REINVESTMENT PROJECT FORM
Module 3 – Distribution costs for a non-national European film
(to be filled in and signed by the distributor)

Declaration on the applicant's honour

I, the undersigned, hereby declare on my honour:
•	that the applicant company is not in one of the exclusion cases listed in Section 6 of the guidelines of Call  EACEA/07/2012;
•	that it is a European company as defined in the guidelines applicable to this Call;
•	that the project for which European Union support is requested is a non national European film as defined in Call for proposals EACEA/07/2012 and that the film does not consist of advertising, pornographic or racist material nor advocates violence;
•	that I am familiar with the Guidelines ``Support for Trans-national Distribution of European Films - The Automatic Scheme`` of Call EACEA/07/2012 of the MEDIA Programme and that I accept and observe the conditions and procedures specified therein, particularly regarding matching funds; 
•	that the applicant company holds the theatrical distribution rights of the film applied for the territories and duration specified in this Reinvestment Project Form and that a copy of such contract is enclosed with this application;
•	that the information contained in this Reinvestment Project Form and the Company Form are true, verifiable and up-to-date;
•	that the company has the financial and operational capacity to complete the proposed action;
•	that I have been duly authorised by the applicant company to sign this application.
I am fully aware that my organization is not entitled to receive more than one grant from the European Union Budget for the action covered by this application and will therefore withdraw any application for any other grant from the European Union Budget should this application be successful, or will withdraw this application should any other application be successful.
I also agree to the publication of information about the grant award, should my application be successful.

Name of the legal representative: 			Date: 		
Signature of the legal representative:		
Legal name of the company:	………………………..

CHECK LIST

Identification of the company:
In case of modified circumstances since you sent the Agency your 2012 Company Form (change of ownership/shareholders/signatory, new financial year, change of the bank details...), a new company form must be filled in and sent with the corresponding documents.
Any modification that is not notified to the Agency may cause the delay or the cancellation of the financing and contracting of the selected project(s).

Please enclose the following documents :
	One copy of the distribution contract (with annexes and without alterations), signed with the producers and/or sales agent. The copy of the contract must contain the following statement ‘copy certified as true’ together with the signature of the representative of the company.

	Production cost and corresponding financial plan of the film in national currency, certified by the delegate producer and/or by the relevant national authority.

If the information on the film and/or the distribution contract have already been supplied to the MEDIA Programme as a part of an application in response to previous calls for proposals, they need not be supplied on this occasion. A full list of all films which have already been qualified is available for consultation at: http://eacea.ec.europa.eu/media/films 

I. 	Information regarding the film

Original title: 		

Cast and crew list:

Director: 
Name: ..........................................	Nationality / Residence: 	

This film is the director’s

		1st feature film 		2nd feature film		Other	

Script Writer: 
Name:		Nationality / Residence: 	

Main cast (official credits order):
Name: 		Nationality / Residence: 	
Name: 		Nationality / Residence: 	
Name: 		Nationality / Residence: 	

Composer:
Name: 		Nationality / Residence: 	

Production design (art direction) :
Name: 		Nationality / Residence: 	

Director of photography:
Name: 		Nationality / Residence: 	

Editor:
Name: 		Nationality / Residence: 	

Sound:
Name: 		Nationality / Residence: 	

Shooting location: 		Country:		

Laboratory:		Country: 	

I. 	Information regarding the film

Original Title: 		

Local Title: 	

Genre:
		Fiction		Documentary		Animation
Length (in minutes): .	. 	Format:		
Shooting language:		
Year of copyright:    		
Cost of production: 	local currency 		in EURO (€).............................

Date of beginning of principal photography: 	

Date of completion of principal photography: 	

Financing Plan of the film

Please enclose the Financing Plan, including the Total Production Cost, certified by the lead producer. The Financing Plan should identify the (co)producer(s) of the film (as officially credited) and their share in the (co)production. 

Statement of confidentiality: the above requested document is strictly for the internal use of the MEDIA Programme and for qualification purposes only.

Producer (or Lead producer in case of international co-productions):

Name of the Company	Town	Country	% in the co-production
							
Co-producers:
Name of the Company	Town	Country	% in the co-production

							
							
	TOTAL		

World sales agent:
Name of the Company: 	
Street: 	.		Tel: 			
Town: 			Fax: 		
Country: 			E-mail	

II. 	Informations regarding the distribution of the film

Local Title:		

Distribution territory: ………………………………………………………………………….
Duration of rights ownership of the distributor:   	
Contract type: 	Minimum guarantee		Percentage remuneration		Flat fee
Date of contract signature:		
Amount of MG in currency of the contract: 		
Other rights to the film held by the distributor for those territories: 
Video:	 rental   sell-through	
Television:  Pay-TV	 Free TV    Other (please specify):		

Enclose one copy of the distribution contract or agreement with the producers and/or sales agent (complete copy, with annexes and without any deletion) with the hand written statement "Copy certified as conforming to the original" signed by the statutory legal representative of the company.

Target audience: 		

Predicted number of weeks in exhibition: 		

Forecast date for first release (from 1/10/2012 until 01/10/2014):		
Number of prints for first release:		
Maximum number of prints forecast:		
Number of towns forecast for first release: 
	Cities of greater than 1 million inhabitants: 		
	Towns between 500.000 and 1 million:	.....	
	Towns between 100.000 and 500 000:	.....	
	Towns less than 100.000 inhabitants:	.....	

Publicity campaign for the film: 
Television: 	local		national		European	
Radio: 	local		national		European	
Press:	local		national		European	
Poster:	local		national		European	
Other:	local		national		European	
(Please specify)