GRANT AGREEMENT

BETWEEN

ViiV HEALTHCARE UK LIMITED

AND

[INSERT THIRD PARTY LEGAL NAME]

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This grant agreement (the “Agreement”) is made and entered into as of the date it is executed by both Parties (the
“Effective Date”), by and between

1) ViiV Healthcare UK Limited, a company incorporated and registered in England with company number 06990358,
whose registered office is at 980 Great West Road, Brentford, Middlesex, TW8 9GS, United Kingdom (“ViiV”); and

2) [INSERT FULL NAME OF RECIPIENT LEGAL ENTITY], an organisation incorporated and registered in [INSERT
COUNTRY OF REGISTRATION] with registration number [INSERT], whose registered office is at [INSERT]
(“Recipient”).

(each a “Party”, and together the “Parties”).

WHEREAS

(A) ViiV and its affiliates research, develop, manufacture, distribute and sell pharmaceutical products for the treatment
of HIV.
(B) The ViiV Healthcare Positive Action Programme supports communities affected by HIV and AIDS, in line with ViiV’s
mission of leaving no person living with HIV behind.
(C) Recipient is [a(n) non-profit organisation/educational institution] responsible for [INSERT DESCRIPTION OF
RECIPENT BUSINESS/OBJECTIVES].
(D) ViiV desires to provide funding to Recipient on the terms set out in this Agreement.

1. DEFINITIONS AND INTERPRETATION

In this Agreement, the following terms have the following meanings unless the context otherwise expressly requires:

“Amplify Impact Funding” means, if applicable, the proportion of the Grant to be used by
Recipient to pay for Technical Assistance, as specified in Schedule 1
to this Agreement;

“Applicable Law” means all applicable provisions of any and all statutes, laws,
instruments, rules, regulations, administrative codes, ordinances,
decrees, orders, decisions, injunctions, awards, judgments, permits
and licenses of or from any federal, national, state, provincial or local
governmental or non-governmental authority, agency, undertaking or
body (whether present or future and in any territory) which has any
jurisdiction in respect of or relevance to the applicable Party and its
activities and/or the relevant provisions of this Agreement;

“CAF” means Charities Aid Foundation (Registered Charity Number 268369)

or other similar Third Party partner of ViiV’s choosing;

“Change Form” means a written agreement between the Parties in respect of a

required modification to the Agreement substantially in the form set out
in Schedule 2 to this Agreement;

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“Controller” means a “controller” for the purposes of the General Data Protection
Regulation (GDPR) Regulation (EU) 2016/679 and “data controller” for
the purposes of all other Data Protection Laws (as such legislation is
applicable);

“Data Protection Laws” means all Applicable Laws relating to the processing of Personal
Information and privacy;

“Excluded Activities” means any activities listed in Recipient’s Grant application that will not
be supported by the Grant and that are identified as such in Schedule
1 to this Agreement;

“Expiry Date” means the day immediately following the date of ViiV’s approval of the
Final Grant Report to be delivered by Recipient under this Agreement;

“Government Official” (where ‘government’ means all levels and subdivisions of

governments, i.e. local, regional, national, administrative, legislative,
executive, or judicial, and royal or ruling families) means: (a) any officer
or employee of a government or any department, agency or
instrumentality of a government (which includes public enterprises,
and entities owned or controlled by the state); (b) any officer or
employee of a public international organisation such as the World Bank
or United Nations; (c) any officer or employee of a political party, or
any candidate for public office; (d) any person defined as a government
or public official under applicable local laws (including but not limited
to anti-bribery and corruption laws) and not already covered by any of
the above; and/or (e) any person acting in an official capacity for or on
behalf of any of the above. “Government Official” shall include any
person with close family members who are Government Officials (as
defined above) with the capacity, actual or perceived, to influence or
take official decisions affecting ViiV business;

“Grant” means the financial support awarded under and pursuant to this
Agreement, the amount of which is specified in Schedule 1 to this
Agreement;

“Key Performance Indicators” means the key performance indicators set out in Schedule 1 to this
Agreement against which progress of the Project is measured;

"Losses" means all losses, claims, liabilities, costs, awards, fines, penalties,
expenses (including but not limited to reasonable legal fees and other
professional expenses) and damages of any nature whatsoever, in
each case reasonably foreseeable or avoidable;

“Personal Information” means information relating to an identified or identifiable individual;

“Project” means the project described in Schedule 1 to this Agreement;

“Purpose” has the meaning ascribed to it in Clause 3 of this Agreement;

“Reports” means the reports required to be delivered by Recipient to ViiV under

this Agreement, and “Report” shall be construed accordingly;

“Sanctions & Trade Controls” has the meaning ascribed to it in Clause 12.7 of this Agreement;

“Technical Assistance” means non-financial support in relation to the Project provided by a

Third Party chosen by Recipient (the “Technical Assistance
Provider”);

“Term” has the meaning ascribed to it in Clause 16;

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 “Third Party” means any person other than a Party;

“VAT” means any taxation levied by reference to added value or sales;

“ViiV Healthcare Positive Action has the meaning ascribed to it in Clause 7.1;
Marks”

“ViiV TA Contact” means the individual specified as the ViiV TA Contact in Schedule 1 to
this Agreement, or such other person as ViiV may from time to time
notify to Recipient in writing; and

“Working Day” means a day (other than a Saturday, Sunday or public holiday in
England).

2. GENERAL TERMS
2.1 ViiV awards the Grant to Recipient subject to the terms and conditions of this Agreement.
2.2 Recipient shall at all times undertake the activities under the Project with all due professional diligence, skill and
care and in strict compliance with all Applicable Laws.
2.3 Recipient represents and warrants that (i) the value of the Grant to be received by Recipient in any calendar
year taken together with other financial support from the ViiV Healthcare group of companies in such calendar
year will be no more than [twenty-five percent (25%)/fifty percent (50%)] of the total amount of funding that
Recipient receives or anticipates receiving in such calendar year and that (ii) should this position change at any
time during the Term, Recipient shall immediately inform ViiV of the same.
2.4 Recipient represents and warrants that in entering into this Agreement it perceives no actual or potential conflict
of interest regarding the receipt of the Grant, or that it has disclosed any such conflict of interest to ViiV and has
resolved it through Recipient’s normal conflict clearance and disclosure process;
2.5 The Parties acknowledge that ViiV is not in any way providing the Grant to promote or reward the selection,
prescription, recommendation, favouring, dispensing, use, purchase or reimbursement of any ViiV products, or
to gain any other commercial advantage.
2.6 Nothing in this Agreement shall prevent Recipient from working with any Third Party and Recipient shall be at
liberty to disclose to such Third Party that it has received the Grant from ViiV.

