / Programme providing support

[Insert donor or programme name]

Grant period DD/MM/YYYY – DD/MM/YYYY

Grant amount provided

Click or tap here to enter text.

Purpose of the grant Click or tap here to enter text.

Description Click or tap here to enter text.

Products supported Click or tap here to enter text.

Number of products supported

Click or tap here to enter text.

3. Pro Poor RBF supported products

Please fill out this section related only to products that will be part of the Pro Poor RBF. Please check the Call for Interested Companies for further information on eligible products.

3.1. Products supported by the Pro Poor RBF

Please use the product names as specified on the Lighting Global website (www.lightingglobal.org) and the list of products used in the sales reports provided to EDCL.

Product modelWarranty period for the end user

Annual customers / sales targets

Price for end user (before subsidy) Imported from

[Insert model name] Click or tap here to enter text.

Click or tap here to enter text.

Click or tap here to enter text.

Click or tap here to enter text.

[Insert model name] Click or tap here to enter text.

Click or tap here to enter text.

Click or tap here to enter text.

Click or tap here to enter text.

[Insert model name] Click or tap here to enter text.

Click or tap here to enter text.

Click or tap here to enter text.

Click or tap here to enter text.

3.2. Business model

Please describe your business model and how you plan to target eligible Ubudehe 1, 2 and / or 3 households with the support of the Pro Poor RBF. Ensure that you describe step-by-step how the product moves from you to the end user and who is doing what during the process (incl. payment process). Please take into account that 1) end user eligibility needs to be verified using the Eligibility Tool, 2) subsidised sales need to be (pre-) registered using the Eligibility Tool at the time of contract signing (see FAQs for details), and 3) a local government official will need to witness the sale by signing the contract. You may consider the following additional guiding questions when filling out this section:

Which Ubudehe categories will you be targeting?

How are you reaching rural customers, e.g. directly through your own retail network, through cooperatives, SACCOs, micro-finance institutions, etc.?

How is the relationship between your company and individuals (or other) selling your products set up? Are they your employees? Do they receive a commission per system sold? Are they employees of another organisation? Are they independent entrepreneurs?

How are you training and instructing individuals who will sell to end users (particularly in regard to the use of the Eligibility Tool)?

Who will use the Eligibility Tool to verify end user eligibility, pre-register and register sales?

How are customers informed about using and maintaining the solar system? Do you follow-up with

customers after the sale to sensitise them?

Will customers eventually own the system, or will they only benefit from the service? If they eventually own the system, when will they own the system if payments are made in instalments? What happens when a customer stops paying the instalments? After what period do you decide to take back the system if a customer is not paying?

If you are an NGO, please describe how you follow a commercial approach. If you are working with an NGO, how do you assure that the sales are commercial and not subsidised by the NGO?

[Insert text]

3.3. Warranty system

Please describe the warranty system for supported systems. Please provide step-by-step information on how a faulty product moves from the end user to you, and potentially from you back to the manufacturer. Who covers the costs of the warranty system? How do you make sure that a faulty product brought to you is one you sold before / under the RBF?

[Insert text]

3.4. Verification and data quality

How do you ensure that the data required for verification and reporting to REG / EDCL under the Government of Rwanda’s reporting requirements is collected correctly? Do you give out any incentives for high quality data to the individuals collecting data? Do you collect data on paper or electronically? Do you analyse your own customer data? Data required for processing claims must be submitted electronically to REG / EDCL as per the Government’s reporting requirements. How will you ensure that the data is submitted electronically and on time to REG / EDCL?

[Insert text]

3.5. End-of-life management

Please describe your policy or plan for ensuring the appropriate disposal / recycling of broken systems within the guarantee period and thereafter. Do you have an agreement with a recycler in Rwanda or elsewhere? What is your agreement? Do you pay for your system to be recycled? How do broken system get from the customer to you and from you to the recycler?

[Insert text]

4. Annexes and supporting documents

4.1. Certification of complianceOnce the application is accepted it will become part of the contract and be signed by the company at contract signing. When submitting your application, please only fill out the relevant sections above.

I, [name], certify that I am the [title] of [name of the company] and that by signing this application for and on behalf of [name of the company] I am acknowledge that all information contained herein is accurate and truthful. I understand that any willful misstatement described in the application form may lead to the disqualification or dismissal of [name of the company] from the programme.

I am committed to:

Complying with the rules and obligations governing the Pro Poor RBF fund;

Claiming incentives only for eligible solar systems mentioned in this application and sold to eligible end users;

Claiming incentives only for solar system that did not receive other grants or subsidies;

Adhering to the monthly reporting requirement as set out by the Government of Rwanda and providing baseline data required to participate in the programme;

Using the Eligibility Tool to verify the eligibility of end users and registering subsidised sales to be claimed;

Providing the information and documentation reported for the implementation of the Pro Poor RBF and participating in (cross-) checks or interviews conducted by the programme;

Funding all activities before the reception of incentive payments;

Providing a product warranty for three years to all customers in line with the Ministerial Guidelines on Minimum Standards Requirements for Solar Home Systems and warranty cards for each product sold.

I understand that any willful disrespect herein may lead to the cancelation of this contract and disqualification for incentive disbursements.

_________________________________________________ Stamp

Date, Signature

4.2. Annexes

4.2.1. Copy of the RDB certificate of domestic company registration, RGB registration as an NGO, or RCA registration as a cooperative

Please include the document here or attach it as an extra file named as follows:

Annex 1_[Company name]_RDB certificate of domestic company registration

OR

Annex 1_[Company name]_RGB registration as an NGO

OR

Annex 1_[Company name]_RCA registration as a cooperative

4.2.2. Copy of the RDB registration form showing shareholders, shares and manager of the company

Please include the document here or attach it as an extra file named as follows:

Annex 2_[Company name]_RDB registration form

4.2.3. Copy of a valid RRA tax clearance certificate

Please include the document here or attach it as an extra file named as follows:

Annex 3_[Company name]_RRA tax clearance certificate

4.2.4. Copy of a valid RSSB social security clearance certificate

Please include the document here or attach it as an extra file named as follows:

Annex 4_[Company name]_RSSB social security clearance certificate

4.2.5. Copy of a valid EDCL Cooperation Agreement

Please include the document here or attach it as an extra file named as follows:

Annex 5_[Company name]_EDCL Cooperation Agreement

If the Cooperation Agreement is still being negotiated, Urwego Bank Plc. will confirm with EDCL the status of the negotiations. Please ensure that you had it in once it has been signed.

4.2.6. For systems in the country at the launch of the programme: Copy of import papers

Please include the document here or attach it as an extra file named as follows:

Annex 6_[Company name]_Import papers_[Name of product]

4.2.7. Copy of a valid Lighting Global certificate for products sold

Please include the document here or attach it as an extra file named as follows:

Annex 7_[Company name]_Lighting Global certificate_[Product model]

4.2.8. Optional: End-of-life management / recycling policy or plan

Please include the document here or attach it as an extra file named as follows:

Annex 8_[Company name]_End-of-life management policy or plan

Pro Poor RBF is co-funded by:EnDev is funded by: Coordinated by: