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Disbursement Methods Section 2 (**)

Direct Payment

Reimbursement

Advance

DA-A

DA-B

Methods Available

Yes

Yes

Yes

For expenditures under Category 1

For expenditures under Category 2

Schedule 1 Disbursement Arrangements

Copy of records

Supporting Documentation Subsections 4.3 and 4.4 (**)

o Customized Statement of Expenditures for Capitation Payments financed under Category 1, in the format provided in Attachment 2 of the DFIL;

o Customized Statement of Expenditures for Category 2, in the format provided in Attachment 3 of the DFIL;

o Verification by the Project Verification Commission, required when reporting expenditures under Categories 1 and 2; and

o Statement of Expenditure for Category 3, in the format provided in Attachment 4 of the DFIL.

o Cash flow forecast, when requesting advance, as defined in Section Ill of DFIL; o Customized Statement of Expenditures for Capitation Payments in the format provided

in Attachment 2 of the DFIL; o Verification by the Project Verification Commission; and o Designated Account Activity Statement in the form provided in Attachment 5 with a copy

of the Designated Account Bank Statement. o Customized Statement of Expenditures in the format provided in Attachment 3 of the

DFIL; o Verification by the Project Verification Commission; and o Designated Account Activity Statement in the form provided in Attachment 5 with a copy

of the Designated Account Bank Statement.

DA-C For expenditures under

Category 3 o Statement of Expenditure in the format provided in Attachment 4 of the DFIL; and o Designated Account Activity Statement in the form provided in Attachment 5 with a copy

of the Designated Account Bank Statement.

Special Commitments No Not Applicable

Designated Account A

Type Segregated Ceiling I Variable Financial Institution - Name Banco Central de Nicaragua Currency I USD

Frequency of Reporting, Quarterly Amount I Based on Semi-annual forecast

Subsection 6.3 (**)

Designated Account B

Type Segregated Ceiling I Variable Financial Institution - Name Banco Central de Nicaragua Currency I USD

Frequency of Reporting, Quarterly Amount I Based on Semi-annual forecast

Subsection 6.3 (**)

Designated Account C

Type Segregated Ceiling I Fix Financial Institution - Name Banco Central de Nicaragua Currency I USD

Frequency of Reporting, Quarterly Amount I 6,000,000

Subsection 6.3 (**)

Authorized Signatures: A letter in the Form attached (Attachment 1) should be furnished to the Association at the address indicated below providing the name(s) and specimen signature(s) of.the official(s) authorized to sign Applications:

The World Bank 1818 H Street, N.W. Washington, DC 20433, USA Attention: Mrs. Seynabou Sakho, Country Director

Applications: Completed Applications for withdrawal, together with supporting documents, should be provided through the Association's Client Connection, web-based portal, following the instructions for electronic delivery. In the case the Recipient does not have internet access, the Association may permit the delivery of A_eplicatio11s_!_or withd~awal, together with sup_p_orting documents, to !_h_e following address:

Banco Mundial SCN Quadra 02, Lote A Ed. Corporate Financial Center, 72 andar 70712-900, Brasilia, D.F. - Brazil Attention: Monica Tambucho, Team Leader, Loan Operations

The World Bank Financial Management Unit needs to conduct an evaluation of the CUT implementation. Once the assessment is completed and if the Bank is satisfied with the arrengements, the Bank could proceed to make adjustments in the project Designated Accounts, amending this Document.

** Sections and subsections indicated relate to the Disbursement Guidelines for Investment Project Financing dated February 2017

The World Bank 1818 H Street, N.W. Washington, D.C. 20433 United States of America

[Letterhead] Ministry of Finance

[Street address] [City] [Country]

Attention: Mrs. Seynabou Sakho, Country Director

Attachment 1

[DATE]

Re: IDA Credit __ -NI (NICARAGUA - Integrated Provision of Health Care Services Project)

I refer to the Financing Agreement (" Agreement") between the International Development Association (the "Association") and the Republic of Nicaragua (the "Recipient"), dated providing the above Credit. For the purposes of Section 2.02 of the General Conditions as defined in the Agreement, any t[one] of the persons whose authenticated specimen signatures appear below is authorized on behalf of the Recipient to sign applications for withdrawal [and applications for a special commitment] under this Credit.