3. USE OF GRANT
3.1 Recipient shall use the Grant in accordance with the budget template submitted in Recipient’s Grant application
(as amended and agreed between the Parties during the Grant approval process, where applicable) and for the
sole purpose of Recipient undertaking the agreed activities under the Project (the “Purpose”), and not for any
other purpose or activity.
3.2 Notwithstanding Clause 3.1, Recipient represents and warrants that:
i) the Grant will not be used for entertainment, recreation or lavish accommodations or benefits that are
disproportionate to the Purpose;
ii) the Grant will not be used for anti-retroviral (ARV) treatment of people living with HIV, or for purchasing or
prescribing of HIV prescription medicines (for the avoidance of doubt, “treatment” does not include HIV
testing, diagnosis services or other supportive care);

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 iii) the Grant will not be used to support any Excluded Activities; and
iv) the Grant will not be passed in whole or in part, directly or indirectly, to any Third Party as a rebate or
discount for the purchase of ViiV products.

4. PAYMENT OF GRANT
4.1 The Grant is stated in Pounds Sterling and exclusive of VAT and other applicable indirect taxes or duties.
4.2 Subject to Recipient’s compliance with its obligations under this Agreement, payment of the Grant will be made
by ViiV or CAF (to be decided by ViiV at its sole discretion) in three instalments as follows:
a) First Instalment (as set out in Schedule 1) will be authorised by ViiV on the execution of this Agreement by
both Parties, and where payment is made by CAF, be contingent on Recipient’s agreement to CAF’s terms
and conditions of payment; and
b) Second and Third Instalments (as set out in Schedule 1) will be authorised by ViiV on approval by ViiV of
the First and Second Annual Reports, respectively, and be contingent on (i) Recipient providing CAF or ViiV
all documentation CAF or ViiV reasonably considers necessary to undertake due diligence verifications on
Recipient and (ii) Recipient fulfilling any CAF or ViiV due diligence verifications as determined by CAF or
ViiV at their sole discretion.
4.3 Recipient acknowledges that:
i) payment of First and Second Instalments, once authorised by ViiV, may take up to six (6) weeks, and
payment of the Third Instalment, once authorised by ViiV, may take up to ten (10) weeks, to reach
Recipient’s chosen bank account; ViiV will use reasonable endeavours to ensure compliance with such
timelines but shall in no event be liable for late payment; and
ii) the timeline may increase significantly in the event Recipient is delayed in providing the necessary
documentation to CAF or ViiV (as applicable).
4.4 Where payment of the Grant is made by ViiV, payment will be made in Pounds Sterling. Where payment of the
Grant is made by CAF, Recipient may choose to be paid in Pounds Sterling, US Dollars, Euros, or local currency,
in which case the Grant will be converted into the chosen currency by CAF at the currency exchange rate
provided to it by its bank on the date the payment is made. No adjustment will be made to the amount of the
Grant where there has been any fluctuation in currency exchange rates between the Effective Date and date of
payment. ViiV acknowledges that any significant fluctuation in currency exchange rates may affect the ability of
Recipient to undertake the Project and the Parties shall discuss in good faith any reasonable adjustments to the
Project if such a situation arises.
4.5 ViiV may at its sole discretion and at any time withhold or suspend payment of the Grant pending any
investigation into Recipient’s breach or potential breach of this Agreement.

5. KEY PERFORMANCE INDICATORS

Project progress under this Agreement shall be measured against the Key Performance Indicators. Recipient
shall use all reasonable endeavours to make reasonable progress against the Key Performance Indicators
throughout the Project term.

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6. REPORTS
6.1 Recipient shall submit to ViiV the Reports listed below on or before the relevant due date using Recipient’s
account on the CyberGrants platform through which it submitted its application for the Grant, or by any other
method indicated by ViiV at its sole discretion.

Reports Project period to be covered Due date

by Reports

First Intermediary Report (narrative) in the Project months 1-6 6 months and 1 week
form of and containing the information set after the Effective Date
out in Schedule 4

First Annual Report (narrative and Project months 1-12 13 months after the
financial) in the form of and containing the Effective Date
information set out in Schedules 4 and 5

Second Intermediary Report (narrative) in Project months 13-18 18 months and 1 week
the form of and containing the information after the Effective Date
set out in Schedule 4

Second Annual Report (narrative and Project months 13-24 25 months after the
financial) in the form of and containing the Effective Date
information set out in Schedules 4 and 5

Third Intermediary Report (narrative) in Project months 25-30 30 months and 1 week
the form of and containing the information after the Effective Date
set out in Schedule 4

Final Grant Report (narrative and Project months 1-36 37 months after the
financial) in the form of and containing the Effective Date
information set out in Schedules 4 and 5

6.2 Following submission of each Report by Recipient, ViiV shall review the Report and assess Project progress
against the Key Performance Indicators. Within fifteen (15) Working Days of submission of the Report, ViiV
shall indicate to Recipient whether it wishes to discuss the Report and/or Project with Recipient, and Recipient
shall make itself available (over the telephone or video conferencing facilities) for such discussion at ViiV’s
request.
6.3 Within five (5) Working Days of the discussion referred to under Clause 6.2 above, or twenty (20) Working Days
of the submission of a Report (or re-submission under Clause 6.3ii)) whichever is latest, ViiV shall inform
Recipient that it either:
i) approves the Report as submitted; or
ii) if the Report provides insufficient information or is otherwise not of a suitably high standard, rejects the
Report as submitted providing reasons for such rejection. Recipient shall update and re-submit the Report
within five (5) Working Days of such notification, or such other period as ViiV and Recipient may agree.
6.4 If upon review of a Report and/or discussion between the Parties, ViiV, in its reasonable opinion, assesses that
Recipient has failed to demonstrate reasonable progress against the Key Performance Indicators ViiV may, at

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 its sole discretion, withhold payment of further Grant under this Agreement and/or terminate this Agreement (in
accordance with Clause 17).

