Application Form
Community Ice Action Grants 2017 – Round 3
SECTION 1: CONTACT AND ORGANISATION INFORMATION:
Part A: Applicant organisation details
Fields marked (*) are mandatory
* Legal name of organisation:
* Trading name of
organisation:
* Main street address:
* Town/suburb:
* Postcode:
* State:
Postal address (if different from above):
Town / Suburb:
Postcode:
State:
Authorised person (This is the person who is authorised by the organisation to make the application on their
behalf)
* Title:
* First name:
* Last name:
Position:
Telephone:
Email:
Incorporated association
Other (please specify)
* Type of
Organisation:
Are you an Aboriginal community
led organisation?
Yes
Local government
No
Applicant organisation’s Australian Business Number (ABN)*
Note: If operating under an auspice arrangement the ABN provided
should be that of the auspice.
Part B: Auspice organisation details
If your organisation is not incorporated, you must arrange for an incorporated organisation to manage the grant
funds. This organisation will be the ‘auspice organisation’ for the application and you will need to provide their
details in Part B.
Name of auspice organisation:
Main street address:
Town/suburb:
Postcode:
State:
Postcode:
State:
Postal address (if different from above):
Town/suburb:
Authorised person
Title:
First name:
Last name:
Position:
Telephone:
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Email:
Type of organisation:
Incorporated association
Local government
Other (please specify)
Organisation’s Australian Business Number (ABN):
Has the auspice organisation agreed to manage the grant on your behalf?
Yes
No
Part C: Contact Details for Project Manager
Title:
First name:
Last name:
Position:
Telephone:
Email:
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SECTION 2: PROJECT OVERVIEW
* Project name
Please use 10 words or less. We will use this name on all
correspondence.
* Project description
Describe the project in 100 words or less. We will use this in reports
and other publications.
* Where will your project be delivered?
Please specify the Local Government Area where your activities will
primarily be delivered from.
Local Government Area (LGA)
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SECTION 3: PROJECT BUDGET
Section 3 – Project Budget
Please provide details of the income and expenditure for your project, excluding GST.
You are required to submit your budget using the categories provided.
Income
Expenditure
* Community Ice Action Grants 2017 amount requested (up to $10,000)
$
Administration overheads
$
Local Government funding
$
Training
$
Federal Government funding
$
Project coordination
$
Funds from your organisation
$
Security and first aid
$
Funds from other community organisations $
Venue/room hire
$
Funds from business contributions
$
Equipment hire
$
Funds from philanthropic contributions
$
Transportation
$
In-kind support from your organisation
$
Marketing and promotion
$
In-kind from other sources
$
Printing
$
Other (please specify)
$
Equipment and materials (general)
$
Salaries
$
Other (please specify)
$
*Total income $
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*Total expenditure $
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SECTION 3: RESPONSE TO THE GRANT CRITERIA
Please indicate how your Community Ice Action Grants project will addresses the following criteria. In your
response please answer all questions listed in each of the three sections – Project overview, Project delivery and
outcomes, and Project stakeholders.
Please limit your response for each question to 500 words or less.
1. Project overview (20% weighting)
a) Provide an overview of the project – identify the type of project, its goals and objectives and target
audience
b) Describe the local need(s) for the project in your community
c) Provide evidence of these needs – use statistics, data, research, anecdotal evidence and community
consultation
d) Outline what has already been done locally/how this will build on existing services and/or community
activities
2. Project delivery and outcomes (50% weighting)
a) Outline the specific activities and initiative/s proposed (including key dates and events)
b) Describe the objectives of the project and the intended outcomes (i.e., what are the benefits or changes
you expect to see as a result of the proposed activities or initiative?)
c) Describe how these benefits / changes will be measured (i.e., how have the intended outcomes been
achieved)
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d) Provide a rationale/evidence base for the proposed activities
3. Project stakeholders (30% weighting)
a) List the key partners that will support the implementation of this project (including schools, community
organisations, councils and businesses)
b) Describe the role each of the key partners will play in implementing the initiative
c) Demonstrate engagement with those already undertaking local activities in response to local ice issues
d) Outline how project stakeholders will be engaged and their efforts coordinated to achieve outcomes and
to manage and report on projects effectively
e) Describe how the group will function (i.e., who will be the fund holder, how decisions will be made and
how any disputes will be resolved?)
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Supporting documents
If you have any additional documents to submit in support of your application please note you can include up to
three documents with an aggregated size not exceeding 15 MB.
If you are entering into an auspice arrangement one of your attachments must be a letter signed by an
authorised representative of your organisation and your auspice which specifies the agreement to the auspice
arrangement and the roles and responsibilities of each organisation in relation to project implementation.
Please specify the full file name and file extension of any additional documents forming part of your application
below.
Document 1:
Document 2:
Document 3:
Declaration
I state that the information in this application and attachments is to the best of my knowledge true and correct. I
will notify DHHS of any changes to this information and any circumstances that may affect this application. I
acknowledge that DHHS may refer this application to external experts or other Government Departments for
assessment, reporting, advice or for discussions regarding alternative grant funding opportunities. I understand
that DHHS is subject to the Freedom of Information (FOI) Act 1982 and that if a FOI request is made, DHHS will
consult with the applicant before any decision is made to release the application or supporting documentation. I
understand that this is an application only and may not necessarily result in funding approval.
* Signature:
* Date:
* Print name:
* Position:
(To be signed by a person with delegated authority to apply - i.e. Chairperson, Secretary, Public Officer or
Treasurer)
Submitting your application
Applications, including any attachments, must be submitted on or before Thursday 15 June 2017.
Late or incomplete applications will not be considered.
Receipt of applications will be acknowledged by email.
Applications, including a signed, dated and scanned copy of this completed Application Form together with any
additional attachments, must be submitted via email, at: [email protected]
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