Measure 2 application form
word version
APPLICATIONS TO THE DORMANT ACCOUNTS FUND MUST BE MADE ON LINE
VIA THE POBAL WEBSITE
Life after caring – Transitioning support for Carers
June 2017
THIS DOCUMENT IS FOR INFORMATION PURPOSES ONLY
DORMANT ACCOUNTS FUND
APPLICATION FORM
SECTION 1
Dormant Account Fund ELIGIBILITY
1.1 Enter the legal name of the applicant
organisation
Enter name*
WARNING: When you enter your organisation legal name and save your application form as draft you will not be able to
edit this field. Please ensure that you enter the correct name. Should you do this incorrectly, you will need to start a
new application form.
Options * : Association, Cooperative, A Designated Activity
Community (DAC), limited by shares; A Designated Activity
1.2 Please select your organisation type.
Company (DAC) limited by guarantee; a company limited
by guarantee; a private charitable trust; other
If ‘Other’ is selected, please explain.
1.2.1 CRO Number
1.2.2 Enter your Charity Registration Number
1.3 Please attach a copy of your 2016 signed Audit
Accounts.
Note:


Number (optional)
Number
(Note: this is not your CHY number, this is the number
issued to you by the Charities Regulator).
(Optional)
Facility to attach annual signed audited accounts for 2016
If you have already submitted your audited accounts for 2016 to Pobal then you do not need
attach them to this form
Statutory bodies do not need to attach their audited accounts
1.4 Enter the amount of grant you are requesting
from the Dormant Accounts Fund.
Refer to the application guidelines available on the Pobal
website.
€*
The amount entered must be between €50,000 and
€350,000; the figure entered cannot be greater than the total
project costs at Q5.1
1.5 Referring to the application measure guidance (click this link to download a copy).
Please select the Dormant Accounts measure that you are applying under:
Options *:
Measure 2: Life after caring
Measure 4: Supports for female refugees
WARNING: When you select the measure and save the application form to draft, you will not be able to edit this field. If
you have selected the wrong measure, you will need to complete a new application form and follow the steps from the
beginning again.
1
SECTION 2 Measure Specific Eligibility Criteria
MEASURE 2: Life after caring
THE FOLLOWING ELIGIBILITY CRITERIA MUST BE COMPLETED IN FULL
*
2.1 Explain how your organisation is a national
Text box, 8,000 characters mandatory
organisation as defined in the measure guidelines.
Facility to attach a relevant documents (optional)
Facility to insert hyperlink to specific document or website
page (optional)
2.2 How many years’ experience does your
organisation have working directly with family
carers?
*
Enter number of years (must be 3 years or more to be
eligible)
2.3 Provide a summary of your relevant experience in *Text box, 8,000 characters, mandatory
working directly with family carers.
2
3 ORGANISATION DETAILS
NOTE: IF YOU ARE APPLYING AS A PARTNERSHIP THIS SECTION OF THE APPLICATION FORM MUST BE COMPLETED BY THE LEAD
PARTNER ONLY
3.1 Legal Name of the Organisation
Pre-fills from 1.1
3.2 Does your organisation currently have a grant
*Option Yes or No
agreement/contract with Pobal?
3.2.1 If Yes, please insert your URN/Grant ID
*Enter URN/Grant ID
Number
3.3 Provide your Business Name if different from
your Legal Name at Question 3.1 above
3.4 Provide your Organisation Address
Street 1*
Street 2*
Street 3
Street 4
Town *
County (options)*
County Division (options)*
EIRCODE*
3.5 Organisation Website Address
3.6 Tax Registration Number
Optional
3.7 Enter your TCAN (Tax Clearance Access
Optional
Number)
3.7.1 Attach evidence of your TCAN from revenue
Optional
e.g. letter or e-mail from revenue
3.8 Primary Contact Information
(the person who can be contacted in relation to this application)
3.8.1 Salutation
*Options
3.8.2 First name
*
3.8.3 Last name
*
3.8.4 Email
*
3.8.5 Job Title
*Options
3.8.6 Landline
*
3.8.7 Mobile phone
*
3.9 Chairperson Contact Details
(if different from the Primary Contact Details at Q3.8)
3.9.1 Salutation
Options
3.9.2 First name
3
3.9.3 Last name
3.9.4 Email
3.9.5 Landline
3.9.6 Mobile phone
3.10 Attach a copy of your Memorandum and
Articles of Association or relevant government
document
3.11 Is your organisation affiliated or part of
another organisation?
Attach governing documents
Option yes or no
3.12 If Yes to Q 3.11 , please explain
Maximum of 500 characters.
3.12 Governance Arrangements
3.12.1 Insert the details of your current board of directors
Name of Board
Member
Position on Board
Representative Of:
(Target
Group/Organisation/Sector)
3.12.2 How often does your Board meet?
Options
Once a Month
Bi-Monthly
Bi-Annually
Annually
Other
Please explain other- if
selected
3.12.3 Have you any sub-committees in place? Option Yes or No
3.12.4 If you answered ‘Yes’ to Q 13.12.3, please complete the following table for the relevant sub-committees
you have in place.