6A. TECHNICAL ASSISTANCE

6A.1 This Clause 6A shall apply where the Grant includes Amplify Impact Funding.
6A.2 Recipient hereby grants ViiV the right to discuss the Project and the Technical Assistance with the Technical
Assistance Provider.
6A.3 Recipient shall enter into a written agreement with the Technical Assistance Provider regarding the provision of
the Technical Assistance funded by the Amplify Impact Funding (the “Technical Assistance Agreement”) prior
to any such provision.
6A.4 Recipient shall grant the Technical Assistance Provider the right in the Technical Assistance Agreement to
discuss the Project and the Technical Assistance with ViiV.
6A.5 Recipient shall use reasonable efforts to ensure that the Technical Assistance Provider contractually agrees in
the Technical Assistance Agreement:
i) To meet (over the telephone or video conferencing facilities or otherwise) with the ViiV TA Contact prior
to the provision of any Technical Assistance to Recipient to discuss such provision;
ii) To meet (over the telephone or video conferencing facilities or otherwise) with the ViiV TA Contact
promptly after expiry or earlier termination of the Technical Assistance Agreement to discuss the
Technical Assistance provided to Recipient pursuant to that agreement;
iii) To consider promptly and in good faith all suggestions and recommendations made by the ViiV TA
Contact at any time;
iv) Promptly to answer any questions the ViiV TA Contact may ask at any time to the reasonable
satisfaction of the ViiV TA Contact;
v) To provide Recipient with a written report, not earlier than six (6) months and not later than twelve (12)
months after the Effective Date (of this Agreement), detailing the Technical Assistance provided to
Recipient during the term of the Technical Assistance Agreement up to the date of that report;
vi) If it has provided Recipient with any further Technical Assistance not detailed in the report referenced
in Clause 6A.5(v), to provide Recipient with a further written report, not earlier than eighteen (18) months
and not later than twenty-four (24) months after the Effective Date (of this Agreement), detailing all such
Technical Assistance provided to Recipient up to the date of the further written report; and
vii) To permit Recipient to provide such reports and any information therein to ViiV.
6A.6 Recipient shall, promptly after entering into the Technical Assistance Agreement, inform ViiV in writing of the
name and contact details (including contact email address) of the Technical Assistance Provider.
6A.7 Recipient shall, upon ViiV’s request, promptly provide to ViiV copies of the reports referenced in Clause 6A.5,
provided that Recipient is permitted to do so under the Technical Assistance Agreement.
6A.8 References in this Clause 6A to the ViiV TA Contact include his or her nominee.

7. USE OF ViiV HEALTHCARE POSITIVE ACTION NAME AND LOGO

7.1 Subject to Recipient’s compliance with its obligations under Clause 8, ViiV hereby grants Recipient a non-
exclusive, fully paid-up, royalty-free, non-assignable licence (without the right to sublicense, save with prior

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 written consent from ViiV) to use, in accordance with ViiV’s brand guidance, the ViiV Healthcare Positive Action
name and logo set out in Schedule 3 (hereafter referred to as the “ViiV Healthcare Positive Action Marks”)
on any materials relating to the Project. For the avoidance of doubt, Recipient is not permitted to use the words
“ViiV Healthcare” in isolation from the words “Positive Action”, and vice versa, on any materials.
7.2 Recipient agrees to provide ViiV, on reasonable request by ViiV from time to time, with samples of the materials
that use any ViiV Healthcare Positive Action Marks, to enable ViiV to ensure compliance with this Agreement.
7.3 Recipient acknowledges that all goodwill associated with the use of the ViiV Healthcare Positive Action Marks
by Recipient vests and shall vest in ViiV and that Recipient shall not by virtue of this Agreement obtain any
rights in the ViiV Healthcare Positive Action Marks other than those expressly set out in this Agreement.
7.4 Recipient undertakes not to commit or omit any act or pursue any course of conduct, or assist any Third Party
in pursuing any course of conduct, which would be likely to:
i) bring any of the ViiV Healthcare Positive Action Marks into disrepute;
ii) damage the goodwill or reputation attaching to any of the ViiV Healthcare Positive Action Marks;
iii) prejudice the validity or enforceability of any of the ViiV Healthcare Positive Action Marks; or
iv) dilute or reduce the value or strength of any of the ViiV Healthcare Positive Action Marks or any registrations
thereof.

8. PUBLICITY AND TRANSPARENCY

Recipient’s rights and obligations

8.1 Recipient shall acknowledge the ViiV Healthcare Positive Action Programme as a supporter of the Project by
use of the phrase “supported by the ViiV Healthcare Positive Action Programme” (the “Acknowledgment”) on
all materials (including but not limited to press releases) relating to the Project.
8.2 Except as provided under Clause 8.3 below, all external communications (including but not limited to press
releases) by Recipient referencing ViiV or a URL or domain name for any ViiV website or web page, or using
the ViiV Healthcare Positive Action Marks, shall be approved beforehand by ViiV, such approval not to be
unreasonably withheld. Recipient shall submit copies of all materials to ViiV for approval at
positiveaction@viivhealthcare.com, before printing (in the case of printed materials) or release (in the case of
electronic materials) of such materials. ViiV shall respond to any such request for approval from Recipient
within fifteen (15) Working Days of receipt of such request, with an approval or a written statement of why the
request is not approved by ViiV.
8.3 Where reference to ViiV in any materials relating to the Project is in the form of, and limited to, the
Acknowledgment, Recipient is not required to submit the materials to ViiV for approval under Clause 8.2. For
the avoidance of doubt, any variation in the acknowledgment of ViiV’s support from the approved
Acknowledgment is subject to approval by ViiV under Clause 8.2 of this Agreement.

ViiV’s rights and obligations

8.4 ViiV shall be entitled to freely disclose without seeking Recipient’s approval:
i) the amount of Grant and the identity of Recipient as the recipient of the Grant; and

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 ii) all such information that is necessary for ViiV to meet the requirements of its internal policies and
obligations under the Association of the British Pharmaceutical Industry and European Federation of
Pharmaceutical Industries and Associations Codes of Practice.
8.5 In addition to the rights under Clause 8.4 for which ViiV is not required to seek approval from Recipient, and
subject to compliance with its obligations regarding approval under Clause 8.6 below, ViiV shall have the right
to:
i) use the Reports (or excerpts thereof) for non-promotional purposes (appropriately acknowledging Recipient
as the author of the Report(s)); and
ii) make any other disclosures and/or external communications concerning the Project (including but not
limited to publishing or publicising the Grant outcomes).
8.6 Except as provided under Clause 8.4 of this Agreement, all external communications by ViiV regarding the
Project, including but not limited to any external communications using the Reports or Recipient’s name, shall
be approved beforehand by Recipient, such approval not to be unreasonably withheld. ViiV shall submit copies
of all such communications to Recipient for approval at [insert email address/postal address] before printing (in
the case of printed materials) or release (in the case of electronic materials) of such external communications.
Recipient shall respond to any such request for approval from ViiV within fifteen (15) Working Days of receipt
of such request, with an approval or a written statement of why the request is not approved by Recipient.

9. DATA PROTECTION
9.1 ViiV and Recipient acknowledge that the status of each Party is a question of fact determined under Data
Protection Laws. Without limiting the foregoing, ViiV and Recipient each understand that, in relation to the
Personal Information processed under or in connection with this Agreement, each Party independently
determines how and why such Personal Information is processed by that Party (and accordingly each Party
acts as a Controller of that Personal Information).
9.2 In relation to the processing of all Personal Information, each Party:
(a) shall comply with its obligations under Data Protection Laws; and
(b) acknowledges that it is (as between the Parties) solely responsible for meeting all of its obligations under
Data Protection Laws.
9.3 Recipient shall not include any Personal Information (including but not limited to photos of individual(s)) in any
Reports.

