OFFICIAL THE WORLD BAIOCUMENTS IBRD * IDA I WORLDBANKGROUP MS. ELLEN GOLDSTEIN Country Director Myanmar, Cambodia, Lao PDR East Asia and Pacific Region November 6, 2017 H.E. Mr. Somdy Douangdy Deputy Prime Minister and Minister Ministry of Finance 23 Singha Road Vientiane, Lao PDR Re: IDFHP Grant No. TF0A5620 (Health Governance and Nutrition Development Project) Additional Instructions: Disbursement Excellency: I refer to the Grant Agreement ("Agreement") between the Lao People's Democratic Republic ("Recipient") and the International Bank for Reconstruction and Development and International Development Association ("World Bank"), acting as administrator of the Integrating Donor-Financed Health Programs Multi-Donor Trust Fund for the above-referenced project, dated November 6, 2017. The Agreement provides that the World Bank may issue additional instructions regarding the withdrawal of the proceeds of IDFHP Grant TF0A5620 This letter ("Disbursement Letter"), as revised from time to time, constitutes the additional instructions. The attached Disbursement Guidelines for Investment Project Financing, dated February 2017, ("Disbursement Guidelines") (Attachment 1), are an integral part of the Disbursement Letter. The manner in which the provisions in the Disbursement Guidelines apply to the Grant is specified below. Sections and subsections in parentheses below refer to the relevant sections and subsections in the Disbursement Guidelines and, unless otherwise defined in this letter, the capitalized terms used have the meanings ascribed to them in the Disbursement Guidelines. I. Disbursement Arrangements (i) Disbursement Methods (section 2). The following Disbursement Methods may be used under the Grant: * Reimbursement * Advance * Direct Payment * Special Commitment (ii) Disbursement Deadline Date (subsection 3.7). The Disbursement Deadline Date is 4 months after the Closing Date specified in the Agreement. Any changes to this date will be notified by the World Bank. (iii) Disbursement Conditions (subsection 3.8). Please refer to the Disbursement Condition(s) in the Agreement. II. Withdrawal of Grant Proceeds (i) Authorized Signatures (subsection 3.1). A letter in the Form attached (Attachment 2) should be furnished to the World Bank at the address indicated below providing the name(s) and specimen signature(s) of the official(s) authorized to sign Applications: The World Bank No. 57, Pyay Road, 6 2 Mile, Hlaing Township, Yangon, Myanmar Attention: Ellen Goldstein Country Director (ii) Applications (subsections 3.2 - 3.3). Please provide completed and signed (a) applications for withdrawal, together with supporting documents, and (b) applications for special commitments, together with a copy of the commercial bank letter of credit, to the address indicated below: The World Bank 26/F, One Global Place 5th Ave. corner 25' Street Bonifacio Global City Taguig City, Philippines Attention: Loan Department (iii) Electronic Delivery (subsection 3.4) The World Bank may permit the Recipient to electronically deliver to the World Bank Applications (with supporting documents) through the World Bank's Client Connection, web-based portal. The option to deliver Applications to the World Bank by electronic means may be effected if: (a) the Recipient has designated in writing, pursuant to the terms of subparagraph (i) of this Section, its officials who are authorized to sign and deliver Applications and to receive secure identification credentials ("SIDC") from the World Bank for the purpose of delivering such Applications by electronic means; and (b) all such officials designated by the Recipient have registered as users of Client Connection. If the World Bank agrees, the World Bank will provide the Recipient with SIDC for the designated officials. Following which, the designated officials may deliver Applications electronically by completing Form 2380, which is accessible through Client Connection (https://clientconnection.worldbank.org). The Recipient may continue to exercise the option of preparing and delivering Applications in paper form. The World Bank reserves the right and may, in its sole discretion, temporarily or permanently disallow the electronic delivery of Applications by the Recipient. (iv) Terms and Conditions of Use of SIDC to Process Applications. By designating officials to use SDIC and by choosing to deliver the Applications electronically, the Recipient confirms through the authorized signatory letter its agreement to: (a) abide by the Terms and Conditions of Use of Secure Identification Credentials in connection with Use ofElectronic Means to Process Applications and Supporting Documentation ("Terms and Conditions of Use of SIDC") provided in Attachment [3]; and (b) to cause such official to abide by those terms and conditions. (v) Minimum Value of Applications (subsection 3.5). The Minimum Value of Applications for Direct Payment, Reimbursement and Special Commitment is USD100,000 equivalent (vi) Advances (sections 5 and 6). * Type of Designated Account (subsection 5.3): Segregated, the same account used under the Original Financing (IDA D0730 and IDA 5676) and the Additional Financing (IDA 6145-LA) * Currency of Designated Account (subsection 5.4): US Dollars * Financial Institution at which the Designated Account Will Be Opened (subsection 5.5): Bank of Lao, PDR * Ceiling (subsection 6.1): forecast for 2 quarters as provided in the Interim Financial Report III. Reporting on Use of Grant Proceeds (i) Supporting Documentation (section 4). Supporting documentation should be provided with each application for withdrawal as set out below: For Part 2 of the Project * For requests for Reimbursement: o Interim Financial Report in the form attached (Attachment 4); and o List of payments against contracts that are subject to the World Bank's prior review, in the form attached (Attachment 5) For Part 4 of the Project * For requests for Reimbursement and reporting eligible expenditures paid from the Designated Account (DA): o Statement of Expenditure in the form attached (Attachment 6); and o List of payments against