Consultancy to Undertake a Detailed Review of Shared Benefits in the BUPUSA Transboundary Basin

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Request for Proposals (RfP) Consultancy to Undertake a Detailed Review of Shared Benefits in the BUPUSA Transboundary Basin IUCN ESARO, South Africa Country Office, Water and Wetlands Programme
RFP REFERENCE: IUCN-02-2024-BUPUSA BASIN BENEFIT-SHARING REVIEW
Welcome to this Procurement by IUCN. You are hereby invited to submit a Proposal. Please read the information and instructions carefully because non-compliance with the instructions may result in the disqualification of your Proposal from this Procurement.
1. REQUIREMENTS
1.1. A detailed description of the services and/or goods to be provided can be found in Attachment 1.
2. CONTACT DETAILS
2.1. During the course of this procurement, i.e. from the publication of this RfP to the award of a contract, you may not discuss this procurement with any IUCN employee or representative other than the following contact. You must address all correspondence and questions to the contact, including your proposal.
IUCN Contact : Tenders South Africa Office tenders.sa@iucn.org
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3. PROCUREMENT TIMETABLE
3.1. This timetable is indicative and may be changed by IUCN at any time. If IUCN decides that changes to any of the deadlines are necessary, we will contact you.
DATE ACTIVITY
19 February 2024
Publication of the Request for Proposals
26 February 2024
Deadline for confirmation of intention to bid
05 March 2024
Deadline for submission of questions
06 March 2024
Planned publication of responses to questions 08 March 2024 Deadline for submission of proposals to IUCN (“Submission Deadline”)
12 March 2024
Clarification of proposals
15 March 2024
Planned date for contract award
18 March 2024
Expected contract start date
31 August 2024 Submission of the final report/submission
3.2. Please email the IUCN contact to confirm whether or not you are intending to submit a proposal by the deadline stated below.
4. COMPLETING AND SUBMITTING A PROPOSAL
4.1. Your Proposal must consist of the following three documents:
• Signed Declaration of Undertaking (see Attachment 2)
• Technical Proposal (see Section 4.4 below)
• Financial Proposal (see Section 4.5 below)
Proposals must be prepared in English.
4.2. Your Proposal must be submitted by email to the IUCN Contact (see Section 2). The subject heading of the email shall be RfP-IUCN-02-2024-BUPUSA BASIN BENEFIT-SHARING REVIEW
4.3. The bidder name is the name of the company/organisation on whose behalf you are submitting the proposal, or your own surname if you are bidding as a self-employed consultant. Your proposal must be submitted in PDF format. You may submit multiple emails suitably annotated, e.g. Email 1 of 3, if attached files are too large to suit a single email transmission. You may not submit your Proposal by uploading it to a file-sharing tool.
4.4. Eligibility Not Applicable
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4.5. Technical Proposal The technical proposal must address each of the criteria stated below explicitly and separately, quoting the relevant criteria reference number (left-hand column). Proposals in any other format will significantly increase the time it takes to evaluate, and such Proposals may therefore be rejected at IUCN’s discretion. Where CVs are requested, these must be of the individuals who will actually carry out the work specified. The individuals you put forward may only be substituted with IUCN’s approval. IUCN will evaluate technical proposals with regard to each of the following criteria and their relative importance:
Description Information to provide Relative weight 1 Understanding of the task/scope of work Detailed (technical) proposal 15% 2 Expert specialisation & work experience Comprehensive Curriculum Vitae 25% 3 Demonstrated experience and expertise in similar assignments
Portfolios/reports/case studies (or similar) demonstrating expertise 30% 4 Methodology & Workplan Alignment Methodology with detailed (prelim) Workplan 30% TOTAL 100%
4.6. Financial Proposal
4.6.1. The financial proposal must be a fixed and firm price for the provision of the goods/services stated in the RfP in their entirety.
4.6.2. Prices include all costs Submitted rates and prices are deemed to include all costs, insurances, taxes (except VAT, see below), fees, expenses, liabilities, obligations, risks and other things necessary for the performance of the Terms of Reference or Specification of Requirements. IUCN will not accept charges beyond those clearly stated in the Financial Proposal. This includes applicable withholding taxes and similar. It is your responsibility to determine whether such taxes apply to your organisation and to include them in your financial offer.
