Ref. Ares(2018)6549080 - 19/12/2018
ANNEX V
Request for payment for PAGODA
Date of the request for payment <.......>
For the attention of
<
Address of the Contracting Authority>
<Financial unit indicated in the Agreement>1
Reference number of the Agreement: ...
Title of the Agreement: ...
Name and address of the Organisation: ...
Request for payment number: ...
Period covered by the request for payment: ...
Dear Sir/Madam,
I hereby request payment of pre-financing/interim payment/balance2 under the Agreement
mentioned above.
The amount requested is [in accordance with Article 4 of the Special Conditions of the
Agreement/the following: ...]3
Please find attached the following supporting documents:
narrative and financial progress report (for pre-financing / interim payments )
final narrative and financial report (for payment of the balance)4
The payment should be made to the following bank account:...5
Please when making the payment indicate the following communication: …
I hereby certify on honour that the information contained in this request for payment is full,
reliable and true, that the costs incurred can be considered eligible in accordance with the
Agreement and that this request for payment is substantiated by adequate supporting
documents that can be checked.
Yours faithfully,
<signature>
1
If applicable, please do not forget to address a copy of this letter to the European Union Delegation
mentioned in Article 5 of the Special Conditions of the Agreement.
2
Delete the options which do not apply.
3
Delete the option which does not apply.
4
Delete the items which do not apply.
5
Indicate the account number shown on the identification form annexed to the Agreement. In the event of
change of bank account, please complete and attach a new identification form as per model.
N.B.: Instalments of pre-financing, interim payments and final payments shall be made upon approval of the
payment request accompanied by a progress or final report (see Articles 19 and 26 of the General
Conditions of Agreement).
November 2014
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Request for payment.doc