10. COMPLIANCE WITH APPLICABLE LAWS

10.1 Each Party agrees that it shall comply fully at all times with all Applicable Laws, including but not limited to anti-
corruption laws, and that it has not, and covenants that it will not, in connection with the performance of this
Agreement, directly or indirectly, make, promise, authorise, ratify or offer to make, or take any act in furtherance
of any payment or transfer of anything of value for the purpose of influencing, inducing or rewarding any act,
omission or decision to secure an improper advantage; or improperly assisting it or the other Party in obtaining
or retaining business, or in any way with the purpose or effect of public or commercial bribery, and warrants that
it has taken reasonable measures to prevent subcontractors, agents or any other Third Parties, subject to its
control or determining influence, from doing so. For the avoidance of doubt this includes facilitating payments,

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 which are unofficial, improper, small payments or gifts offered or made to government officials to secure or
expedite a routine or necessary action to which we are legally entitled.
10.2 Each Party shall inform the other Party in writing, if, during the course of this Agreement, it is convicted of or
pleads guilty to a criminal offence involving fraud or corruption or becomes the subject of any government
investigation for such offenses, or is listed by any government agency as debarred, suspended, proposed for
suspension or debarment, or otherwise ineligible for government programs.
10.3 Recipient shall not contact, or otherwise knowingly meet with any Government Official for the purpose of
discussing activities arising out of or in connection with this Agreement, without the prior written approval of ViiV
and, when requested by ViiV, only in the presence of a designated representative of ViiV. Notwithstanding the
foregoing, Recipient may contact and/or consult with such Government Officials as listed in and for such specific
purposes as set out in Schedule 1 (Project) to the extent that such contact is required to fulfil the objectives of
the Project.
10.4 Recipient represents and warrants that except as disclosed to ViiV in writing prior to the commencement of this
Agreement: (1) none of its significant shareholders (>25% shareholding) or senior management have influence
over ViiV’s business; (2) no significant shareholders (>25% shareholding), members of senior management
team, members of the Board of Directors, or key individuals who will be responsible for the Project, are currently
or have been in the past two years a Government Official with actual or perceived influence which could affect
ViiV’s business; (3) it is not aware of any immediate relatives (e.g. spouse, parents, children or siblings) of the
persons listed in the previous subsection (2) having a public or private role which involves making decisions
which could affect ViiV’s business or providing services or products to, or on behalf of ViiV; (4) it does not have
any other interest which directly or indirectly conflicts with its proper and ethical performance of this Agreement;
and (5) it shall maintain arm’s length relations with all Third Parties with which it deals for or on behalf of ViiV in
performance of this Agreement. Recipient shall inform ViiV in writing at the earliest possible opportunity of any
conflict of interest as described in this Clause 10 that arises during the performance of this Agreement.
10.5 Each Party shall ensure that all transactions under the Agreement are properly and accurately recorded in all
material respects on its books and records and each document upon which entries such books and records are
based is complete and accurate in all material respects. Each Party must maintain a system of internal
accounting controls reasonably designed to ensure that it maintains no off-the-books accounts.
10.6 Each Party agrees that in the event that the other Party believes that there has been a possible violation of the
terms of this Agreement, the Party may make full disclosure of such belief and related information at any time
and for any reason to any competent government bodies and their agencies, and to whomsoever the Party
determines in good faith has a legitimate need to know.

11. ENVIRONMENT, HEALTH AND SAFETY

Recipient shall:
(i) implement, or already has implemented, an Environment, Health and Safety (“EHS”) policy and risk-based
management system with a commitment to provide a safe and healthy workplace and protect the
environment;
(ii) ensure there is at least one senior executive with responsibility for EHS and the organisation has access to
technical expertise to support it in meeting EHS legal obligations;

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 (iii) disclose and report proactively to ViiV on incidents requiring notification to EHS regulators and any
associated fines, prosecutions or civil actions;
(iv) provide relevant information, education and training to workers on the hazards, risks and controls associated
with their job; and
(v) provide and maintain emergency detection systems and an effective response capability.

12. REPRESENTATIONS, WARRANTIES AND INDEMNIFICATION

12.1 Each Party warrants to the other that it has the necessary right and authority to enter into this Agreement and
that the execution, performance and delivery of this Agreement will not conflict with any obligation to which any
of the Parties is subject;
12.2 Subject to Clause 13, and in addition to any other remedies which may be available to ViiV by law or under this
Agreement, Recipient shall indemnify, defend and hold ViiV, its officers, directors, agents and employees
harmless from and against all Losses suffered or incurred by ViiV arising out of or in connection with (a)
Recipient’s material breach of this Agreement, including but not limited to any breach by Recipient of any
warranty, representation, promise or undertaking made by Recipient under this Agreement, or (b) any
negligence or wilful misconduct by Recipient.
12.3 Unless otherwise required or prohibited by law, Recipient warrants that in relation to its performance of this
Agreement:
i) it does not employ, engage or otherwise use any child labour in circumstances such that the tasks
performed by any such child labour could reasonably be foreseen to cause either physical or emotional
impairment to the development of such child;
ii) it does not use forced labour in any form (prison, indentured, bonded or otherwise) and its employees are
not required to lodge original identification papers or monetary deposits on starting work;
iii) it provides a safe and healthy workplace, presenting no immediate hazards to its workers. Any housing
provided by Recipient to its workers is safe for habitation;
iv) it provides access to clean water, food, and emergency healthcare to its workers in the event of accidents
or incidents at its workplace;
v) it does not discriminate against any workers on any ground (including but not limited to race, religion,
disability, gender, sexual orientation or gender identity);
vi) it does not engage in or support the use of corporal punishment, mental, physical, sexual or verbal abuse
and does not use cruel or abusive disciplinary practices in the workplace;
vii) it pays each employee at least the minimum wage, or a fair representation of the prevailing industry wage,
(whichever is the higher) and provides each employee with all legally mandated benefits;
viii) it complies with the laws on working hours and employment rights in the countries in which it operates; and
ix) it is respectful of its employees’ rights to join and form independent trade unions and freedom of
association.
12.4 Recipient is responsible for controlling its own supply chain and shall encourage compliance with ethical
standards and human rights by any subsequent supplier of goods and services that are used by Recipient when
performing its obligations under this Agreement.