4.6.3. Applicable Goods and Services Taxes Proposal rates and prices shall be exclusive of Value Added Tax.
4.6.4. Currency of proposed rates and prices All rates and prices submitted by Proposers shall be in [USD currency].
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4.6.5. Breakdown of rates and prices For information only, the price needs to be broken down as follows:
Description Quantity
Unit Price (US$) & (Days/Hours) Total Price (US$) 1
Benefit Identification Framework Development (&Conceptualisation) 1
3 Stakeholder Engagements and/or Consultation(s) & Data Collection (Virtual) 1
4 Report Compilation (Analysis& Editing) 1
TOTAL
4.7. Additional information not requested by IUCN should not be included in your Proposal and will not be taken into account in the evaluation.
4.8. Your proposal must remain valid and capable of acceptance by IUCN for a period of 90 calendar days following the submission deadline.
4.9. Withdrawals and Changes You may freely withdraw or change your proposal at any time prior to the submission deadline by written notice to the IUCN Contact. However, in order to reduce the risk of fraud, no changes or withdrawals will be accepted after the submission deadline.
5. EVALUATION of PROPOSALS
5.1. Completeness
IUCN will firstly check your proposal for completeness. Incomplete proposals will not be considered further.
5.2. Technical Evaluation
5.2.1. Scoring Method
Your proposal will be assigned a score from 0 to 10 for each of the technical evaluation criteria, such that ‘0’ is low and ‘10’ is high.
5.2.2. Minimum Quality Thresholds
Proposals that receive a score of ‘0’ for any of the criteria will not be considered further.
5.2.3. Technical Score
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Your score for each technical evaluation criterion will be multiplied with the respective relative weight (see Section 4.4) and these weighted scores added together to give your proposal’s overall technical score.
5.3. Financial Evaluation and Financial Scores
The financial evaluation will be based upon the full total price you submit. Your financial proposal will receive a score calculated by dividing the lowest financial proposal that has passed the minimum quality thresholds (see Section 5.2.2) by the total price of your financial proposal.
Thus, for example, if your financial proposal is for a total of CHF 100 and the lowest financial proposal is CHF 80, you will receive a financial score of 80/100 = 80%
5.4. Total Score
Your proposal’s total score will be calculated as the weighted sum of your technical score and your financial score.
The relative weights will be:
Technical: 70%
Financial: 30%
Thus, for example, if your technical score is 83% and your financial score is 77%, you will receive a total score of 83 * 70% + 77 * 30% = 58.1% + 23.1% = 81.2%.
Subject to the requirements in Sections 4 and 7, IUCN will award the contract to the bidder whose proposal achieves the highest total score.
6. Explanation of procurement procedure
6.1. IUCN is using the Invitation Procedure for this procurement. This means that only invited bidders may submit a proposal. IUCN typically invites from four to six bidders to submit a proposal.
6.2. You are welcome to ask questions or seek clarification regarding this procurement. Please email the IUCN Contact (see Section 2), taking note of the deadline for submission of questions in Section 3.1.
6.3. All proposals must be received by the submission deadline in Section 3.1 above. Late proposals will not be considered. All proposals received by the submission deadline will be evaluated by a team of two or more evaluators in accordance with the evaluation criteria stated in in this RfP. No other criteria will be used to evaluate proposals. The contract will be awarded to the bidder whose proposal received the highest Total Score. IUCN does, however, reserve the right to cancel the procurement and not award a contract at all.
6.4. IUCN will contact the bidder with the highest-scoring proposal to finalise the contract. We will contact unsuccessful bidders after the contract has been awarded and provide detailed feedback. The timetable in Section 3.1 gives an estimate of
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when we expect to have completed the contract award, but this date may change depending on how long the evaluation of proposals takes.
7. Conditions for participation in this procurement
7.1. To participate in this procurement, you are required to submit a proposal, which fully complies with the instructions in this RfP and the Attachments.
7.1.1. It is your responsibility to ensure that you have submitted a complete and fully compliant proposal.
7.1.2. Any incomplete or incorrectly completed proposal submission may be deemed non-compliant, and as a result you may be unable to proceed further in the procurement process.
7.1.3. IUCN will query any obvious clerical errors in your proposal and may, at IUCN’s sole discretion, allow you to correct these, but only if doing so could not be perceived as giving you an unfair advantage.