contracts that are subject to the World Bank's prior review, in the form attached (Attachment 5) o For DA applications, Designated Account Reconciliation Statement in the form attached (Attachment 7) and copy of bank statement * For requests for Direct Payment: records evidencing eligible expenditures, e.g., copies of receipts, supplier invoices (ii) Frequency of Reporting Eligible Expenditures Paid from the Designated Account (subsection 6.3): quarterly IV. Other Disbursement Instructions a) The value of each DLI is set out in the Schedule 4 of the Financing Agreement. The amount for disbursement under each application will be specified in the DLI Achievement Notice. b) Only reimbursement method is applicable. Funds will be disbursed based on the lesser of (i) eligible expenditures related to the IDFHP-financed part and reported in the IFR; and the (ii) value of target DLIs achieved. V. Other Important Information For additional information on disbursement arrangements, please refer to the Disbursement Handbook available on the World Bank's public website at https://www.worldbank.org and its secure website "Client Connection" at https://clientconnection.worldbank.org. Print copies are available upon request. From the Client Connection website, you will be able to download Applications, monitor the near real-time status of the Grant, and retrieve related policy, financial, and procurement information. If you have not already done so, the World Bank recommends that you register as a user of the Client Connection website (https://clientconnection.worldbank.org). From this website you will be able to download Applications, monitor the near real-time status of the Grant, and retrieve related policy, financial, and procurement information. All Recipient officials authorized to sign and deliver Applications by electronic means are required to register with Client Connection before electronic delivery can be effected. For more information about the website and registration arrangements, please contact the World Bank by email at . If you have any queries in relation to the above, please contact WFALN Manila@worldbank.ore using the above reference. Yours sincer ly, Ellen Goldstein Country Director Myanmar, Laos PDR and Cambodia East Asia and Pacific Region Attachments 1. Disbursement Guidelines for Investment Project Financing, dated February 2017 2. Form for Authorized Signatures 3. Terms and Conditions of Use ofSecure Identification Credentials in connection with Use of Electronic Means to Process Applications and Supporting Documentation, dated March 1, 2013 4. Form of insert Interim Financial Report 5. Form of Payments Against Contracts Subject to the Bank's Prior Review 6. Form of Statement of Expenditure 7. Form of Designated Account Reconciliation Statement Cc with copies: Dr. Founkham Rattanavong Deputy Director General Department of Planning and International Corporation Ministry of Health Vientiane, Lao PDR Tel: 856-21 264086; 20 55509676 Email: rfounkham(gmail.com Dr. Chansaly Phommavong Deputy Director of HGNDP National Program Coordination Office Ministry of Health Vientiane, Lao PDR Tel: 856-21 214058; 20 22002722 Email: hsipchansalvetllao.com Disbursement Guidelines for Investment Project Financing February 2017 WORLD BANKGROUP 1. CONTENTS LIU, I Purpose 1 2 Disbursement Methods 1 3. Withdrawal of Funds from Financing Account 2 4. Supporting Documentation Requirements 3 5. Designated Accounts 4 6 Terms and Conditions Applicable to Advances 6 7. Ineligible Expenditures 7 8. Refunds 8 1. Purpose I 1 The purpose of the Disbursement Guidelines for Investment Project Financing (the guidelines) is to set out the World Bank's procedures and requirements for disbursement of funds in projects.' Specifically. the guidelines set out (a) the different arrangements used by the World Bank to disburse funds from the Financing Account. (b) the requirements for withdrawal from the Financing Account. 1c) the types of supporting documentation that the borromer may be required to pro-ide to demonstrate the use of tinds of the Financing Account for eligible expenditures. (d) the criteria for establishing Designated Accounts', fe) the terms and conditions applicable to advances. (I) the types of disbursement-rclated actions that the World Bank may take if it determines that funds of the Financing Account arc not needed or have been used for ineligible purposes, and Ig) the disbursement consequence of refunds. 2. Disbursement Methods 21 The World Bank establishes disbursement arrangements for a project in consultation with the borrower. taking into consideration. among other things. an assessment of the borrower's financial management and procurement arrangements. the cash 1low needs of the project. and its disbursement experience with the borro%ver. Those arrangements are stated in the Financing Agreement' and additional information is provided in the Disbursement Letter.' 2 2 The World Bank disburses funds from the Financing Account established for cuch loan, to or on the order ofthe borrower, using one or more of the following disbursement methods, as determined by the World Bank. In this document the W11rld BAnk includes the International Bank for Reconstruction and Developient (IBR) and the Inunational Deelopnicnt Association (ID1A. whethcr acting on its own acouni or in the capaciti as administrator of trust funds funded bN donors. Fn in oBnk lan mneludes an; loan, credit, or grant made by the World Bank from its own reonrces. Irom trust fund-, funded hN odher donor, and administered by the World Bank, or from a combination of these Bt)rr,wer means a borrowter or recipient of a Bank loan for a project and an, other entity involved in the imnplementation ofthc projeei financcd i vhe Rank loan These guidelineS applN to all Bank loans for an Investment Proiet Financing. The do not appk; to Program-For-Results Financing and Development Policy Fiancing or tor grants made by the World Bank from trust linds funded b) other doors and adininstered bsn the World Rank. when. exceptionaly. the terms ofl the agreement with the dmior provide