For the purpose of delivering Applications to the Association, 2(each] of the persons whose authenticated specimen signatures appears below is authorized on behalf of the Recipient, acting 3(individually] 4(jointly], to deliver Applications, and evidence in support thereof on the terms and conditions specified by the Association.

S[This confirms that the Recipient is authorizing such persons to accept Secure Identification Credentials (SIDC) and to deliver the Applications and supporting documents to

1 Instruction to the Recipient: Stipµlate if more than one person needs to sign Applications, and how many or which positions, and if any thresholds apply. Please delete this footnote in final letter that is sent to the Association.

2 Instruction to the Recipient: Stipulate if more than one person needs to jointly sign Applications, if so, please indicate the actual number. Please delete this footnote in final letter that is sent to the Association.

3 Instruction to the Recipient: Use this bracket if any one of the authorized persons may sign; if this is not applicable, please delete. Please delete this footnote in final letter that is sent to the Association.

4 Instruction to the Recipient: Use this bracket only if several individuals must jointly sign each Application; if this is not applicable, please delete. Please delete this footnote in final letter that is sent to the Association.

5 Instruction to the Recipient: Add this paragraph if the Recipient wishes to authorize the listed persons to accept Secure Identification Credentials and to deliver Applications by electronic means; if this is not applicable, please delete the paragraph. Please delete this footnote in final letter that is sent to the Association.

the Association by electronic means. In full recognition that the Association shall rely upon such representations and warranties, including without limitation, the representations and warranties contained in the Tenns and Conditions of Use of Secure Identification Credentials in connection with Use of Electronic Means to Process Applications and Supporting Documentation ("Terms and Conditions of Use of SIDC"), the Recipient represents and warrants to the Association that it will cause such persons to abide by those terms and conditions.]

This Authorization replaces and supersedes any Authorization currently in the Association records with respect to this Agreement.

[Name], [position]

[Name], [position]

[Name], [position]

Specimen Signature: ________ _

Specimen Signature: ________ _

Specimen Signature: ________ _

Yours truly,

/signed/

[Position]

MINISTER/0 DE SALUD DIVISION GENERAL ADMINISTRATIVA F.INANCIERA

UNI DAD COORDINADORA DE FON DOS EXTERNOS

Nombre del Proyecto:

Proyecci6n de capitas para el periodo de:

r. ----.--.----------.------.--------- .. ------------ .. ---------.------------------.--------------------------DetaUe de las transferencias del 60% durante el pedodo de: _ _ ·--·· _

SlLAIS Munldplo Costo Responsabllldad i Total Anual C6plta I Pobladon de

Unltarlo (Fuente INIDE) i (Columna c x D)

[,:~tal ··

Monto Semestral

Attachment 2

r-· ---- · FIIIIAIIICIAMIEIIITC> 111~.:l--- _________________ _

t

FECHA:

------------------- No. SOUCITUD -----------------------! CATEGORIA No.: 1

------- ----- .. --------------------------------· l_ __________________ COMPONENTE: _ CAPITACl6N

Completar solamente al Documenter las Tranafertncla1 reallzeda1 por parte de MINSA a 101 Munlclplos i

60% antldpado 160% transferldo a loJ ___ dMol ntto -- i-- T/C --1EquClvrdalenbte1--Fecha de ---rCk./ Transfer ···1 :penenepor: enooas r

por el Banco Munldplos , T sferl · ; (H K) transferenda No. : · ran r ; x . :

------!

MINISTERIO OE SALUO DIVISION GENERAL ADMINISTRATIVA FINANCIERA

UNI DAD COORDINADORA DE FON DOS EXTERNOS

Nombre del Proyecto:

[0et_a_l_le de la certificaci6n del cumplimiento de indicadores y plan de calidad (40%) del perlodo:

!Meta de las indicadores para ei periodo/Porcentaje aceptable de cumplimeinto:

SILAIS Munldplo Total Semestral

l(Capttax Pobloct6n}+2J

40% •leslblo para flnondlmlentodal total

Semestral

Porcentaje 1lcanzado

------------------ ,------- - ----+-- C --- . .. A D•Cx40%

MIio cumpllda 51•1/NO=O

---------------------------: -----------+-----------+------------------------------~ --------

[: l'INA1"4Clll"11_ENTO No.:j

f

l ________ ---------------- FECHA: '.------------------------------i No. SOLICITUD, ,

_ _ CATEGORfA No.:, 1 I

COMPONENTE:J CAPITACION

I i Es raquerldo Pion !