7.2. In order to participate in this procurement, you must meet the following conditions:
• Free of conflicts of interest
• Registered on the relevant professional or trade register of the country in which you are established (or resident, if self-employed)
• In full compliance with your obligations relating to payment of social security contributions and of all applicable taxes
• Not been convicted of failing to comply with environmental regulatory requirements or other legal requirements relating to sustainability and environmental protection
• Not bankrupt or being wound up
• Never been guilty of an offence concerning your professional conduct
• Not involved in fraud, corruption, a criminal organisation, money laundering, terrorism, or any other illegal activity.
7.3. You must complete and sign the Declaration of Undertaking (see Attachment 2)
7.4. If you are participating in this procurement as a member of a joint venture, or are using sub-contractors, submit a separate Declaration of Undertaking for each member of the joint venture and sub-contractor, and be clear in your proposal which parts of the goods/services are provided by each partner or sub-contractor.
7.5. Each bidder shall submit only one proposal, either individually or as a partner in a joint venture. In case of joint venture, one company shall not be allowed to participate in two different joint ventures in the same procurement nor shall a company be allowed to submit a proposal both on its behalf and as part of a joint venture for the same procurement. A bidder who submits or participates in more than one proposal (other than as a subcontractor or in cases of alternatives that
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have been permitted or requested) shall cause all the proposals with the bidder’s participation to be disqualified.
7.6. By taking part in this procurement, you accept the conditions set out in this RfP, including the following:
• It is unacceptable to give or offer any gift or consideration to an employee or other representative of IUCN as a reward or inducement in relation to the awarding of a contract. Such action will give IUCN the right to exclude you from this and any future procurements, and to terminate any contract that may have been signed with you.
• Any attempt to obtain information from an employee or other representative of IUCN concerning another bidder will result in disqualification.
• Any price fixing or collusion with other bidders in relation to this procurement shall give IUCN the right to exclude you and any other involved bidder(s) from this and any future procurements and may constitute a criminal offence.
8. Confidentiality and data protection
8.1. IUCN follows the European Union’s General Data Protection Regulation (GDPR). The information you submit to IUCN as part of this procurement will be treated as confidential and shared only as required to evaluate your proposal in line with the procedure explained in this RfP, and for the maintenance of a clear audit trail. For audit purposes, IUCN is required to retain your proposal in its entirety for 10 years after the end of the resulting contract and make this available to internal and external auditors and donors as and when requested.
8.2. In the Declaration of Undertaking (Attachment 2) you need to give IUCN express permission to use the information you submit in this way, including personal data that forms part of your proposal. Where you include personal data of your employees (e.g. CVs) in your proposal, you need to have written permission from those individuals to share this information with IUCN, and for IUCN to use this information as indicated in 8.1. Without these permissions, IUCN will not be able to consider your proposal.
9. Complaints procedure If you have a complaint or concern regarding the propriety of how a competitive process is or has been executed, then please contact procurement@iucn.org. Such complaints or concerns will be treated as confidential and are not considered in breach of the above restrictions on communication (Section 2.1).
10. Contract The contract will be based on IUCN’s template, the terms of which are not negotiable. They may, however, be amended by IUCN to reflect particular requirements from the donor funding this particular procurement.
