Disclaimer and Importance Notice

Claim form for Incubation Support Programme

DISCLAIMER AND IMPORTANCE NOTICE:

Please read the relevant pages of the claim form guide detailing the legal implications of filling out this form or claiming an incentive grant under the programme. Specific attention is drawn to the dti’s rights to or cancels any agreements based on incorrect or misleading information provided in this form. Fraudulent applications and claims made will be persecuted to the full extent of the law.

PLEASE NOTE THE FOLLOWING BEFORE COMPLETING THE FORM:

1. Please study the ISP information brochure Incubation Support Programme Guideline. 2: Please be aware of the fact that the brochure forms part of the agreement with the dti. 3: Each page must be initialled by authorised representative for applicant; the last page of the claim form must be signed by the authorised official of the applying incubator. 4: Before submitting, be sure to have attached all required documents. 5: All amendments to the original claim submitted must be initialled. 6: The standard format of the claim form cannot be changed.

All applicants are encouraged to submit complete claim forms and supporting documents via the e-mail for efficient processing of the claims on

SECTION 1 /
DOCUMENT CHECKLIST
1: REFERENCE NUMBER
2. NAME OF APPLICANT (as registered with CIPRO / CIPC)
2.1. TRADING NAME OF INCUBATOR

3. LIST OF ADDITIONAL DOCUMENTS (Tick the items that are attached to the claim)

Fully completed and signed claim form / A Valid Tax Clearance Certificate
Incubators bank account showing private partner funds (Q1) / Signed Minutes of Advisory Board Meetings Incorporating:
Resolutions – appointment of Advisory Board Members, Calendar meetings & Board member’s Profiles.
Declaration by the CFO of the incubator confirming authenticity of all invoice copies are certified as original
Certified invoices as original by the commissioner of oath
Supplier Maintenance Form for the incubator (Signed, dated & stamped by the bank and the bank stamp must not be older than 3 months) / Factual Finding Report (FFR)
List of Incubatees i.e. Quarter 2,3 and 4 / Lease Agreements (where applicable)
Deliverable cost breakdown & supporting invoices for Quarter 2, stage 3 & stage 4 / Activity and Asset list related to the Quarter of claim
Invoices & Bank statement Q 2,3 & 4 / Asset re-evaluation certificates (where applicable)
Quarter 1 / Quarter 2 / Quarter 3 / Quarter 4

4. CLAIM TYPE

5. CLAIM PERIOD

START DATE / CCYY / MM / END DATE / CCYY / MM

------Date:

Authorised Representative for Applicant initials

SECTION 2 / CLAIM FORM

6. PHYSICAL ADDRESS OF FACILITY / INCUBATOR POSTAL ADDRESS

Postal Code

Name & Surname

7. CONTACT PERSON

Mr / Mrs / Ms / Dr / Prof / Sir

Title

CONTACT DETAILS
e.g. +27(0) 12394 0000
e.g. +27(0) 72000 0000
e.g. +27(0) 12394 0000

8. CONTACT DETAILS (with area codes)

E-MAIL

FAX

MOBILE

WORK

WEBSITE

Insert registered tax office
TAX NUMBER
TAX CLEARANCE EXPIRY DATE / CCYY / MM

9. TAX OFFICE

VAT NUMBER (if applicable)

TAX CLEARANCE CERTIFICATE NUMBER

10. LITIGATION (Provide Details of On-going Litigation)

11. BANKING DETAILS

BANK NAME

ACCOUNT NUMBER

BRANCH CODE

ACCOUNT TYPE

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Authorised Representative for Applicant initials

SECTION 3 / CLAIM FORM

12. NUMBER OF INCUBATEES / ENTITIES (Total number of incubate companies for this claim period?)

13. (A) TOTAL NUMBER OF JOBS CREATED BY ALL INCUBATEES FOR THIS CLAIM

WHITE / BLACK / INDIAN / COLOURED / OTHER / TOTAL
MALE / FEMALE / MALE / FEMALE / MALE / FEMALE / MALE / FEMALE / MALE / FEMALE / MALE / FEMALE
How many of the above total are disabled (Insert the number under the total column)

14. (B) TOTAL NUMBER OF JOBS CREATED BY THE INCUBATOR

SECTION 4: ACTUAL EXPENDITURE FOR THE CLAIM PERIOD

CLAIM PERIOD / DAY / MONTH / YEAR
DAY / MONTH / YEAR

EXPENDITURE / TOTAL / GRANT AMOUNT ( FROM the dti) / GRANT PERCENTAGE / %
Business development services
Total

· Please attach a detailed cost breakdown spread sheet, asset and activity lists for the expenditure relating to these quarter claim. The amount claimed for payment is subject to the dti verification, site visits, invoices, activities and approved business plan of the supported incubator.

------Date:

Authorised Representative for Applicant initials

SECTION 5: DOMICILIUM, RESOLUTION AND DECLARATION

DOMICILIUM Indicate your domicilium citandi et executandi for the serving of legal documents and other notices (physical address of facility

I hereby declare that the information submitted with this claim is true and correct and I have initialled each page of this form to this effect. The financial statements or information used in the preparation of the claim are attached. I hereby authorise the dti to submit this claim form and financial statements to SARS if the dti deems it necessary. I also declare that all qualifying capital expenditure and operating expenditure were utilised in the approved Incubation project and was operational during the period of the claim.
I am aware of the fact that the information which I have submitted above will have a material bearing on the authorisation of this claim and if it, therefore, subsequently appears that any information as per this claim is incorrect, or that certain information was omitted, the dti shall, without prejudice to any other of its rights, be entitled to claim back any amounts already paid with interest or to withhold the payment of any amounts due to the entity.
I confirm that I am aware that the evaluation of this claim by the dti is subject to the ISP guidelines.

DECLARATION

Signed

Capacity

Name in Print

Date

RESOLUTION:

The Board of Directors of Hereby authorises

In his / her capacity as to sign all documents pertaining to the claim to the dti or any documentation pertaining thereto

Signed at on this day of
NAME OF DIRECTORS / SIGNATURES OF DIRECTORS

------Date:

Authorised Representative for Applicant initials