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(to be sent via the official channels to Unit B4 of DG Justice, Freedom and Security, LX 46, B-1049 Brussels)

Name of programme: …

Commission Decision No … of ….

Pursuant to Article 13 of Decision 2004/904/EC, I, the undersigned (name in capitals, stamp, position and signature of competent authority), representing the authority responsible for implementing the European Refugee Fund request payment of the amount of EUR … as an second pre-financing payment/final payment. This request for payment meets admissibility requirements because:

Delete as appropriate
  1. (a)

    the progress report on implementation of the annual work programme and a declaration of expenditure accounting for at least 70 % of the amount of the initial payment provided for by Article 23(3) of Decision 2004/904/EC

  • has been supplied

  • is enclosed

  1. (b)

    the annual programme’s final implementation report and the final declaration of expenditure provided for by Articles 24(4) and 28 (2) of Decision 2004/904/EC

  • has been supplied

  • is enclosed

  1. (c)

    the decisions of the responsible authority are consistent with the total amount of Fund contribution to the priorities concerned

  1. (d)

    any recommendations for improving the monitoring and management arrangements made by the Commission under Article 27 of Decision 2004/904/EC

  • have been acted upon

  • explanations have been given

  • no recommendations made

  1. (e)

    any request for corrective measures under Article 26 of Decision 2004/904/EC

  • have been acted upon

  • have been commented on

  • no expenditure included

  • no requests made

Payment should be made to:

Beneficiary
Bank
Account no
Account holder (if different from beneficiary)
DateName in capital letters, stamp, position and signature of competent authority