for different requirements The Financing Account refers to the account opened b% the World Bank in its accounting system in the name of the horrowur to Ahich the amount of the 1inancing is redited. A 1!xnignaled c,cunrt is a bank account into uhich the World ank may deposit amounts wsithdrawn from the Financing Account to pa; for eligible expenditures as they arc incurred. The Femincing Igrov-nm is the agieemient bemween the World Rank and the Buooer pro% ding for the Bank loan. The Disbursement Letter contains additional instructions describing the disbursement arrangements tor *ithdrawing protccds fron the Financing AcLOunt unider . partiular mnvestmet proict. (a) Reimbursement: The World Bank ma% reimburse the borrower fior expenditures eligible for financing pursuant to the Financing Agreement (eligible expenditures) that the borrower has prcfinanced from its own resources. b Adance: The World Bank may advance funds from the Financing Account into a Dcsignated Account of the borrower to finance eligible expenditures as the\ are incurred and for which supporting documents will be pro%ided at a later date (see section 5. Designated Accounts). (c) Direct Payment: The World Bank may make payments. at the borrower's request, directly to a third party (for example. supplier. contractor. or consultantI for eligible expenditures. (d) Special Commitment: 11h World Bank may pay amounts to a third party for eligible expenditures under special commitments entered into, in writing, at the borrower's request and on temis and conditions agreed betwvcn the World Bank and the borrower 3. Withdrawal of Funds from the Financing Account 3 1 Authorized Signatures. Before funds from the Financing Account na> he withdrawn or committed. the authorized representati% e of the borrower (as designated in the Financing Agreement) must funish to the World Bank. electronically through the Client Connection website (http cI ientconnection.workdbank ,or). or through an authorized signatory designation letter, the name(s) of the otficial(s) authorized (a) to sign and submit applications for withdrawal and applications for a spccial commitment (collectivel. Applications). and (b) to recei%e Secure Identification Credentials (SIDC) from the World Bank. The borrower must notif- the World Bank of any changes in signature authority. either electronicall% in Client Connection or through an updated authorized signatory designation letter 3 2 Terms and Conditions of Use of Secure Identification Credentials (SIDC) to Process Applications. By designating officials to usc SIDC and by choosing to submit the applications electronically. the borrower confirms its agreement to abide by the terms and conditions ofusc of SIDGI 3.3 Applications. Applications must be provided to the World Bank in such form as is required to access funds from the Financing Account and must include such information as the World Bank may reasonably request 3.4 Applications and necessary supporting documents (see section 4 Supporting Docuentation Requirements) should be submitted to the World Bank electronically. i a Teis and conditions of usc of SIDC are providcd in the Disbursement Lettcr manner and on terms and conditions specified bn the World Bank. through the Client Connection website at http:/ clientconnection.worldbank.org. The World Bank may. at its discretion. temporarily or permanently. disallow the electronic submission of applications by the borrower. [he World Bank may permit the borrower to complete and submit applications manually in paper form. Paper applications forms can he found in the Client Connection website at http. clientconnection.worldbank.org or ma) be obtained from the World Bank upon request. 5 Minimum Value ofApplicalions. The World Bank establishes a minimum value Ibr applications for reimbursement, direct payment. and special commitment. [he World Bank reserves the right not to accept applications that are below such minimum \alue. 3 6 Loan Disbursing Period. The World Bank processes Applications only after the Financing Agreement has been declared elfecti%e in accordance with the terms of the Financing Agreement. [he e\penditures thr which the Applications are made must be: (a) Paid for on or after the date of the Financing Agreement. or alternatively. in the case of proiccts that permit rctroacti\c linancing. on or after the earlier date specilied in the Financing Agreement for that purposc and (h) Incurred on or before the closing date specified or referred to in the Financing Agreement (the Closing Date). except as otherwise specifically agreed with the World Bank 3.7 ['he loan disbursing period ends on die final date established b the World [ank for receipt by the World Bank of applications for withdrawal and supporting docunentation (the Disbursement Deadline Date). The Disbursement Deadline Date may be the same as the Closing Date or tip to four months alter the Closing Date. To support orderly protect completion and closure of the Financing Account, the World Bank does not accept applications ftr withdrawal or supporting documentation recened after the Disbursement Deadline Date. 'The borrower must promptly inform the World Bank of any expected implementation delays or exceptional administrative issues before those dates The World Bank notifies the borrower of any exception that the World Bank may make to the Disbursement Deadline Date 3.8 Disbursement Conditions. If the Financing Agreement contains a disbursement condition for a specific expenditure category. the World Bank will disburse funds from the Financing Account for that category only after the disbursement condition has becn fulfilled and the World Bank has notified the horrower to that elect. 