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11. About IUCN IUCN is a membership Union uniquely composed of both government and civil society organisations. It provides public, private and non-governmental organisations with the knowledge and tools that enable human progress, economic development and nature conservation to take place together. Headquartered in Switzerland, IUCN Secretariat comprises around 1,000 staff with offices in more than 50 countries. Created in 1948, IUCN is now the world’s largest and most diverse environmental network, harnessing the knowledge, resources and reach of more than 1,300 Member organisations and some 10,000 experts. It is a leading provider of conservation data, assessments and analysis. Its broad membership enables IUCN to fill the role of incubator and trusted repository of best practices, tools and international standards. IUCN provides a neutral space in which diverse stakeholders including governments, NGOs, scientists, businesses, local communities, indigenous people’s organisations and others can work together to forge and implement solutions to environmental challenges and achieve sustainable development. Working with many partners and supporters, IUCN implements a large and diverse portfolio of conservation projects worldwide. Combining the latest science with the traditional knowledge of local communities, these projects work to reverse habitat loss, restore ecosystems and improve people’s well-being. www.iucn.org https://twitter.com/IUCN/
12. ATTACHMENTS Attachment 1 Specification of Requirements / Terms of Reference Attachment 2 Declaration of Undertaking (select 2a for companies or 2b for self-employed as applicable to you)
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Terms of Reference (ToRs): Consultancy to Undertake a Detailed Review of Shared Benefits in the BUPUSA Transboundary Basin
The International Union for Conservation of Nature (IUCN) helps the world find pragmatic solutions to the most pressing environmental and development challenges. The institution’s work focuses on valuing and conserving nature, ensuring effective and equitable governance of its use, and deploying nature-based solutions to global challenges in climate, food and human development. IUCN supports scientific research, develops and disseminates conservation ‘knowledge products’, and manages field projects demonstrating practical interventions all over the world. It brings governments, NGOs, CSOs, the UN and the private sector together to develop policies, laws and best practices. IUCN is the world’s oldest and largest global environmental organisation, with more than 1,200 government and NGO members and almost 11,000 volunteer experts in some 160 countries. IUCN’s work is supported by over 1,000 staff in 45 offices and hundreds of partners in the public, NGO and private sectors around the world. IUCN’s Eastern and Southern Africa Regional Office (ESARO) cover twenty-four countries in the Horn of Africa, Eastern Africa, Southern Africa and the Western Indian Ocean Islands.
2. Background
The aim of Building River Dialogues and Governance (BRIDGE) is to consolidate the knowledge and expertise gathered in previous phases to facilitate multi-scale transboundary agreements and strengthen institutions through key ongoing negotiation processes. Through BRIDGE, IUCN intends to maximize the impact of its programme outcomes by aligning them with a series of strategic priorities and connecting them to specific regions and basins. As a result of this methodology, BRIDGE sites can receive tailored solutions based on their needs. These efforts will be complemented with a set of global-scale interventions responding to the UN call to accelerate the implementation of SDG 6.5. BRIDGE strives to provide tailored solutions based on geographic priorities and respond globally to the urgent need for accelerated transboundary cooperation to improve security and foster peaceful development by adopting this design.
Through IUCN ESARO, BRIDGE has been aimed at catalysing sustainable water resources management and development, safeguarding water supply and sanitation, biodiversity conservation and transboundary cooperation that has been implemented in Mozambique and Zimbabwe in the Buzi-Pungwe-Save (BuPuSa) basins. Further, the BRIDGE programme seeks to support benefit-sharing efforts and/or agreements in basins to enable basin-wide planning perspective by bringing together basin ;kjk.stakeholders to enhance coordination in the management and development and also provide greater scope for optimising (water) resource use.
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Mozambique and Zimbabwe share the BuPuSa Transboundary Basin, which consists of three catchment areas, namely the Buzi, Pungwe, and Save Rivers (and their tributaries). The Buzi catchment area encompasses 27,700 km2, of which 24,500 km2
(88%) are located in Mozambique and 3,200 km2 (12%) in Zimbabwe. A total area of 31,151 km2 is covered by the Pungwe Basin, of which 1,461 km2 (4.7%) is located in Zimbabwe and 29,690 km2 (95.3%) in Mozambique. Approximately 400 km of the Pungwe River runs through Zimbabwe, and the Save River flows into the Indian Ocean in Mozambique.
3. Objectives of the Consultancy
To address the efforts of the IUCN BRIDGE programme, which is to pilot benefit-sharing opportunities in identified transboundary basins; a comprehensive scoping exercise is required. The overall objectives of this consultancy are to carry out the scoping exercise to (preliminary) determine the current and future(potential) benefits of transboundary cooperation for the riparian states -sharing the watercourse (s)- and all stakeholders in the BUPUSA.
4. Deliverable
The successful consultant will develop and deliver a comprehensive report on the current and future/potential benefits that are/can be achieved through transboundary cooperation in water resources management in the BuPuSa Basin. This report will provide a detailed exploration of the benefits and identify stakeholders who derive advantages from the shared watercourse. The specific outputs to be delivered are as follows:
a)
On-Ground Benefit Identification Report:
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Conduct an exhaustive analysis of tangible benefits resulting from transboundary cooperation in water resources management within the BuPuSa Basin.
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Present a comprehensive report outlining the on-ground benefits observed in the selected demonstration sites.
