Project/Programme Title: _____________________________

Country/Region: _____________________________

Accredited Entity: _____________________________

National Designated Authority: _____________________________

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Please submit the completed form to [email protected]

A. Project / Programme Information

A.1. Project / programme title

A.2. Project or programme Choose an item.

A.3. Country (ies) / region
A.4. National designated
authority(ies)
A.5. Accredited entity
A.6. Executing entity / Executing Entity:
beneficiary Beneficiary:
A.7. Access modality Direct ☐ International ☐
A.8. Project size category
(total investment, million Micro (≤10) ☐ Small (10<x≤50) ☐ Medium (50<x≤250) ☐ Large (>250) ☐
USD)
A.9. Mitigation / adaptation
Mitigation ☐ Adaptation ☐ Cross-cutting ☐
focus
A.10. Public or private Choose an item.
Which of the following targeted results areas does the proposed project/programme
address?

Reduced emissions from:

☐ Energy access and power generation
(E.g. on-grid, micro-grid or off-grid solar, wind, geothermal, etc.)
☐ Low emission transport
(E.g. high-speed rail, rapid bus system, etc.)
☐ Buildings, cities, industries and appliances
(E.g. new and retrofitted energy-efficient buildings, energy-efficient equipment for companies and
supply chain management, etc.)
☐ Forestry and land use
A.11. Results areas (E.g. forest conservation and management, agroforestry, agricultural irrigation, water treatment
(mark all that apply) and management, etc.)

Increased resilience of:

☐ Most vulnerable people and communities
(E.g. mitigation of operational risk associated with climate change – diversification of supply
sources and supply chain management, relocation of manufacturing facilities and warehouses,
etc.)
☐ Health and well-being, and food and water security
(E.g. climate-resilient crops, efficient irrigation systems, etc.)
☐ Infrastructure and built environment
(E.g. sea walls, resilient road networks, etc.)
☐ Ecosystems and ecosystem services
(E.g. ecosystem conservation and management, ecotourism, etc.)
A.12. Project / programme life
…………… years
span
A.13. Estimated Start: ………………………...
implementation start and end
date End: ………………………….

1Please use the following naming convention for the file name: “[CN]-[Agency short name]-[Date]-[Serial
number]” (e.g. CN-ABC-20150101-1).
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B. Project/Programme Details

The Fund requires the following preliminary information in order to promptly assess the eligibility of
project/programme investment. These requirements may vary depending on the nature of the project/programme.

B.1. Project / programme

description (including
objectives)

Describe project/programme sponsor’s operating experience in the host country or

other developing countries.
B.2. Background information
on project/programme Describe financial status and how the project/programme sponsor will support the
sponsor project/programme in terms of equity, management, operations, production and
marketing.

Describe the market for the product(s) or services including the historical data and
forecasts.

Provide the key competitors with market shares and customer base (if applicable).
B.3. Market overview

Provide pricing structures, price controls, subsidies available and government

involvement (if any).

Provide details of government licenses, or permits required for implementing and

operating the project/programme, the issuing authority, and the date of issue or
expected date of issue.
B.4. Regulation, taxation and
insurance Describe applicable taxes and foreign exchange regulations.

Provide details on insurance policies related to project/programme.

Describe construction and supervision methodology with key contractual

agreements.

Describe operational arrangements with key contractual agreements following the

B.5. Implementation completion of construction.
arrangements

Provide a timetable showing major scheduled achievements and completion for each
of the major components of the project/programme.
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C. Financing / Cost Information

Please provide:
 a breakdown of cost estimates analysed according to major cost categories.
C.1. Description of  a financial model that includes projection covering the period from financial
financial elements of the closing through final maturity of the proposed GCF financing with detailed
project / programme assumptions and rationale;
 a description of how the choice of financial instrument(s) will overcome barriers
and achieve project objectives, and leverage public and/or private finance.

Financial
Amount Currency Tenor Pricing
Instrument
Total project
financing ………………… Options
(a) = (b) + (c)

(i) Senior Loans

………………… Options ( ) years ( )%
(ii) Subordinated
Loans ………………… Options ( ) years ( )%
(iii) Equity ………………… Options ( ) % IRR
(iv) Guarantees ………………… Options
(b) (v) Reimbursable ………………… Options
Requested grants *
………………… Options
GCF amount
(vi) Grants *

C.2. * Please provide detailed economic and financial

Project justification in the case of grants.
financing
information Total Requested
………………… Options
(i+ii+iii+iv+v+vi)