4. Supporting Documentation Requirements 4.1 The borrower provides supporting documentation to the World Bank to show that funds from the Financing Account have been or are being used to finance eligible expenditures 4 2 For special commitments. the commercial bank pro% ides its confirmation directl. to the World Bank that conditions for the release of payments committed for w ithdrawal have been met. 4 3 Types of Supporting Documentation. The World Bank requires either copies of the original documents e,idencing eligible expenditures (Recordsi or summari reports of expenditure (Summary Reports) in such form and substance as the World Bank ma% specitV. Records include such documents as invoices and receipts. A Summary Report may be either (a) the interim unaudited financial report required under the Financing Agreement (Interim Financial Report) or tb) a statement of expenditure summarizing eligible expenditures paid during a stated period (Statement of Expenditure). In all cases. the borrower is responsible for retaining the original documents evidencing eligible expenditures and making them available for audit or inspection. 4 4 The World Bank determines the types of supporting documentation that the borrower must proide. taking into consideration the disbursement method used The supporting documentation may be the followimg: (a) For applications for Reimbursement: (i) Interim Financial Reports. (ii) Statements of Expenditure. or (iii) Records b) Eor reporting on Ike use of Advances (i) Interim Financial Reports. (isI Statements of Fxpenditure. or (iii) Records (c) For applications for Direct Payments- (i) Records such as copies of supplier in%oices: (it) a bank guarantee for advance or retention payment (d) For applications for Special Commitment: Copy of the I etter of Credit (with valid expiry date) that the commercial hank, known as the opening bank. has issued For payment, a SWIFT (Society for Worldwide Interbank Tclecommunication) message must be sent b% the commercial bank, and (c) Any other supporting documentation that the World Bank may request by notice to the borrower or as specified in the Disbursement Letter 4-5 Failure to Provide Audited Financial Statements. If the horwmer fails to prokide any of the audited tinancial statements required in accordance with and within the period of time specified in, the Financing Agreement- the World Bank may at its discretion. decide not to accept applications for withdrawal supported by Summar) Reports. cen if such reports are accompanied by Records. 5. Designated Accounts 5 I he borrower may open one or more designated accounts into which the World Bank may. at the borroer's request. deposit amounLs withdrawn from the Financing Account for the purpose of paying for eligible expenditures as the% are incurred. Before the World Bank authori7es establishment of a Designated Account. the borrower must have adequate administrative capability. internal controls. and accounting and auditing procedures to ensure effective use of the Designated Account 5.2 Ihe World Bank mav decide not to permit the use of Designated Accounts in new projects if the borrower has failed to refund undocumented advances in the Designated Account of an, other loan to. or guaranteed by. the borrower within two months after the Disbursement Deadline Date for that loan. 5.3 Type of Designated Account. A Designated Account may be established in one of two ways - as a segregated account or pooled account as appropriate for the project concerned, and as determined and notified by the World Bank (a) Segregated Account: An account of the borrower into which only proceeds of the V inancing Account may be deposited (b) Pooled Account- An account of the borrower into which the tinds from the Financing Account and funds of other financing for the prolect (such as borrower resources or financing by other development partners) may be deposited. 5 4 Currency of the Designated Account. Designated Accounts must be in a currency acceptable to the World Bank. In countries that have a f'reely convertible currency. Designated Accounts may he held in the currency of the borrower or any frcel% con,,ertible currency. I he World Bank may also agree to local currency Designated Accounts when, among other things. the country's currency (even if not freely convertible) is stable and the expenditures to be financed are primarily in local currency [he borrower bears all rsks associated with foreign exchange fluctuations between (a) the currenc> of denomination of the loan and that of the horrower"s Designated Account, and (b) the currency of denomination of the borrower's Designated Account and the currency or currencies of project cxpenditures. 5-3 Financial Institution. Designated Accounts must be opened and maintained in a financial institution' selected by the borrower and acceptable to the World Bank. A financial institution is acceptable if it meets all the following requirements (a) It is financially sound: (b) It is in good standing (C) It is authorized to maintain the Designated Account in the currency agreed between the World Bank and the borrower. (d) It is audited regularly. and receix e satisfactory audit rcports: A finanmal iswitutin may he (he counin s central hank, a local development hank or a commercial ank. (e) It can execute a large number of transactions promptly: (fl It can satisfactorily perform a wide range of banking services (g) It can provide a detailed statement of the Designated Account: th) It is part of a satislctor% correspondent bunking network: (i) It charges reasonable fees for its services. 5.6 The World Bank reserves the right not to transfer funds to a financial institution if that institution has asserted or asserts a claim to set off. seiLe. or attach the proceeds of an% Bank loan on deposit in a Designated Account maintained by the institution 6. Terms and Conditions Applicable to Advances 6.1 Ceiling, the World Bank notiiLes the borrower of the maximum amount of funds from the Financing Account that may be on deposit in a Designated Account (the Ceiling). The World Bank. at its discretion. may establish the Ceiling as either (aI a fixed amount, or (b) an amount that is adjLsted from time to time durng project implementation on the basis of periodic forecasts of project cash flow needs. 