ANNEX VISupplementary provisions
ANNEX VI Model for the payment application including additional information concerning financial instruments PAYMENT APPLICATION EUROPEAN COMMISSION Fund concerned ( 1 ) : <type='S' input='S'> ( 2 ) Commission reference (CCI): <type='S' input='S'> Name of operational programme: <type='S' input='G'> Commission Decision: <type='S' input='G'> Date Commission Decision: <type='D' input='G'> Payment application number: <type='N' input='G'> Date of submission of the payment application: <type='D' input='G'> National reference (optional): <type='S' maxlength='250' input='M'> Please specify the type of the payment application: An interim payment application, in accordance with Article 131 of Regulation (EU) No 1303/2013 <radio button> A final application for interim payment in accordance with Article 135(2) of Regulation (EU) No 1303/2013 <radio button> According to Article 135 of Regulation (EU) No 1303/2013, this payment application refers to the accounting period: From ( 3 ) <type='D' input='G'> until: <type='D' input='G'> Expenditure broken down by priority and category of regions as entered into the accounts of the certifying authority (Including programme contributions paid to financial instruments (Article 41 of Regulation (EU) No 1303/2013) and advances paid in context of State aid (Article 131(5) of Regulation (EU) No 1303/2013)) Priority Calculation basis (public or total) Total amount of eligible expenditure incurred by beneficiaries and paid in implementing operations Total amount of public expenditure incurred in implementing operations (A) (B) (C) Priority 1 Less developed regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Transition regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> More developed regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Outermost regions and Northern sparsely populated regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> YEI ( 4 ) <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Priority 2 Less developed regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Transition regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> More developed regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Outermost regions and Northern sparsely populated regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> YEI <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Priority 3 Less developed regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Transition regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> More developed regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Outermost regions and Northern sparsely populated regions <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Priority 4 YEI ( 5 ) <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Totals Less developed regions <type='Cu' input='G'> <type='Cu' input='G'> Transition regions <type='Cu' input='G'> <type='Cu' input='G'> More developed regions <type='Cu' input='G'> <type='Cu' input='G'> Outermost regions and Northern sparsely populated regions <type='Cu' input='G'> <type='Cu' input='G'> YEI <type='Cu' input='G'> <type='Cu' input='G'> Grand Total <type='Cu' input='G'> <type='Cu' input='G'> The model is automatically adjusted on basis of the CCI. As an example, in case of programmes not including categories of regions (Cohesion Fund, ETC, EMFF, ENI and IPA contributions to ETC, YEI dedicated operational programme without technical assistance, if applicable) the table shall look as follows: Priority Calculation basis (public or total) ( 6 ) Total amount of eligible expenditure incurred by beneficiaries and paid in implementing operations Total amount of public expenditure incurred in implementing operations (A) (B) (C) Priority 1 <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Priority 2 <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Priority 3 <type='S' input='G'> <type='Cu' input='M'> <type='Cu' input='M'> Grand Total <type='Cu' input='G'> <type='Cu' input='G'> CERTIFICATE By validating this payment application the Certifying Authority certifies that the responsibilities foreseen in points (a), (d), (e), (f), (g) and (h) of Article 126 of Regulation (EC) No 1303/2013 are fulfilled and requests the payment of the amounts as mentioned below. Representing the Certifying Authority: <type='S' input='G'> APPLICATION FOR PAYMENT FUND AMOUNTS Less developed regions Transition regions More developed regions Outermost regions and Northern sparsely populated regions (A) (B) (C) (D) <type='S' input='G'> <type='Cu' input='G'> <type='Cu' input='G'> <type='Cu' input='G'> <type='Cu' input='G'> YEI ( 7 ) <type='Cu' input='G'> The model is automatically adjusted on basis of the CCI. As an example, in case of programmes not including categories of regions (Cohesion Fund, ETC, EMFF, ENI and IPA contributions to ETC, YEI dedicated operational programme without technical assistance, if applicable) the table shall look as follows: FUND AMOUNT <type='S' input='G'> <type='Cu' input='G'> The payment will be made on the following bank account: Designated body <type='S' maxlength='150' input='G'> Bank <type='S' maxlength='150' input='G'> BIC <type='S' maxlength='11' input='G'> Bank account IBAN <type='S' maxlength='34' input='G'> Holder of account (where not the same as the designated body) <type='S' maxlength='150' input='G'> ( 1 ) If a programme concerns more than one fund, application for payment should be sent separately for each of them. Irrespective of the way YEI is implemented (dedicated OP, specific priority axis or part of a priority axis), expenditure related to YEI activities will always be declared under an ESF payment application and will therefore cover both YEI specific allocation and ESF corresponding support. ( 2 ) Legends: type: N = Number, D = Date, S = String, C = Checkbox, P = Percentage, B = Boolean, Cu = Currency input: M = Manual, S = Selection, G = Generated by system ( 3 ) First day of the accounting year, automatically encoded by the IT system. ( 4 ) The YEI is implemented through part of a priority as referred to in Article 18 of Regulation (EU) No 1304/2013. ( 5 ) The YEI is implemented through a dedicated priority as referred to in Article 18 of Regulation (EU) No 1304/2013. ( 6 ) For the EMFF co-financing applies only on ‘Total eligible public expenditure’. Therefore, in case of EMFF, the calculation base in this model will automatically be adjusted to ‘Public’. ( 7 ) Covers the specific allocation for the YEI and the corresponding ESF support.