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CDM-SUZ-FORM Proposed special underdeveloped zone submission form (Version 01.0) Submitting DNA: Contact Information: (name of person or office, e-mail addresses and phone contacts) Signature, and stamp of the authorized signatory of the DNA: Date of submission: IDENTIFICATION OF THE SPECIAL UNDERDEVELOPED ZONE Name and geographical coordinates of the region proposed as special underdeveloped zone (SUZ): Attach map indicating the region proposed as SUZ: Attach official notifications for development assistance by the host country in which the region proposed as SUZ has been identified: INFORMATION TO BE ATTACHED (fill (a) and/or (b)) (a) The proportion of the population of the proposed SUZ with income less than USD 2 per day (PPP adjusted) is greater than 50%: Yes No If yes: Public available data on the proportion of population of the region proposed as SUZ with income less than USD 2 per day (PPP) are attached. The source of the data is provided. (b) The Gross National Income (GNI) per capita of the country is less than USD 3000 and the population of the region is among the poorest 20% in the poverty ranking of the host country: Yes No If yes: Public available data on the GNI of the host country are attached. Public available data on the poverty ranking within the host country are attached. Information to conclude that the population of the region proposed as SUZ is among the poorest 20% in the poverty ranking of the host country is attached. Version 01.0 Page 1 of 2 CDM-SUZ-FORM The sources of the data are provided. FURTHER INFORMATION Any additional information or data and their sources you consider relevant to identify the proposed SUZ: SECTION BELOW TO BE FILLED IN BY UNFCCC SECRETARIAT Submission number: Date when the form was received by UNFCCC Secretariat: ----Document information Version Date Description 01.0 26 November 2012 Initial publication. Decision Class: Regulatory Document Type: Form Business Function: Methodology Keywords: special underdeveloped zones, additionality Version 01.0 Page 2 of 2