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Include case studies, narratives, and visual documentation to vividly portray the identified benefits.
b)
Statistical Data Compilation and Analysis:
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Gather, compile, and rigorously analyze statistical data from designated demonstration sites to quantify the identified benefits.
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Develop and present relevant metrics and indicators for measuring the current and potential future benefits of transboundary water resources management.
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Ensure the statistical data is robust, verifiable, and presented in formats suitable for both technical and non-technical audiences.
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c)
Stakeholder Perspectives Report:
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Engage with key stakeholders, including riparian states, local communities, and other relevant entities.
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Document stakeholder perspectives on the benefits derived from the shared watercourse, incorporating their experiences and insights.
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Conduct a comparative analysis of stakeholder perspectives to provide a comprehensive view of the benefits.
d)
Strategic Recommendations and Action Plan:
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Develop strategic recommendations based on the identified benefits and stakeholder input, aimed at enhancing transboundary cooperation.
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Formulate an actionable plan outlining steps for maximizing positive outcomes in the BuPuSa Basin.
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Align recommendations with the overarching goals of the IUCN BRIDGE programme.
e)
Interactive Presentation/Workshop:
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Prepare an engaging presentation or workshop to disseminate key findings, statistical insights, and recommendations to stakeholders.
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Facilitate a discussion session to gather feedback and refine recommendations based on stakeholder input.
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Ensure the presentation is accessible and comprehensible for diverse audiences, including those with non-technical backgrounds.
f)
Final Comprehensive Report:
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Compile all findings, statistical analyses, stakeholder perspectives, and recommendations into a comprehensive final report.
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Include an executive summary, methodology, detailed results, and supporting documentation.
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Structure the report logically for easy reference and understanding.
5. Requirements and/or Criteria
The successful candidate/consultant for the on-ground identification and statistical analysis phase should possess the following minimum qualifications and experience:
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At least 10 years of experience in Environmental Economics, with a focus on sustainable resource management and benefit-sharing.
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Postgraduate degree (NQF 9/Masters or higher) in Environmental Economics (or a related field),
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Documented experience in undertaking and successfully completing similar projects involving on-ground benefit identification, preferably in transboundary basins.
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A record of at least 3 published academic papers specifically in the field of Environmental Economics, showcasing a depth of knowledge and contributions to the discipline,
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Familiarity with the BUPUSA Basin(s) and the land use, populations and key features in the landscape,
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Desirable regional experience in Southern/Eastern Africa, with an understanding of the socio-economic and environmental dynamics of the region.
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Knowledge of local language(s) would be an added advantage
6. Evaluation of Quotations/ Offer
The selection will be determined by capacity/experience, the ability to work within the estimated timelines and the economic offer [Technical: 70%Financial: 30%].
You are cordially invited to respond (prepared in English) detailing the following (in a single document or zipped folder):
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Updated Curriculum Vitae
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Technical Proposal/Envisaged Approach (3 pages max, Arial/Calbri, 1.15 spacing)
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At least 3 examples showcasing previous work similar to this call
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Financial Proposal/Estimate Budget
To Tenders South Africa tenders.sa@iucn.org by 08 March 2024 (15h00 CAT). Contracting is expected to be concluded by 18 March 2024.
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DECLARATION OF UNDERTAKING in relation to RfP-IUCN-02-2024-BUPUSA BASIN BENEFIT-SHARING REVIEWSTAKEHOLDER
I, the undersigned, hereby confirm that I am an authorised representative of the following organisation:
Registered Name of Organisation (the “Organisation”): _______________________
Registered Address (incl. country): _______________________________________
Year of Registration: __________________________________________________
I hereby authorise IUCN to store and use the information included in the attached Proposal for the purpose of evaluating Proposals and selecting the Proposal IUCN deems the most favourable. I acknowledge that IUCN is required to retain the Proposal in its entirety for 10 years after then end of the resulting contract and make this available to internal and external auditors and donors as and when reasonably requested.
Where the Proposal includes Personal Data as defined by the European Union’s General Data Protection Regulation (GDPR), I confirm that the Organisation has been authorised by each Data Subject to share this Data with IUCN for the purposes stated above.
I further confirm that the following statements are correct:
1.
The Organisation is duly registered in accordance with all applicable laws.
2.
The Organisation is fully compliant with all its tax and social security obligations.
3.
The Organisation and its staff and representatives are free of any real or perceived conflicts of interest with regards to IUCN and its Mission.