Financial Name of
Amount Currency Seniority
Instrument Institution

Options ………………… Options ………………… Options

(c) Co-
financing Options ………………… Options ………………… Options
Options ………………… Options ………………… Options
Options ………………… Options ………………… Options

Lead financing institution: ………………………

(d)
Covenants
(e)
Conditions
precedent to
disbursement
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D. Expected Performance against Investment Criteria

Please explain the potential of the Project/Programme to achieve the Fund’s six investment criteria as listed below.
Specify the climate mitigation and/or adaptation impact. Provide specific values for
the below indicators and any other relevant indicators and values, including those
D.1. Climate impact potential from the Fund’s Performance Measurement Frameworks.
[Potential to achieve the  Total tonnes of CO2 eq to be avoided or reduced per annum
GCF's objectives and  Expected total number of direct and indirect beneficiaries and number of beneficiaries
results] relative to total population (e.g. total lives to be saved from disruption due to climate-
related disasters)

Provide the estimates and details of the below and specify other relevant factors.
D.2. Paradigm shift potential
 Potential for scaling-up and replication (e.g. multiples of initial impact size)
[Potential to catalyze
 Potential for knowledge and learning
impact beyond a one-off  Contribution to the creation of an enabling environment
project or programme  Contribution to the regulatory framework and policies
investment]

Provide the estimates of economic, social and environmental co-benefits. Examples

include the following:
 Economic co-benefits
- Total number of jobs created
- Amount of foreign currency savings
- Amount of government’s budget deficits reduced
D.3. Sustainable development  Social co-benefits
- Improved access to education
potential
- Improved regulation or cultural preservation
[Potential to provide wider - Improved health and safety
development co-benefits]  Environmental co-benefits
- Improved air quality
- Improved soil quality
- Improved biodiversity
 Gender-sensitive development impact
- Proportion of men and women in jobs created

Describe the scale and intensity of vulnerability of the country and beneficiary groups
and elaborate how the project/programme addresses the issues. Examples of the
issues include the following:
D.4. Needs of recipient
[Vulnerability to climate  Level of exposure to climate risks for beneficiary country and groups
 Does the country have a fiscal or balance of payment gap that prevents from
change and financing
addressing the needs?
needs of the recipients]  Does the local capital market lack depth or history?
 Needs for strengthening institutions and implementation capacity

Provide details of the below and specify other relevant factors.

D.5. Country ownership
 Coherence and alignment with the country’s national climate strategy and priorities in
[Beneficiary country mitigation or adaptation
ownership of project or  Brief description of executing entities (e.g. local developers, partners and service
programme and capacity providers) along with the roles they will play
to implement the proposed  Stakeholder engagement process and feedback received from civil society
activities] organizations and other relevant stakeholders
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Provide details of the below and specify other relevant factors (i.e. debt service
D.6. Effectiveness and coverage ratio), if available.
efficiency
 Estimated cost per t CO2 eq (total investment cost/expected lifetime emission
[Economic and financial reductions)
soundness and  Co-financing ratio (total amount of the Fund’s investment as percentage of project)
effectiveness of the  Economic and financial rate of return
proposed activities] - With the Fund’s support
- Without the Fund’s support

E. Brief Rationale for GCF Involvement and Exit Strategy

Please specify why the GCF contribution is critical for the project/programme.

Please explain how the project/programme sustainability will be ensured in the long run, after the project/programme is
implemented with support from the GCF and other sources.

F. Risk Analysis
Please describe the financial and operational risks and discuss mitigating measures.

Please briefly specify the substantial environmental and social risks that the project/programme may face and the
proposed risk mitigating measures.

G. Multi-Stakeholder Engagement
Please specify the plan for multi-stakeholder engagement, and what has been done so far in this regard.

H. Status of Project/Programme

1) A pre-feasibility study is expected to be completed at this stage. Please provide the report in section J.

2) Please indicate whether a feasibility study and/or environmental and social impact assessment has been
conducted for the proposed project/programme: Yes ☐ No ☐
(If ‘Yes’, please provide them in section J.)

3) Will the proposed project/programme be developed as an extension of a previous project (e.g. subsequent phase),
or based on a previous project/programme (e.g. scale up or replication)? Yes ☐ No ☐
(If yes, please provide an evaluation report of the previous project in section J, if available.)

I. Remarks
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J. Supporting Documents for Concept Note

☐ Map indicating the location of the project/programme
☐ Financial Model
☐ Pre-feasibility Study
☐ Feasibility Study (if applicable)
☐ Environmental and Social Impact Assessment (if applicable)
☐ Evaluation Report (if applicable)