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12.5 Recipient shall ensure that it has ethical and human rights policies and an appropriate complaints procedure to
deal with any breaches of such policies. In the case of any complaints, Recipient shall report the alleged
complaint and proposed remedy to ViiV.
12.6 ViiV reserves the right upon reasonable notice (unless inspection is for cause, in which case no notice shall be
necessary) to enter upon Recipient’s premises to monitor compliance with the provisions of Clauses 12.3, 12.4
and 12.5, and Recipient shall, subject to compliance with Applicable Laws, provide to ViiV any relevant
documents requested by ViiV in relation thereto.
12.7 Recipient represents and warrants that it is aware of and, in carrying out its obligations under this Agreement,
will comply at all times with and not become exposed to penalties under Sanctions & Trade Controls (i.e., all
sanctions, export control, and anti-boycott laws, regulations, orders, directives, designations, licenses, and
decisions of the European Union, the United Kingdom, the United States of America, and of any other country
with jurisdiction over activities undertaken in connection with this Agreement).
12.8 Recipient represents and warrants that at all times, in the performance of its obligations under this Agreement,
it will not take any action that causes ViiV to violate or otherwise become exposed to penalties under any
Sanctions & Trade Controls.
12.9 ViiV shall not be required to take or refrain from taking any action, nor shall it be required to furnish any
information, that would be prohibited or penalisable under any Sanctions & Trade Controls.

13. LIMITATION OF LIABILITY

13.1 ViiV shall not be in any way liable or responsible for any Losses that may arise out of or in connection with this
Agreement.
13.2 Except in relation to any Third Party claims against ViiV, Recipient’s maximum aggregate liability under or in
connection with this Agreement whether in contract, tort (including but not limited to negligence) or otherwise,
will in no circumstance exceed the total value of the Grant payable to Recipient under this Agreement.

14. RECORDS, INSPECTION AND AUDIT

14.1 Recipient shall keep complete, accurate and systematic records of all transactions under this Agreement
together with any related documentation during the Term and for a period of three (3) years following the expiry
or termination of this Agreement.
14.2 At ViiV's request, Recipient shall provide to ViiV proper and audit-worthy itemisation and documentation on the
use of the Grant, to ensure that such use is consistent with the Purpose.
14.3 ViiV shall have the right during the Term and for a period of three (3) years following the expiry or termination
of this Agreement to conduct an audit of Recipient’s activities under this Agreement to monitor compliance with
the terms of this Agreement, including but not limited to Recipient’s use of the Grant. Recipient shall cooperate
fully with such audit, the scope, method, nature and duration of which shall be at the sole reasonable discretion
of ViiV.

15. NOTICES
15.1 Any notice made under, or in connection with the matters contemplated by, this Agreement shall only be
effective if it is in writing.
12
15.2 Any such notice shall be sent to a Party at its address and for the attention of the individual set out below:
If to ViiV:
Attention: Head of ViiV Healthcare Positive Action Programme,
Address: 980 Great West Road, Brentford, Middlesex, TW8 9GS, United Kingdom
With a copy to be sent via email to positiveaction@viivhealthcare.com
If to Recipient:
Attention: [PLEASE INSERT DETAILS]
Address: [PLEASE INSERT DETAILS]
15.3 Any notice or communication given or made under, or in connection with the matters contemplated by, this
Agreement shall be deemed to have been duly given as follows:
(a) if delivered personally, on delivery;
(b) if sent by overnight courier service, two (2) clear Working Days after the date of posting; and
(c) if sent by airmail, seven (7) clear Working Days after the date of posting.
15.4 A Party may change its address details for receipt of notices by notice to the other Party. Such change shall
take effect on the Working Day after that notice is deemed given pursuant to this Clause.
15.5 Except as provided under this Agreement, a notice given under this Agreement is not valid if sent by fax or by
email. However, this is not intended to prohibit the use of email for day to day operational communications
between the Parties.

16. TERM
This Agreement shall come into force and effect on the Effective Date, and subject to the provisions of Clause
17 (Termination), shall remain in force until the Expiry Date (the “Term”).

17. TERMINATION

Termination by either Party

17.1 Without affecting any other right or remedy available to it, each Party shall be entitled to terminate this
Agreement immediately on written notice to the other Party if:
i) the other Party commits a material breach of any term of this Agreement which breach is irremediable or
(if such breach is remediable) which that Party fails to remedy within a period of thirty (30) days after being
notified in writing to do so;
ii) the other Party fails to perform its obligations in accordance with Clause 10 (Compliance with Applicable
Laws); or
iii) the other Party becomes insolvent, or proceedings are instituted against the other Party for winding up or
reorganisation or other relief under any insolvency law; or any substantial part of the other Party’s assets
comes under the jurisdiction of a receiver, administrator, liquidator, trustee or similar officer in an insolvency
proceeding authorised by law (an “Insolvency Event”).

13
 Termination by ViiV
17.2 Without affecting any other right or remedy available to it, ViiV shall be entitled to terminate this Agreement
immediately on written notice to Recipient if:
i) upon review of a Report and/or discussion between the Parties, ViiV, in its reasonable opinion, assesses
that Recipient has failed to demonstrate reasonable progress against the Key Performance Indicators,
which failure is irremediable;
ii) there is a material change in the status of Recipient and/or the Project affecting Recipient’s ability to
undertake its obligations under this Agreement, as determined by ViiV at its sole discretion;
iii) Recipient obtains duplicate funding from a Third Party for the Project;
iv) in ViiV’s sole discretion, Recipient breaches any of Clauses 12.7, 12.8 or 12.9 or, in ViiV’s sole discretion,
ViiV’s performance of its obligations pursuant to this Agreement may breach or be penalisable under
Sanctions & Trade Controls (whether or not in existence at the date of this Agreement and whether or not
there have been any other changes in circumstance from those that existed at the date of this Agreement);
v) Recipient or any member of the governing body, employee or volunteer of Recipient:
(a) has acted dishonestly or fraudulently in any way, or negligently in respect of any material matter, in
each case in connection with this Agreement; or
(b) has taken any action which, in the reasonable opinion of ViiV, brings or is likely to bring ViiV’s name
or reputation into disrepute.
17.3 Without affecting any right or remedy available to the Parties, in the event that either Party is dissolved, this
Agreement will automatically terminate with immediate effect.