4.
The Organisation agrees to declare to IUCN any real or perceived emerging conflicts of interests it or any of its staff and representatives may have concerning IUCN. The Organisation acknowledges that IUCN may terminate any contracts with the Organisation that would, in IUCN sole discretion, be negatively affected by such conflicts of interests.
5.
None of the Organisation’s staff has ever been convicted of grave professional misconduct or any other offence concerning their professional conduct.
6.
Neither the Organisation nor any of its staff and representatives have ever been convicted of fraud, corruption, money laundering, supporting terrorism or involvement in a criminal organisation.
7.
The Organisation acknowledges that engagement by itself or any of its staff in fraud, corruption, money laundering, supporting terrorism or involvement in a criminal organisation will entitle IUCN to terminate any and all contracts with the Organisation with immediate effect.
8.
The Organisation is a going concern and is not bankrupt or being wound up, is not having its affairs administered by the courts, has not suspended business activities, is not the subject of proceedings concerning those matters, or in any analogous situation arising from a similar procedure provided for in national legislation or regulations.
9.
The Organisation complies with all applicable environmental regulatory requirements or other legal requirements relating to sustainability and environmental protection.
10.
The Organisation is not included in the UN Security Council Sanctions List, EU Sanctions Map, US Office of Foreign Assets Control Sanctions List, or the World Bank listing of ineligible firms and individuals. The Organisation agrees that it will not provide direct or indirect support to firms and individuals included in these lists.
11.
The Organisation has not been, is not, and will not be involved or implicated in any violations of Indigenous Peoples’ rights, or injustice or abuse of human rights related to other groups or individuals, including forced evictions, violation of fundamental rights of workers as defined by the International Labour Organization’s (ILO) Declaration on the Fundamental Principles and Rights at Work, child labour, sexual exploitation, sexual abuse, or sexual harassment.
______________________________________________________
<Date and Signature of authorised representative of the Proposer>
____________________________________________________
< Name and position of authorised representative of the Proposer >
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Declaration in relation to RfP-IUCN-02-2024-BUPUSA BASIN BENEFIT-SHARING REVIEW
I, the undersigned, hereby confirm that I am self-employed and able to provide the service independent of any organisation or other legal entity.
Full name (as in passport):__________________________________________________________
Home or Office (please delete as appropriate) Address (incl. country):___________________________________________________________________________________________________________________________________________________________________________________________
I hereby authorise IUCN to store and use the information included in the attached Proposal for the purpose of evaluating Proposals and selecting the Proposal IUCN deems the most favourable, including Personal Data as defined by the European Union’s General Data Protection Regulation (GDPR). I acknowledge that IUCN is required to retain my Proposal in its entirety for 10 years after then end of the resulting contract and make this available to internal and external auditors and donors as and when reasonably requested.
I further confirm that the following statements are correct:
1.
I am legally registered as self-employed in accordance with all applicable laws.
2.
I am fully compliant with all my tax and social security obligations.
3.
I am free of any real or perceived conflicts of interest with regards to IUCN and its Mission.
4.
I agree to declare to IUCN any real or perceived emerging conflicts of interests I may have concerning IUCN. I acknowledge that IUCN may terminate any contracts with me that would, in IUCN sole discretion, be negatively affected by such conflicts of interests.
5.
I have never been convicted of grave professional misconduct or any other offence concerning my professional conduct.
6.
I have never been convicted of fraud, corruption, money laundering, supporting terrorism or involvement in a criminal organisation.
7.
I acknowledge that engagement in fraud, corruption, money laundering, supporting terrorism or involvement in a criminal organisation will entitle IUCN to terminate any and all contracts with me with immediate effect.
8.
I am not included in the UN Security Council Sanctions List, EU Sanctions Map, US Office of Foreign Assets Control Sanctions List, or the World Bank listing of ineligible firms and individuals. I agree that I will not provide direct or indirect support to firms and individuals included in these lists.
9.
I have not been, am not, and will not be involved or implicated in any violations of Indigenous Peoples’ rights, or injustice or abuse of human rights related to other groups or individuals, including forced evictions, violation of fundamental rights of workers as defined by the International Labour Organization’s (ILO) Declaration on the Fundamental Principles and Rights at Work, child labour, sexual exploitation, sexual abuse, or sexual harassment.
______________________________________________________
<Date and Signature>