Monto do pqo ! Manto Manto de Acd6n O

Manto • redblr Manto onvtodo , 1utorlzado 11 1 Rllonldo Ratanldo Fortai.dmlanto (l} 11 Pr ... ntar el al Fonda

Munldplo on USD1 on 11 parfodo Acumulodo (SI/NO) Pion Camlin , T/C

Manto di p110 outorlzado 11 Munldplo

enCordobos

G H•D-G K i M •• .....

MINISTER/0 DE SALUD

DIVISION GENERAL ADMINISTRATIVA FINANCIERA

UNIDAD COORDINADORA DE FONDOS EXTERNOS

Nombre del Proyecto:

Periodo: r== ____ ]

Attachment 3

! ____ : __________ FINP.I\ICIAMIENTO No.: [ ________________ - ---_ -__i i FECHA:t i ( _____________________________ No. SOLICITUDj---------------------------

11

i CATEGORfA No.: 2 [_::::::- ___________ :_:- __ COMPONENTE: _______________ - -- ____ __]

I I Poblaci6n de M d

I Numero de

I Saldo del Manto total

2 • onto e Manto tota . 1,1

1 1 Tipo Actividad de Casto II referenc,a A . . d I

productos ·r. d Ant1cipo para el / certificado por SILAIS o Curso , . . . nt1c1po e . cert, ,ca o por T C

Salud Publica Umtano I est1mada para el 5

US cert1ficados por S IS/C U pr6ximo SILAIS/Curso en emestre en D ILA urso en SD ,

semestre SILAIS/Curso penodo Cordobas

r----·-·-·······-··- ·····------···+-----·-···· - --···-····-·-+···--·······-

!

' '

t--~--- ----- +---------- -----+----·

···t--· ··+·

---·--+--------·--- -+------· -

··+··

·······+·· ··············· I···

I

l Total______________ _ ___ L________ _ ____ ·--- __ J__________ _J _________________ oL ___________________ o[__ __________ o/___________ _ ____ o L_____ ----··---o [_ _________ . _J___ -----·-·--OJ

1 2 3

Hombre dal Breve deacrlpcl6n C6d4lo dal Proveedor del gaeto galto

lnstrucciQnes:

4

Contrato Sujeto a

BANCO INTERNACIONAL OE RECONSTRUCCl6N Y FOMENTO

Certftcado de Gaatoa

5 8 7 8

Reglatro Moneda Monto Total Manto dal dol dal acumulado

revllli6n prevla contrato contrato Contrato del contrato (SI oNO) enC.C. (lncluldo • n

SOEaanterlore•)

Cotumno 1: lnbnne el nombra del pro- _

9

NUmero de la

Factura o Reclbo

Cotumna a: Hacer una txw, descripclcln del gaoto (ajemplo: honorario8 dic/2012, co,.~ aer.icio do limpieza, li4llcoo, aer.icioo do audttoti.., etc).

10 11 12

Monto % Fecha del Pagado al Flnanc.

Pago Proveador porBIRF

0.00

Cotumna 3: ldonll8car cual tipo do gesto lua hacho (ejemplo: CS: co,-!Moria I CW: o- / GO: blenoo / OP: coatoe --1- / lR: en1.-o I NCS: ~ do no_, SP: Sut,p,oyectoe) Cotumna 4: lnbnnar al el contRlllo lua o no oomelido a r81ial6n Pf8',ie dol Banco Mundlel. Cotumna I: lnbnnar n(maro do reglatm del C0111181o an Client Connection Cotumna I: lnbnnar moneda del conlRlllo Cotumna 7: lnbnnar *' dei'contRlllo (an la monad• que lua lndloada an la columns D) Cotumna 8: lnfonnar "81or dol contRlllo que yo lua pogado, lncluldo en SOEo anlerton,o. Cotumna t: lnfonnar el numllO do la r.cton o NCllbo del ~ Cotumna 10: lnbmar-del pogo al pro-Cotumna 11: lnbmar '8lor pogado al~. an la moneda lndlcada an la lllctura. Cotumna 12: lr)dloar el poroenlual do lnmic:lamlanto (de aouerdo al OOIM<lio de pnlotamo/donacl6n)