18. EXPIRY AND EFFECT OF TERMINATION

18.1 On expiry of this Agreement, Recipient shall return any remaining unused Grant to ViiV within sixty (60) days of
the Expiry Date.
18.2 On termination of this Agreement by ViiV pursuant to Clauses 17.1i), 17.1ii), or 17.2v) the Grant shall become
immediately repayable to ViiV; such repayment shall be of an amount proportionate to the severity of the act or
breach, up to a maximum of 100% of the Grant, as determined by ViiV at its sole discretion.
18.3 On termination of this Agreement by ViiV pursuant to Clauses Error! Reference source not found.17.2i),
17.2ii) or 17.2iv), any unused and uncommitted Grant as at the date of termination shall become repayable to
ViiV within sixty (60) days of the termination date. Further, on termination of this Agreement by ViiV pursuant to
Clause 17.2iv), ViiV shall not be obliged to make any payments, indemnify, or otherwise provide compensation
to Recipient subsequent to the termination of this Agreement.
18.4 On termination of this Agreement by ViiV pursuant to Clauses 17.2iii), 100% of the Grant shall become
immediately repayable to ViiV.
18.5 On termination of this Agreement by ViiV pursuant to Clauses 17.1iii), any unused and uncommitted Grant as
at the date of the Insolvency Event (as defined under Clause 17.1iii)) shall become immediately repayable to
ViiV.
18.6 On termination of this Agreement by either Party pursuant to Clause 17, each Party shall discontinue any use
of the other Party’s trade marks in any materials and communications in relation to the Grant, unless agreed
otherwise by the Party who owns the marks at their sole discretion.
14
18.7 On termination of this Agreement by a Party pursuant to Clause 17, the other Party shall have no claim against
that Party for compensation for any loss of whatever nature by virtue of the termination of this Agreement.
18.8 Termination of this Agreement shall not release either Party from any obligation or right which accrued to that
Party prior to the termination date or which later accrues from an act or omission which occurred prior to the
termination date.

19. WAIVER
Any delay in enforcing a Party’s rights under this Agreement or any notice of waiver (only effective if in writing
and signed) as to a particular default or other matter shall not constitute a waiver of such Party’s rights with
regard to the future enforcement of its rights under this Agreement.

20. ENTIRE AGREEMENT

20.1 This Agreement constitutes the entire agreement and understanding between the Parties hereto with respect
to the subject matter of this Agreement and supersedes and extinguishes any and all prior agreements,
promises, assurances, warranties, representations and understandings between the Parties, whether oral or
written, relating to such matter. No course of dealing or usage of trade shall be used to modify the terms of this
Agreement.
20.2 Each party acknowledges that in entering into this Agreement it does not rely on, and shall have no remedies
in respect of, any statement, representation, assurance or warranty (whether made innocently or negligently)
that is not expressly set out in this Agreement. No Party shall have any claim for innocent or negligent
misrepresentation on the basis of any statement in this Agreement.

21. AMENDMENT AND VARIATION

An amendment or variation of this Agreement shall be made in writing by means of a Change Form executed
by both Parties.

22. SURVIVAL
Any provisions in this Agreement which by their nature or effect are required or intended to survive, will survive
the expiration or termination of this Agreement.

23. FORCE MAJEURE

If either Party is delayed in performing an obligation under this Agreement by strike lockout, or other labour
troubles of a Third Party; by restrictive governmental or judicial order not directly related to this Agreement; by
pandemic or epidemic (other than HIV epidemic); or by riots, insurrection, war, inclement weather, or Acts of
God; performance is excused for the period of such delay. The delayed Party shall promptly notify the other in
writing of the delaying event and any actions taken to mitigate its effects.

15
24. ASSIGNMENT
ViiV may assign its rights and duties under this Agreement without Recipient’s consent. Any assignment of the
performance of any obligations under this Agreement by Recipient is valid only upon the prior written consent
of ViiV. To the extent permitted above, this Agreement shall be binding upon and inure to the benefit of the
Parties and their permitted successors and assigns.

25. RELATIONSHIP OF PARTIES

25.1 Nothing in this Agreement is intended to, or shall be deemed to, establish any partnership or joint venture
between the Parties, constitute a Party the agent of the other Party, or authorise a Party to make or enter into
any commitments for or on behalf of the other Party.
25.2 Each Party confirms it is independent of the other and is acting on its own behalf and not for the benefit of any
other person.

26. COUNTERPARTS
26.1 This Agreement may be signed in counterparts each executed by at least one of the Parties. Each counterpart
will be an original and all counterparts taken together will constitute one instrument.
26.2 An executed counterpart of this Agreement (the entire Agreement, not just a signature page) may be delivered
by e-mail (in PDF or other agreed format).

27. THIRD PARTY RIGHTS

A person who is not a Party to this Agreement has no right to enforce any of its terms.

28. DISPUTE RESOLUTION

28.1 The Parties wish to facilitate the resolution of any dispute arising out of or relating to this Agreement including
but not limited to the breach, termination, interpretation or validity thereof (a “Dispute”) in an expedient manner
by mutual cooperation and agree to follow the procedures set forth in this Clause 28 to resolve any such Dispute.

28.2 ESCALATION – If a Dispute cannot be resolved between the Parties within thirty (30) days of written notice by
one Party to the other, such Dispute shall be referred in writing to the Parties’ respective executive officers or
their designees for attempted resolution by good faith negotiations which shall take place within thirty (30) days
after such referral (or within such other time period as may be agreed by the Parties in writing).

28.3 MEDIATION – Any Dispute remaining unresolved thirty (30) days (or such other time period as may be agreed
by the Parties in writing) after referral to the Parties’ executive officers pursuant to Clause 28.2 shall first be
submitted to mediation in accordance with the fast track mediation rules of procedure of the International
Institute for Conflict Prevention and Resolution (“CPR”) in effect as of the date the mediation is initiated. Such
mediation shall be attended on behalf of each Party for at least one session by a senior executive with authority
to resolve the dispute and shall be held in London, UK. Unless otherwise agreed by the Parties, the Parties
shall select a mediator from the CPR Panel of Distinguished Neutrals. If the Parties cannot agree on the

16
 selection within fourteen (14) days after the matter has been referred to mediation, they will defer to the CPR to
select a mediator pursuant to the CPR rules.

28.4 ARBITRATION – Either party may refer any Dispute not resolved by mediation within forty-five (45) days (or
within such other time period as may be agreed by the Parties in writing) after the appointment of the mediator,
for resolution by final and binding arbitration conducted in accordance with the Rules of Arbitration of the
International Chamber of Commerce (the “ICC Rules”) provided that to the extent that the following provisions
of this Clause conflict with the said ICC Rules the following provisions shall prevail:
i) the arbitration shall be conducted by a sole arbitrator;
ii) the seat of the arbitration shall be London;
iii) the language of the arbitration shall be English;
iv) the decision of the arbitrator shall be final and binding on both Parties;
v) judgment upon the arbitration award may be entered by any court having jurisdiction thereof or having
jurisdiction over the relevant Party and its assets; and
vi) all documents and proceedings in any arbitration pursuant to this Clause 28.4 shall be confidential and all
hearings shall be held in private, save to the extent necessary to enforce any award or to comply with any
requirement of any lawful authorities. No public statement shall be made with regard to any arbitral
proceedings save to the extent agreed between the Parties in writing.

28.5 INJUNCTIVE RELIEF – Notwithstanding the foregoing, nothing in this Clause 28 shall be construed as
precluding a Party from bringing an action in court for interim injunctive relief or other interim equitable relief.

29. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of England and Wales without
reference to conflict of law principles.