6-2 AppliCaions for Advances. The borrower may apply for an advance in an amount tip to the Ceiling less the aggregate amount of those ad,anccs previously received by the borrower for which the horrower has not yet provided supporting documentation. Normally, to support orderly closure of' the Financing Account, the World Bank does not advance funds from the Financing Account into the Designated Account after the Closing Date. 6 3 Frequency of Reporting Eligible Expenditures Paid from the Designated Account. The borrower reports on the use of inds from the Financing Account advanced to the Designated Account at intenals specified by de World Bank bN notice to the borrower. 11e borrower must ensure that all amounts deposited into the Designated Account are accounted for and that their use is reported prior to the Disbursement Deadline Date After that date, the borrower must retiand to the World Bank anN advances still unaccounted for or remaining in the Designated Account. 64 Withholding Advances. The World Bank is not required to make any deposit into the Designated Account if any of the following conditions applh (a) The World Bank determines that payment of the deposit would result in exceeding the Ceiling (see subsection 6-2. Applications for Ad\ances): (b) 1Te World Bank is not satisfied that the borrower's planned project expenditures justify the deposit. The World Bank may adjust the amount it dcposits or withhold trther deposits into the Designated Account until it is satistied that the financial needs of the proiect warrant further deposits. tc) I he borrower fails to take the action required pursuant to the determinations made b. the World Bank tinder subsections 7 I and 7.2 of these guidelines: (d) The horrower fails to prouide an) of the audited tinancial statements required in accordance with. and within the period of time specified in. the Financing Agreement: (c) The World Bank determines that all irt-her withdrawals of linds from the Financing Account should be made by the horrower directly from the Financing Account, or (1) The World Bank has notified the borrower of its intention to suspend in whole or in part the borrower's right to make withdrawals from the Financing ccount 6.5 Ecess Adances. If at any time the World Bank determines that any amount deposited in the Designated Account will not be required to cover further payments for eligible expenditures (the Excess Amount). it may. at its discretion. require the borrower to take one of the following two disbursement-rclated actions: (A) Prot ide esidence satisfiactors to the World Bank within a period specified by die World Bank that the Excess Amount will be used to pay for eligible expenditures. If the evidence is not furnished within the time period specified. the borrower must promptly refund the Fxcess %mount to the World Bank: or (h) Refund the Excess Amount promptly. 1he borrower must perform the action requested promptly aficr recil'ing notification from the World Bank that it must do so 7. Ineligible Expenditures 7 I Ineligible Fxpenditures Generally. If the World Bank determines that any amount of the funds from the Financing Account was used to pay for an expenditure that is not eligible pursuant to the Financing Agreement (an ineligible expenditure). the World Bank may. at its discretion. require the borrower to take one of the following two disbursement-related actions, without prejudice to the Bank's right to exercise remedies under the General Conditions" or Standard Conditions' and Financing Agreement. (a) Refund an equivalent amount to the World Bank (b) Exceptionally. provide substitute documentation c%idencing other eligible expenditures. The borrower must perform the action requested promptly after receiving notification from the World Bank that it must do so The General ( inditoms 4 forh .ertain ierms and ;ondiiions gener4llN applicable to IBRD kirnt and IDA credits and grants The Standard Condmtv set ifth ertan teri and ondions that are gencralIl applicabie to tnut fund-ind idanves made h% the Bank under the Project Preparation Facility 7-2 Ineligible Erpenditures Paid from the Designated Account. If the World Bank determines that any payment out of the Designated Account was not justified by the c%idence furnished to the World Bank or was made for an ineligible expenditure. the World Bank ma). at its discretion, require the borroer to take one of the following actions. (a) Provide the additional evidence requested by the World Bank (b) Deposit an equi\alent amount into the Designated Account 1c) Relund an equi% alent amount to the World Bank (d) Fxceptionally, provide substitute documentation evidencing other eligible expenditures. The borrower must perform the action requested promptly after receiving notitication from the World Bank that it must do so- 8. Refunds 8 I Borrower Decision to Refund. IThe borrower may. upon notice to the World Bank. relund all or any amount of the loan on deposit in the Designated Account to the World Bank for credit to the Financing Account. 8 2 Consequence of Refunds. The World Bank shall determine w%hether rclunds made to the World Bank in accordance with sections 6 and 7 and subsection .1 of these guidelines %ill be credited to the Financing Account. Relunds of unds into the Financing Account maN result in (a) swap termination fees (bi unwinding costs for amounts for which the interest rate basis or currency has been converted or hedged. Ic) both. 8 3 Other Rights and Obligations Unaffected by Refunds. Refunds of loan amounts do not alfect other legal rights and obligations of the parties under the Financing Agreement. Attachment 2 Form of Authorized Signatory Letter [Letterhead] Ministry of Finance [Street address] [City] [Country] [DATE] The World Bank 1818 H Street, N.W. Washington, D.C. 20433 United States of America Attention: [Country Director] Dear [Country Director]: Re: IDFHP Grant No. TF0A5620 (Health Governance and Nutrition Development Project) I refer to the Grant Agreement ("Agreement") between the International Bank for Reconstruction and Development and International Development Association ("World Bank"), acting as administrator of the above-referenced trust fund grant, and the Lao People's Democratic Republic ("Recipient"), dated , providing the