Application No.
Application Form Notes
1. Please ensure you fully read the supporting guidance
notes before completing your application form to ensure
the eligibility of your project.
2. If you require further copies please contact us on 0300
300 0059.
3. Please be aware that the Community Chest Committee
meet on a quarterly basis (February, May, August,
November) so all applications need to be received in the
month prior.
4. Please send completed form and supporting documents
to:
Sustainable Communities Team, Severnside Housing
Brassey Road, Old Potts Way, Shrewsbury, SY3 7FA
1. Name of Organisation/Group:
2. Project Title:
3. Contact Details:
Name:
__________________________________________
Address:
__________________________________________
__________________________________________
Postcode:
__________________________________________
Telephone: __________________________________________
Email:
__________________________________________
Position within group:
5. Details of the project
5. Expected dates for project
Start:___________________
Finish:___________________
6. Grant Required:
Please list the items of expenditure for projects requiring funding over
£50 which the grant will pay for (attach additional sheet if necessary)
Quote 1.
Cost of item £
£
Source
Quote 2.
£
Quote 3.
£
Total £
Independent estimates (where appropriate) – Photocopied catalogue pages
are acceptable
7. Total cost of project if this is greater than the amount applied for from
Community Chest
£ _________________
Please list any other funding you have previously received for this project or
names of organisations that you have applied to funding:
Organisation
Amount of funding
Received/ Expected
Outcome
8. This section gives you the opportunity to show how your project will
directly benefit our residents/communities
a). Which groups of the community will have access to or benefit from
the project?
b). How will you manage, maintain or fund this project in the future?
c). Does your project involve working with children, young people
(under the age of 18) or vulnerable adults?
Yes / No
(If yes, please answer question below)
d). Do all the project worker(s) have an up to date Disclosure Barring
Service check?
Yes / No
(Proof may be required prior to any monies being awarded)
e). Are there any health and safety implications relating to this project?
Yes / No
If yes, have you undertaken a Risk Assessment?
Yes / No
f). Is there appropriate Public Liability Insurance cover? (if applicable)
Yes / No
(Please be aware that proof of insurance will be required prior to award
being given).
STATEMENTS OF AGREEMENT
Terms and Conditions
We have read and understood the terms and conditions of the
Severnside Housing Community Chest. We agree to provide all
necessary documentation for verification prior to consideration of
funding and to provide regular project feedback and financial
monitoring information as required.
We understand that any grant awarded may be subject to a Disclosure
Barring Service (DBS) check and that payment of funds may be denied
if proof is not given.
Data Protection Statement
The information requested on this form is required by Severnside Housing
in order to assess whether or not a Community Chest grant can be
awarded and will be shared with panel members of the Community
Chest Group.
Your approval to share this information is requested; please note that if
you do not give approval we will not be able to assess your application
for a Community Chest grant.
We hereby give approval for Severnside Housing to share any
appropriate information as stated in the terms and conditions in
connection with the assessment for Community Chest funding.
Signature: ____________________________
Date:____________
On Behalf of
(Organisation): _______________________________________________
Payment Details
Please complete the form below and return it to:
Sustainable Communities Team
Severnside Housing
Brassey Road
Old Potts Way
Shrewsbury
SY3 7FA
Organisation name
Address
Cheque to be
made payable to:
The information that you have provided on this form will only be used for the
purpose of handling payments made to. The information will not be made
available to a third party.
Checklist
Have you enclosed any of the following?
Most recent statement of accounts/bank statement
Yes / No
Costing and 3 quotes, where applicable, to support
your application
Yes / No
Have you been awarded grant funding before?
If applicable, proof of Disclosure Barring Service
Check (DBS)
Yes / No
Yes / No /
To follow
Office use
Only
Application No:
__________________
Organisation Name:
___________________________________________
Amount Requested:
£___________________________
Decision:
Approved
Declined
Reason for Approval / Decline
Amount Approved: £ __________________________
Cost Code:
92/027
Expense Code:
76/CMCH
Authorised by
Signature:
_______________________________ (Charity Trustee)
Signature:
_______________________________ (Community Chest Chair)
Signature:
_______________________________ (Resident member)
Date:
_______________________________