This Agreement has been entered into:

For and on behalf of ViiV Healthcare UK Limited For and on behalf of [PLEASE INSERT FULL
LEGAL NAME OF RECIPIENT]

Signature: ______________________________
Name: [IMPORT] Signature: _____________________________
Position: [IMPORT] Name: [IMPORT]
Date: [IMPORT] Position: [IMPORT]
Date: [IMPORT]

17
 SCHEDULE 1
PROJECT DESCRIPTION

Day to day contacts

The day to day contacts for each Party for the Project are:
- ViiV: [INSERT CONTACT NAME AND EMAIL]
- Recipient: [INSERT CONTACT NAME AND EMAIL]

Where the Grant includes Amplify Impact Funding, the ViiV TA Contact is: [INSERT CONTACT NAME
AND EMAIL]

Title of the Grant

[INSERT TITLE]

Project Outline

Overall goal(s) of Project:

[Import overall objective from cybergrants/grant manager to insert]

Project specific objectives:

[to be imported from application]

Project summary:
[to be imported from application]

Excluded Activities:

The Grant shall not be used for the following activities listed in Recipient’s original Grant application:
[any activity listed in Recipient’s proposal which will not be supported to be inserted here / if no activities
are excluded, insert n/a]

Key Performance Indicators

The following Key Performance Indicators shall be used to measure Project progress:

[IMPORT/INSERT LIST OF KEY PERFORMANCE INDICATORS]

18
Grant

Grant total = [PLEASE INSERT TOTAL AMOUNT OF GRANT] [Pounds Sterling]

First Instalment
Second Instalment
Third Instalment
Project Funding: [PLEASE INSERT AMOUNT OF FIRST
INSTALMENT (Project Funding component only)] [Pounds Sterling]
Amplify Impact Funding: [PLEASE INSERT AMOUNT OF FIRST
INSTALMENT (Amplify Impact Funding component only)] [Pounds
Sterling]
Project Funding: [PLEASE INSERT AMOUNT OF SECOND
INSTALMENT] [Pounds Sterling]
Project Funding: [PLEASE INSERT AMOUNT OF THIRD
INSTALMENT] [Pounds Sterling]

Recipient’s use of Grant

Recipient shall use the Grant in accordance with the budget template submitted in Recipient’s Grant
application (as amended and agreed between the Parties during the Grant approval process, where
applicable).

Authorised interactions with Government Officials

The following interactions with Government Officials shall be permitted under this Agreement:
Government Official Type of interaction Purpose of interaction
[NEED FIELDS IN
QUESTINNAIRE TO FILL THESE
IN]

19
 SCHEDULE 2
CHANGE FORM
CHANGE FORM No.

FROM: TO:

PROPOSED IMPLMENTATION DATE:

DETAILS OF CHANGE

Approved for and on behalf of ViiV Healthcare UK Approved for and on behalf of [INSERT
Limited RECIPIENT LEGAL NAME]

Signature: ____________________________ Signature: ______________________________

Name: Name:

Position: Position:

Date: Date:

20
 SCHEDULE 3

ViiV HEALTHCARE POSITIVE ACTION MARKS

Pursuant to Clause 7.1 of the Agreement, Recipient is permitted to use:

- the following ViiV Healthcare Positive Action name: “ViiV Healthcare Positive Action”; and

- the ViiV Healthcare Positive Action logo available at:

https://www.cybergrants.com/viiv/images/contract_logo.png.

21
 Schedule 4
REPORT CONTENT & FORM: NARRATIVE

Preview Form: Intermediary Report

This is an example of the application questions with which you will be presented. It is recommended
that you compose the answers to the paragraph questions in a word processing program and then
cut and paste that text into the online application.

Request Information

Information below is from your original application. It is for your reference only and cannot be edited.

*Project Title
Instructions:
(Text)(255 character maximum)

Instructions:
Concept
• Describe your project, how it was developed,
(Paragraph)(4000 character maximum)
its key objectives and how it works:

Milestone Narrative

Instructions:
*Progress in Achieving Indicators?
• Are you progressing against achieving your
(Yes/No)
indicators?

Instructions:
Lessons Learned in Monitoring
• What have you learned from the process of
(Paragraph)(4000 character maximum)
monitoring?

*Implementation Progress
Instructions:
(Paragraph)(4000 character maximum)

22
 • What has worked well in the implementation
of the project?

Instructions:
*Implementation Challenges
• What challenges have you faced in the
(Paragraph)(4000 character maximum)
implementation of the project?

Instructions:
Addressing Challenges
• How are you addressing or planning to
(Paragraph)(4000 character maximum)
address these challenges?

Instructions:

*Key Lessons • What are some of the key lessons that you
(Paragraph)(4000 character maximum) have learned and how will you integrate this into
ongoing implementation?

*Changes to Project? Instructions:

(Yes/No) • Are there any changes to the project?

Describe Changes to Project

Instructions:
(Paragraph)(4000 character maximum)

Instructions:
*Amplify Impact Budget Used?
• Have you used your amplify impact budget
(Yes/No)
yet?

Use of Amplify Impact Budget Instructions:

(Paragraph)(4000 character maximum) • How has this been used?

Instructions:
Amplify Impact and Follow Up
• What is the impact and follow up from this
(Paragraph)(4000 character maximum)
intervention?

When will Amplify Impact budget be used?

Instructions:
(Paragraph)(4000 character maximum)

23
 Instructions:
Identifying what is Required
• Have you identified what is required? If yes,
(Paragraph)(4000 character maximum)
please explain. If no, please justify.

*Budget Deviations? Instructions:

(Yes/No) • Are you on track with your budget?

Explain Budget Deviation

Instructions:
(Paragraph)(4000 character maximum)

Instructions:
Other Issues
• Are there any other issues that you would like
(Paragraph)(4000 character maximum)
to highlight or bring to our attention?

*Primary Priority Populations

(Checkbox List)
Instructions:

• Children • Which priority populations has your project

• Adolescent girls (10-19) been working with?
• Adolescent boys (10-19) Please identify those populations who have directly
• Sex workers (female) been impacted by your project.
• Person who uses drugs (female)
• Other

Key Indicators

Please provide final indicators. The first seven indicators are required; the last four are optional.

*# of people directly reached by PA funded

projects Instructions:
(Number)(15 character maximum)

*# of people linked to HIV testing services

Instructions:
(Number)(15 character maximum)

*# of people tested for HIV

Instructions:
(Number)(15 character maximum)

24
*# of people linked to HIV treatment and care
services Instructions:
(Number)(15 character maximum)

*# of people receiving HIV treatment/adherence

Instructions:
literacy services
(Paragraph)(15 character maximum)

*# of people accessing mental wellbeing related

Instructions:
services and/or programmes

*# of service providers trained

Instructions:
(Number)(15 character maximum)

Instructions:
User experience of safe spaces

(Paragraph)(4000 character maximum) • Describe user experience of safe spaces

provided

Instructions:

Changes in Norms/Practices
(Paragraph)(4000 character maximum) • Describe changes per country/context in
norms and practices.