above Grant. For the purposes of Section 3.04 (b) of the Standard Conditions, as defined in the Agreement, any [ione] of the persons whose authenticated specimen signatures appear below is authorized on behalf of the Recipient to sign applications for withdrawal [and applications for a special commitment] under this Grant. For the purpose of delivering Applications to the World Bank, 2[each] of the persons whose authenticated specimen signatures appears below is authorized on behalf of the Recipient, acting 3[individually] 4[jointly], to deliver Applications, and evidence in support thereof on the terms and conditions specified by the World Bank. 5[This confirms that the Recipient is authorizing such persons to accept Secure Identification Credentials (SIDC) and to deliver the Applications and supporting documents to I Instruction to the Recipient when sending this letter to the World Bank: Stipulate if more than one person needs to sign Applications, and how many or which positions, and if any thresholds apply. Please delete this footnote in final letter that is sent to the World Bank. 2 Instruction to the Recipient Stipulate if more than one person needs to jointly sign Applications, if so, please indicate the actual number. Please delete this footnote in final letter that is sent to the World Bank. 3 Instruction to the Recipient: Use this bracket if any one of the authorized persons may sign; if this is not applicable, please delete. Please delete this footnote in final letter that is sent to the World Bank. Instruction to the Recipient. Use this bracket only if several individuals must jointly sign each Application; if this is not applicable, please delete. Please delete this footnote in final letter that is sent to the World Bank the World Bank by electronic means. In full recognition that the World Bank shall rely upon such representations and warranties, including without limitation, the representations and warranties contained in the Terms and Conditions of Use of Secure Identification Credentials in connection with Use of Electronic Means to Process Applications and Supporting Documentation ("Terms and Conditions of Use of SIDC"), the Recipient represents and warrants to the World Bank that it will cause such persons to abide by those terms and conditions.] This Authorization replaces and supersedes any Authorization currently in the World Bank records with respect to this Agreement. [Name], [position] Specimen Signature: [Name], [position] Specimen Signature: [Name], [position] Specimen Signature: Yours truly, / signed / [Position] Instruction to the Recipient: Add this paragraph if the Recipient wishes to authorize the listed persons to accept Secure Identfication Credentials and to deliver Applications by electronic means; ifthis is not applicable, please delete the paragraph. Please delete this footnote in final letter that is sent to the World Bank THE WORLD BANK IBRD IDA I WORLDBANKGROUP Attachment 3 Terms and Conditions of Use of Secure Identification Credentials in connection with Use of Electronic Means to Process Applications and Supporting Documentation March 1, 2013 The World Bank (Bank)' will provide secure identification credentials (SIDC) to permit the Borrower' to deliver applications for withdrawal and applications for special commitments under the Agreement(s) and supporting documentation (such applications and supporting documentation together referred to in these Terms and Conditions of Use as Applications) to the Bank electronically, on the terms and conditions of use specified herein. SIDC can be either: (a) hardware-based (Physical Token), or (b) software-based (Soft Token). The Bank reserves the right to determine which type of SIDC is most appropriate. A. Identification of Users. 1. The Borrower will be required to identify in a completed Authorized Signatory Letter (ASL) duly delivered to and received by the Bank each person who will be authorized to deliver Applications. The Bank will provide SIDC to each person identified in the ASL (Signatory), as provided below. The Borrower shall also immediately notify the Bank if a Signatory is no longer authorized by the Borrower to act as a Signatory. 2. Each Signatory must register as a user on the Bank's Client Connection (CC) website (https://clientconnection.worldbank.or ) prior to receipt of his/her SIDC. Registration on CC will require that the Signatory establish a CC password (CC Password). The Signatory shall not reveal his/her CC Password to anyone or store or record the CC Password in written or other form. Upon registration as a CC user, the Signatory will be assigned a unique identifying account name. B. Initialization of SIDC. I. Prior to initialization of SIDC by a Signatory, the Signatory will acknowledge having read, understood and agreed to be bound by these Terms and Conditions of Use. 2. Where a Physical Token is to be used, promptly upon receipt of the Physical Token, the Signatory will access CC using his/her account name and CC Password and register his/her Physical Token and set a personal identification number (PIN) to be used in connection with the use of his/her Physical Token, after which the Physical Token will be initialized for use by the Signatory exclusively for purposes of delivering Applications. Where a Soft Token is to be used, the Signatory will access CC using his/her account 6 "Bank" includes IBRD and IDA. "Borrower" includes the borrower of an IBRD loan, IDA credit, or Project Preparation Facility advance and the recipient of a grant. name and CC Password and set a personal identification number (PIN) to be used in connection with the use of his/her Soft Token, after which the Soft Token will be initialized for use by the Signatory exclusively for purposes of delivering Applications. Upon initialization of the SIDC, the Signatory will be a "SIDC User". The Bank will maintain in its database a user account (Account) for each SIDC User for purposes of managing the SIDC of the SIDC User. Neither the Borrower nor the SIDC User will have any access to the Account. 