ANNEX IVSupplementary provisions
ANNEX IV Model for the payment application PAYMENT APPLICATION EUROPEAN COMMISSION Commission reference (CCI) No: <type=‘S’ input=‘S’> ( 1 ) 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 41 of Regulation (EU) No 223/2014 <radio button> A final application for interim payment in accordance with Article 45(2) of Regulation (EU) No 223/2014 <radio button> According to Article 45 of Regulation (EU) No 223/2014, this payment application refers to the accounting period: From ( 2 ) <type=‘D’ input=‘G’> until: <type=‘D’ input=‘G’> Expenditure broken down by type of expenditure as entered into the accounts of the certifying authority (for OP I) Type of expenditure ( 3 ) Total amount of eligible expenditure incurred by beneficiaries and paid in implementing operations Total amount of public expenditure incurred in implementing operations (A) (B) Technical assistance <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> Type of material assistance 1 <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(a) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(b) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(c) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(d) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(e) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> Type of material assistance 2 <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(a) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(b) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(c) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(d) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(e) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> … Type of material assistance n <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(a) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(b) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(c) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(d) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> of which, expenditure under art. 26-2(e) <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> Total <type=‘Cu’ input=‘G’> <type=‘Cu’ input=‘G’> Expenditure broken down by type of expenditure as entered into the accounts of the certifying authority (for OP II) Type of expenditure Total amount of eligible expenditure incurred by beneficiaries and paid in implementing operations Total amount of corresponding public expenditure incurred in implementing operations (A) (B) Technical assistance <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> Type of action 1 <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> Type of action 2 <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> … Type of action n <type=‘Cu’ input=‘M’> <type=‘Cu’ input=‘M’> 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 33 of Regulation (EU) No 223/2014 are fulfilled and requests the payment of the amounts as mentioned below. Representing the Certifying Authority: <type=‘S’ input=‘G’> APPLICATION FOR PAYMENT FEAD AMOUNT <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=‘’> BIC <type=‘S’ maxlength=‘11’ input=‘’> Bank account IBAN <type=‘S’ maxlength=‘34’ input=‘’> Holder of account (where not the same as the designated body) <type=‘S’ maxlength=‘150’ input=‘’> ( 1 ) Legends: type: N = Number, D = Date, S = String, C = Checkbox, Cu = Currency input: M = Manually, S = Selection, G = Generated by system ( 2 ) First day of the accounting year, automatically encoded by the IT system. ( 3 ) In accordance with Regulation (EU) No 223/2014.