# of people among priority populations and

existing service providers trained (Number)(15 Instructions:
character maximum)

Instructions:
Quality of Collaboration between Community
and Clinic
• Describe the quality of collaboration between
(Paragraph)(4000 character maximum)
community and clinic.

25
Preview Form: Annual / Final Grant Report

This is an example of the application questions with which you will be presented. It is
recommended that you compose the answers to the paragraph questions in a word processing
program and then cut and paste that text into the online application.

Request Information

Information below is from your original application. It is for your reference only and cannot be
edited.

*Project Title
Instructions:
(Text)(255 character maximum)

Instructions:

Concept
(Paragraph)(4000 character maximum) • Describe your project, how it was developed,
its key objectives and how it works:

*Primary Priority Populations

(Checkbox List)
Instructions:

• Children • Which priority populations has your project

• Adolescent girls (10-19) been working with?
• Adolescent boys (10-19) Please identify those populations who have
• Sex workers (female) directly been impacted by your project.
• Person who uses drugs (female)
• Other

Milestone Narrative

26
 Instructions:
*Indicators Achieved
(Yes/No)
• Have you achieved your indicators?

Explanation of Not Achieving Indicators

Instructions:
(Paragraph)(4000 character maximum)

Instructions:

Lessons Learned in Monitoring

(Paragraph)(4000 character maximum) • What have you learned from the process of
monitoring?

Instructions:

*Implementation Progress
(Paragraph)(4000 character maximum) • What has worked well in the implementation
of the project?

Instructions:

*Implementation Challenges
(Paragraph)(4000 character maximum) • What challenges have you faced in the
implementation of the project?

Instructions:

*Key Lessons
• What are some of the key lessons that you
(Paragraph)(4000 character maximum)
have learned and how will you integrate this
into ongoing implementation?

Instructions:
*Use of Amplify Impact Budget
(Paragraph)(4000 character maximum)
• How has this been used?

Instructions:

*Amplify Impact Highlights

(Paragraph)(4000 character maximum) • What worked well in the approach to
technical assistance?

27
 Instructions:

*Amplify Impact Challenges

(Paragraph)(4000 character maximum) • What did not work well with the technical
assistance?

Instructions:

Suggestions for Amplify Impact

• Are there any suggested changes to ensure
(Paragraph)(4000 character maximum)
that the Technical Assistance is more
relevant?

Instructions:
*Full Use of Budget?
(Yes/No)
• Did you fully utilise your budget?

Instructions:

*Sharing Project
(Yes/No) • Are you willing to share your project in a case
study?

Instructions:

Other Issues
(Paragraph)(4000 character maximum) • Are there any other issues that you would
like to highlight or bring to our attention?

Key Indicators

Please provide final indicators. The first seven indicators are required; the last four are optional.

*# of people directly reached by PA funded

projects Instructions:
(Number)(15 character maximum)

*# of people linked to HIV testing services

Instructions:
(Number)(15 character maximum)

28
*# of people tested for HIV
Instructions:
(Number)(15 character maximum)

*# of people linked to HIV treatment and care

services Instructions:
(Number)(15 character maximum)

*# of people receiving HIV

Instructions:
treatment/adherence literacy services
(Paragraph)(15 character maximum)

*# of people accessing mental wellbeing

Instructions:
related services and/or programmes

*# of service providers trained

Instructions:
(Number)(15 character maximum)

Instructions:
User experience of safe spaces

(Paragraph)(4000 character maximum) • Describe user experience of safe spaces

provided

Instructions:

Changes in Norms/Practices
(Paragraph)(4000 character maximum) • Describe changes per country/context in
norms and practices.

# of people among priority populations and

existing service providers trained (Number)(15 Instructions:
character maximum)

Instructions:
Quality of Collaboration between Community
and Clinic
• Describe the quality of collaboration between
(Paragraph)(4000 character maximum)
community and clinic.

29
 Schedule 5
REPORT CONTENT & FORM: FINANCIAL

Positive Action | Financial Report Template

Complete Steps 1 and 2 in full. Once complete, save and upload this document to CyberGrants and
email your Grant Manager.

Positive Action grantees are required to provide a Financial Report covering the full year with each
annual report.

This report should be aligned to the approved project budget submitted during the application process
and should document actual spends vs budgeted spends and provide an explanation for any
discrepancies.

Step 1) Complete the budget template below in GBP (£).

- Please populate the budget rows by using the monthly columns, to access these click on the
"+" above column O, and AB and add in your budget breakdown. The yearly and total columns
will populate automatically
- Please ensure that you scroll to the end of the template, please do not add any additional rows.
- Ensure that the budget is completed in British Pounds.

Budget
Budget
Approved remainder
Budget Line Description spent to Comments
budget (calculates
date
automatically)

a) Staffing costs (related to project):

- Costs related to staff/consultants working on the project and can be
defined as a % of staff time or # of days required. Please note that any full
time employee will have to be justified

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

30
Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

b) Travel costs:
- Costs related to project staff travel for project related activities

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

c) Indirect costs:
- Costs that are required for the effective implementation of the project. This
could include rent, electricity, administration, governance etc. Please note
that this cannot be more than 15% of total budget

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

31
Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

d) Direct costs:
- Costs related to direct implementation of the project funded by Positive
Action. This could include Training, Workshops, mobilisation, linkages, etc

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

e) Advocacy and Communication costs:

- Costs related to advocacy efforts, outreach, social media, media etc

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

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Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

32
f) Monitoring, Evaluation and Learning (MEL):
- Costs related to monitoring and learning implementation activities. A
compulsory fixed amount of £1250 will be allocated from this budget for an
annual linking and learning event. Any evaluation budget will be reviewed
and discussed with your grant manager prior to agreement Please note that
this cannot include staff costs

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

g) Other project related costs:

- Costs related to capacity building, organisational strengthening and
technical assistance. Please note: If you request an AMPLIFY IMPACT budget
a maximum amount of 10% will be added to your overall total budget costs
to meet these needs. Final activities will be agreed with your grant manager
during grant negotiations

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

Enter text here Enter text here £0.00 £0.00 £0.00

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 Enter text here Enter text here £0.00 £0.00 £0.00

TOTAL (calculates automatically)

Ensure these figures match those £0.00 £0.00 £0.00
elsewhere on your application

Step 2) Complete the questions below related to your organisation's budget

In GBP (£), what was your organisation's revenue (income) for the most recent 12month accounting
period?

Enter what this 12month accounting period was, e.g.

- 2019 calendar year (Jan-Dec)

- 2019/20 financial year (1st April- 31st March)

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