3. Prior to first use of the SIDC by the SIDC User, the Borrower shall ensure that the SIDC User has received training materials provided by the Bank in use of the SIDC. C. Use of SIDC. Use of the SIDC is strictly limited to use in the delivery of Applications by the SIDC User in the manner prescribed by the Bank in the Agreement(s) and these Terms and Conditions. Any other use of the SIDC is prohibited. 2. The Bank assumes no responsibility or liability whatsoever for any misuse of the SIDC by the SIDC User, other representatives of the Borrower, or third parties. 3. The Borrower undertakes to ensure, and represents and warrants to the Bank (such representation and warranty being expressly relied upon by the Bank in granting SIDC) that each SILDC User understands and will abide by, these Terms and Conditions of Use, including without limitation the following: 4. Security 4.1. The SIDC User shall not reveal his/her PIN to anyone or store or record the PIN in written or other form. 4.2. The SIDC User shall not allow anyone else to utilize his/her SIDC to deliver an Application to the Bank. 4.3. The SIDC User shall always logout from CC when not using the system. Failure to logout properly can create a route into the system that is unprotected. 4.4. If the SIDC User believes a third party has learned his/her PIN or has lost his/her Physical Token he/she shall immediately notify clientconnectiongworldbank.org. 4.5. The Borrower shall immediately notify the Bank at clientconnection@worldbank.org of any lost, stolen or compromised SIDC, and take other reasonable steps to ensure such SIDC are disabled immediately. 5. Reservation of Right to Disable SIDC 5.1. The Borrower shall reserve the right to revoke the authorization of a SIDC User to use a SIDC for any reason. 5.2. The Bank reserves the right, in its sole discretion, to temporarily or permanently disable a SIDC, de-activate a SIDC User's Account or both. 6. Care of Physical Tokens 6.1. Physical Tokens will remain the property of the Bank. 6.2. The Bank will physically deliver a Physical Token to each Signatory designated to receive one in a manner to be determined by and satisfactory to the Bank. 6.3. Physical Tokens contain delicate and sophisticated instrumentation and therefore should be handled with due care, and should not be immersed in liquids, exposed to extreme temperatures, crushed or bent. Also, Physical Tokens should be kept more than five (5) cm from devices that generate electromagnetic radiation (EMR), such as mobile phones, phone-enabled PDAs, smart phones and other similar devices. Physical Tokens should be carried and stored separate from any EMR device. At close range (less than 5 cm), these devices can output high levels of EMR that can interfere with the proper operation of electronic equipment, including the Physical Token. 6.4. Without derogating from these Terms and Conditions of Use, other technical instructions on the proper use and care of Physical Tokens are available at http://www.rsa.com. 7. Replacement 7.1. Lost, damaged, compromised (in terms of 4.5, above) or destroyed Physical Tokens will be replaced at the expense of the Borrower. 7.2. The Bank reserves the right, in its sole discretion, not to replace any Physical Token in the case of misuse, or not to reactivate a SIDC User's Account. Attachment 4 Annex 2 Statement of Sources (Receipts) and Uses (Payments) Report for the Semi-Annual Reporting Period ended xx InLAK Budget amounts for Actual expenditures Cumulative the current semi- for the current semi- expenditure of Particulars Ref Note annual reporting annual reporting Project to Date penod ended xx period ended xx Opening balance (A) IDA Credit IDA Grant TF xx Total (A) Receipts (B) TDA Credit IDA Grant TF xx Total Receipts (B) Total (C=A+B) Payments (D) Health Sector Governance Reform Service Delivery Nutrition Social and Behaviow Change Communication Project Management, Monitoring and Evaluation Total Payments (D) Total Receipt less total Payments (E-C-D) Closing Bank balances (F) DA (Non-DLI A/C No 0000010121310114 BOL) DA (DLI A/C No 0000010121320115 BOL) OA - BCEL Cash on hand Advance Total (F- total E Annex 3 Statement of Uses of Funds (Payments) By Component and Activities Report for the Semi-Annual Reporting Period ended xx In US$ Budget amounts Actual Ntoffor the current expenditures for Cirnatal ureyatoCumnulative Component and activities tef f annual the current se Variance Curret a y Variance expenditure of reportng Period annual reportig Project to Date ended xx period ended xx Component I- Health Sector Govenance Refonn Component Support to MOH Information Management System Sub-total of Component I Component 2- Service Delivery DLI payments Sub-total ofComponent 2 Component 3- Nutrition Social md Behavior Change Communication Development of national strategy and anplementation plan for Social and Behavioral Change Commutucation to improve health aid nutrition Implementation of national strategy developed, at the national, village levels and selected priority disticts Developncnt and delivery of SBCC campaign Survcys Sub-total of Component3 - - Component 4- Project manage nt and Evaluation Technical and operational support to the National Program coordmnation office Audit and verificanion agency support Admiistation for NPCO Techmcal support to improve planning, budget execution, and reporting nicludig pilot project for results-based plannmg and budgeting tor health sector Sob-totalofComponent 4 pGrand Total---] - Annex 4 Statement of Uses of Funds (Payments) By Component and Activities Report for the Semi-Annual Reporting Period ended xx In LAK Budget amounts Actual Note of IthcurnexedtrsfrCurrent annual Current year toCunlv Component and actnvties f sen-annua the current se Variance Curret a y Variance expendiure of reporting Period annual reportng Project to Date ended xx period ended xx Component I- Health Sector Governance Reform Component Support to MOH iformation Management System Sub-total of Component I Component2- Service Delive7 DI.1 payments Sub-total of Component 2 L Component 3- Nutrition Social and Behavior Change Communication