ࡱ> qsnop Nbjbj k.zz$PH,'..- e'g'g'g'g'g'g'$*,'999''K K K 9Re'K 9e'K K :i%,%0NF% Q''0'%R`-`-%`-%`99K 99999''999'9999`-999999999z :  UNDEF PROJECT EXTENSION REQUEST FORM If this extension request includes a revision to the original budget, please also provide us with the Project Budget Revision Request Form, available on the UNDEF webpage relevant to your grant cycle. UNDEF Project Number: UDF-XXX-XX-XXX Information to be provided byRequirementsthe Implementing Agency Reason for delay in implementation/completion : Extensions do not entail changes in the overall budget. Please note that salary and support costs should not exceed the amounts allocated in the approved budget. Statement certifying that there is no additional financial implication for UNDEF: ________________________________________ SignatureRequested duration (12 months maximum): Attach an updated results framework (see next page) based on the one approved in the Project Document, clearly highlighting: activities already completed activities to be implemented during extension period any changes in activitiesSigned statement certifying that all project partners were consulted: _______________________________________ SignatureTo be filled by UNDEFUNDEF Programme officerNew end date of the project: UNDEF Executive Head Date approved : Signature :  REVISED WORK PLAN(to be submitted with the extension request): Please copy the Work Plan of your signed Project Document in this Example template and follow these steps. Adjust the number of columns to meet the timeframe of your project. For example if your project was for 24 months and you are asking for a 6 month extension. Make sure you have columns for 8 quarters (24 months) and 2 additional columns for the 2 quarters of the extension (1quarter = 3 months). Highlight in yellow activities that are delayed and will be completed during the extension period, adjust the X in the timeframe columns. Highlight in green activities that are new or adjusted from the original work plan and that will be completed during the extension period, adjust the X in the timeframe columns. OutputsKey ActivitiesMilestoneQ1Q2Q3Q4Q5Q6Q7Q8Extension Q9Extension Q10Extension Q11Extension Q12Implementation statusBudget per output (rounded to the nearest $500)Outputs for Outcome 1: State the outcome (exactly as in your Project Document)1.1 A comprehensive baseline survey and needs assessment produced on civic awareness among indigenous populations in the 5 project districts. 1.1.1 Design format and content of baseline survey/needs assessment. xCompleted5,000 1. 1.2 Conduct the baseline survey/needs assessment in 5 districts.xCompleted1.1.3 Publish assessment findings as a comprehensive report.xCompleted 1.1.4 Disseminate report to key stakeholders, including CSOs and government representatives. xxxXTo be completed: additional distribution to new stakeholders (i.e. all the municipalities)1.2 TOT civic awareness program conducted in 5 districts for 2500 representatives from indigenous groups and local CSOs.1.2.1 Identify key CSOs and indigenous representatives in each project district and invite them to take part in the awareness program.xCompleted15,0001.2.2 Design training methodology, content and materials.xCompleted1.2.3 Conduct 30 TOT programs in 5 project districts.M2xxxxXTo be completed: 3 additional trainings1.2.4 Gather evaluation material and feedback from participants.xxxxXTo be completed: compilation of information into a report() ()()()Outputs for Outcome 2: State the outcome (exactly as in your Project Document)xCompleted12,000xCompletedxxxCompletedxxxCompletedxCompleted25,000xCompletedM3xxxxxCompletedxxxxxCompletedxCompletedxCompleted()()()()Outputs for Outcome 3: State the outcome (exactly as in your Project Document)xCompleted12,000xCompletedxxxxCompletedxxxxxxxxCompleted()()()()TOTAL PROJECT COSTUS$ UNDEF Monitoring and EvaluationUS$ TOTAL UNDEF GRANTUS$       %&'  ðzdP70hh5B*CJOJQJaJmH phsH 'h{h?5CJOJQJaJmH sH *h{hjG 5>*CJOJQJaJmH sH h{h?CJOJQJaJ$h{h?CJOJQJaJmH sH 'h{h m6CJOJQJaJmH sH $h{h mCJOJQJaJmH sH h{h?5CJOJQJaJh2:h'R5CJOJQJaJh2:hc.5CJOJQJaJh2:h1 5OJQJ &'  : G $$Ifa$gdx?. 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