Attachment 4

PRESTAMO/CREDITO/DONACION NO.: NO. SOLICITUD:

NO. HOJA:

NO. CATEGORIA:

CUENTA OESIGNADA SOLAMENTE 13 14 15 18

Cantldad Manto THO Fecha Debitada

Admilibla de 06blto Cuanta (Col 11 X 12) Cambia Cuanta Detignada

Delignada (Col 13X 14)

0.00 0.00

0.00 0.00

0.00 o.oc

0.00 0.00

0.00 0.00

0.00 000

0.00 000

0.00 TOTAL 0.00

Cotumna 13: Calculo del rnonlo admlolble para lnanclamianlo (noaultado do la multlpliGaclcln de la colurma 11 por la 12). Paro loo ••oa an que el poroenlual do lnmic:iamlento • de 100'!(,, loa "81on,o de •a cotumna aenin loa mtmoe preeentadoo an la oolumna 11. Cotumna 1,, lndloar la taoa da camblo. F119r 1.,. an CUlll1la gue la t•e de camblo a•• utNlzada debe ..-111111 de lntamallgcloo da Joa l>ndoo. Eo deolr gue. !I poyeolo dg utlllz.ar la mlome 181a gue t., utHlzada pllJI tlW18iHnw loa d6ian,o gue el 8anco omt6 al pn,yecto an monad@ local. EH punto • muy lmporlanle •• el Banco no n,gonoca dl'°'Jnclao de cambio como aeeto eleqlble de lnlncilmlerto. Cotumna 15: F"""8 queen la cull el proyecto nitlro loa - do la cuanta deslgnado (an d6tanlo) y loa omt6 a le cuenla open,lh,a (an rnonada local). Cotumna 18: Collculo de la cotumna 13 x cotumna 14. Eaa cotumna releja en monlo aqul-a an d61- del gaato raallzado. qua aanl oo,._ por el Banco para dooumantacl6n.

Attachment 5

CONCILIACION DE LA CUENT A DESIGNADA PREST AMO/CREDITO/DONACION No: NOMBRE DEL BANCO: NUMERO DE CUENTA:

1. Total de Dep6sitos 2. Menos Total Documentado 3. Saldo por Recuperar

4. Saldo al / / de Acuerdo al Estado Bancario Adjunto

5. Monto de la Solicitud No._ 6. Mas monto pendiente de Reembolso por el Banco 1/ 7. Mas retiros efectuados a(.m no solicitados al Banco 2/ 8. Menos montos debitados despues de la fecha del Estado Adjunto

9. Menos intereses generados por la Cuenta Designada

10. Total (4 + 5 + 6 + 7+ 8 -9)

11. Discrepancias entre (3 y 9)

OBSERVACIONES:

1/ Valor pendiente de reembolso por el Banco No. de Solicitud Monto

2/ Retiros efectuados aun no solicitados al Banco Fecha Descripci6n

Aqui se incluira una explicaci6n del del Punta 8), o sea en que fue gastado el dinero que aun no fue solicitado al Banco. Esto es exigido

cuando este importe supera el 15% del dep6sito en la Cuenta Designada.

1. Suma de todos los irrportes adelantados por el Banco a la Cuenta Designada

2. Suma de todos los importes documentados

3. Linea 1 menos Linea 2

4. Saldo igual al estado de cuenta bancario presentado. (Converter para d61ares)

5. lnformar el importe total a ser documentado en la solicitud que se esta presentando

6. Solo en el caso de tener importes pendientes de pagar por el banco de Solicitudes anteriores.

USO

0.00

0.00

0.00

0.00

0.00

0.00

o.ool

o.ool

I

Monto

0.00

7. Este importe es la parte que fue retirada de la Cuenta Designada y no corresponde a gastos que se estan incluyendo en el

pr6xirro SOE Refiere a nuevos gastos que aun no han sido incluidos en SOE

8. Aqui solo iria algo si hubieran retirado un nuevo importe de la Cuanta Designada, posterior a la fecha del estado de cuenta

bancario que esta siendo presentado