Development of national strategy and inplementation plan for Social and Behavioral Change Communtcation to anprove health and nutrition Implementation of national strategy developed, at the national, village levels and selected priorty districts Development and deliver) of SBCC campaign Surveys Sub-total of Component 3 Component 4- Project management and Evaluation Technical and operational support to die National Prograin coordmation office Audit and venfication agency support Admanstation for NPCO Technical support to improve plaining. budget execution, and repoltg, ncluding pilot project for results-based planaig and budgeting for health sector Sub-total ofComponent 4 Grand Total---- Annex 5 Statement of Uses of Funds (Payments) By Component and by soure for the Semi-Annual Reporting Period ended xx In US$ Total Note of Actual expenditures for the current serm-annual reporting period ended xx Expenditure for Component and activities ref he period ended IDA grant IDA Credit MDTF PHRD IDA Credit- AF Component I- Health Sector Governance Reform Comonent Support to MOH Information Management System Sub-total of Component I Component 2- Service Delivery DLI payments Sub-total ofComponent 2 Component 3- Nutrition Social and Behavior Change Cs mmunication Development of national strategy and implementation plan for Social and Behavioral Change Communication to improve health and nutrtion Implementation of national strategy developed, at the national, village levels and selected priority districts Development and delivery of SBCC campaign Surveys Sub-total ofComponent 3 Component 4- Project manalement and Evaluation Technical and operational suppoit to the National Program coorduation office Audit and verification agency support Administation for NPCO Technical support to improve planning budget execution- and reporting, nicludig pilot project for results-based planning and budgeting for health sector Sub-total ofComponent 4 Grand Total Lao PDR: Ministry of Health: Name of Project: (Insert Here) Certification of Eligible Expenditure Programs (EEPs) in support of Achieved Dis This is the certify that the expenditures listed below have been extracted from the financial Reports/statements of the Ministry of Health as at the year ended September 30, 20XX in respect of the staff emoluments paid by the Government of Lao in respect of provincial Health staff (chapter 10). Kip (in millions) Total Salaries for Provincial Health Workers (chapter 10) xxxxx Total Provincial Health Workers' salaries in financial statements (20XX) XXXX Prepared by: Title: Nam e: ................................................ ......... Signature: .............. ................ D ate : ....................................................................................... Certified by Director General of the Department of Finance, Ministry of Health Name: ...................................... Signature: .............. ................ Date: ......................................... Lao PDR: Ministry of Health: Name of Project: (Insert Here) Certification of Additionality This is the certify that the donor funding has been in additional to government allocated budget to the Health Sector for the budget year xx/xx LAK (in million) (i) Amount of MOH budget approved by Parliament of the xxxx Lao PDR budget year xx/xx (ii) Amount released/disbursed by MOF to MOH under the xxxx budget year xx/xx Prepared by: Title: Name: ............................................ Signature: ........................................... Date: .................. ............................... Certified by Director General of the Department of Finance, Ministry of Health Name: .................. ........................... Signature: ............................................ Date: ................................................. Attachment 5 Payments Made during Reporting Petiod Against (.otracts Subject to the Rank' Prior Review WBIWI' NIN1anM I~aeer Elisale r~A1 A~k Iw~s ue. Am.1ar Co~.I.Zer asmØsn Centruet centrees conract objeues essappur Gramt ArW.sst deseng Number s.p. Dne Amseet i. Cestrace durtu5 Peers_____ Attachment 6 page _ of_ STATEMENT OF EXPENDITURES (No Records Required for Submission) Application No. Loan/Credit/Grant No.: PAYMENTS MADE DURING THE REPORTING PERIOD FROM TO FOR EXPENDITURES UNDER CATEGORY (Enumerate or list categories) 1 2 3 4 5 6 7 11 12 Amount El gibl e for Amount charged to Itm atgoyN. ureny ndToal Currency and Total Financing Dsgae Item CategoryNo. Carnya oa Aonfnovcel Eligible% Fin5 ng exchngeate Remrk No. () Amount of Contract Amuto no e lgbe 4) Acount (if Exchange Rate Remarks Coverd by Application applicable) IDA IDFHP PHIRD Total Note: A separate SOE form should be used for retroactive financing ** Items should be grouped by category Supporting Documents for this SOE retained at (insert location) I certify that the amount claimed under each financing source almse is consistent with the Annual Work Plan and Budget approsed by the Bank. Signed: Name, Project Director Attachment 7 DESIGNATED ACCOUNT RECONCILIATION STATEMENT LOAN/CREDIT/GRANT/PPF/COFINANCIER NUMBER ACCOUNT NUMBER _ WITH (BANK) I. TOTAL ADVANCED BY WORLD BANK (OR COFINANCIER) $ 2 LESS: TOTAL AMOUNT RECOVERED BY WORLD BANK - $ 3. EQUALS PRESENT OUTSTANDING AMOUNT ADVANCED TO THE DESIGNATED ACCOUNT (NUMBER I LESS NUMBER 2) = $ 4. BALANCE OF SPECIAL ACCOUNT PER ATTACHED BANK STATEMENT AS OF DATE S 5. PLUS: TOTAL AMOUNT CLAIMED IN THIS APPLICATION NO. + $_* 6. PLUS: TOTAL AMOUNT WITHDRAWN AND NOT YET CLAIMED REASON: +_ _* 7. PLUS: AMOUNTS CLAIMED IN PREVIOUS APPLICATIONS NOT YET CREDITED AT DATE OF BANK STATEMENTS APPLICATION NO. AMOUNT * SUBTOTAL OF PREVIOUS APPLICATIONS NOT YET CREDITED + $ 8. MINUS: INTEREST EARNED - $ 9. TOTAL ADVANCE ACCOUNTED FOR (NO. 4 THROUGH NO. 9) = $ Part II 10. FORECAST FOR NEXT SIX MONTHS (From Table xx) $ 11. Less: BALANCE OF DA ACCOUNT (Item 4) - $ 12. AMOUNT REQUESTED FOR ADVANCE = $ 13. EXPLANATION OF ANY DIFFERENCE BETWEEN THE TOTALS APPEARING ON LINES 3 AND 9: 11. DATE: SIGNATURE: TITLE: * ALL ITEMS SHOULD BE INDICATED ON THE BANK STATEMENT