Please enter N/A in any fields that are not applicable to you
Sub-Committee
1
Audit/Finance
Sub-Committee
Purpose/Role of the SubCommittee
Text
How often does the SubCommittee report to the Board
/Management Committee?
Options
 Weekly
 Monthly
 Quarterly
 Bi-Annual
 Annually
4
2
3
Human
Resource/Staff
Committee
Marketing and/or
Publicity
Committee
Text
Options
Text
Options
4
Text
Options
Facilities/Specific
Service
Committee
5 Other; please
Text
Options
explain
3.12.5 Has your organisation put in place a governance code or standards of practice?
For more information please go to www.governance.ie
Please note that this answer is for information purposes only.
Options yes or no
13.12.6 If Yes, please provide details of the code or standards of practice.
Text Maximum Characters = 8.000
3.13 Staffing arrangements
3.13.1 How many staff are currently employed in your organisation?
Note: If you do not currently employ staff please enter zero in the table.
Number of Full Time Staff
number
Number of Part Time Staff
number
3.14 Volunteers
3.14.1 How
many
volunteers are
involved in
your
organisation?
Do not include
board
members in
your response.
If you do not have volunteers enter zero
3.15
Previous experience in managing funding
3.15.1 What are your procedures and controls to ensure good financial management?
Mandatory 8,000 characters
5
3.15.2 In the table below, please provide details of EU or exchequer funding that you have managed in the
last three years. Only grants that are relevant to this application should be listed below.
Funder Name
Year Funding
Awarded
Programme
Amount Awarded
4. PROJECT PROPOSAL
Please refer to the guidelines which will provide you with more detail on the sort of information we are looking for in these
questions.
Click this link to download the guidelines
4.1 PROJECT SUMMARY
Please provide a short summary of the project you plan to deliver with Dormant Accounts Funding.
Note: If you are successful, we may use this information in any publicity we produce about your project.
Maximum characters 5,000 mandatory
6
4.2 YOUR PROJECT DETAILS
4.2.1
What is the aim of your project?
Maximum 500 characters
Q4.2.2 List the objectives, related actions and locations where these actions will be delivered during the lifetime
your proposed project
Objective
Actions
Timeframe for
delivery of
actions.
Please name
month and
year
Organisation
with
responsibility
for delivery
Will the proposed project be
delivered on a national,
regional, county-wide or local
basis?
NOTE: A minimum
of 1 project
objective must be
outlined in the
table.
NOTE: Each
project objective
must have at
least one
corresponding
action.
NOTE: Please
provide a
timeframe for
each action.
NOTE: This
column should
only be filled
out for
partnership
applications
Each project
objective must
have at least one
corresponding
action.
Answers should
be inputted in a
month and year
format e.g.
NOTE: Pick one of the four
options for your proposed
project:
 Nationwide
 Regional (more than one
county)
 County-wide (a number
of locations covering
one county)
 Local (one area or a very
limited number of areas
within a city or county)
FAO ICT:
Applicant must choose one of the
four dropdown options:
FAO ICT: Table
must facilitate 5
objectives.
Applicant must enter
a minimum of 1
project objective.
MM/YYYY to
MM/YYYY
A timeframe
must be
provided for
each action.
Free Text
Maximum 500
characters
Objective 1: Free
text
MM/YYYY to
MM/YYYY
Action 1: Free text
Action 2: Free text
Action 3: Free text
Action 4: Free text
ICT to add a
rule/limit for the
dates can be
enteredWaiting on
Dept. to
confirm
timelines for
programme
MM/YYYY to
MM/YYYY*
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
FAO ICT:
Optional
Free Text
Maximum 100
characters for
each cell.




Nationwide
Regional
County-wide
Local
NB: Applicant selects one option
to represent the entire project (i.e.
Applicant does not select one of
the above options for each action).
Free text
Free text
Free text




Nationwide
Regional
County-wide
Local
Free text
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Action 5: Free text
Objective 2: Free
text
Action 1: Free text
Action 2: Free text
Action 3: Free text
Action 4: Free text
Action 5: Free text
Objective 3: Free
text
Action 1: Free text
Action 2: Free text
Action 3: Free text
Action 4: Free text
Action 5: Free text
Objective 4: Free
text
Action 1: Free text
Action 2: Free text
Action 3: Free text
Action 4: Free text
Action 5: Free text
Objective 5: Free
text
Action 1: Free text
Action 2: Free text
Action 3: Free text
Action 4: Free text
Action 5: Free text
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY*
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY*
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY*
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY*
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
MM/YYYY to
MM/YYYY
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
Free text
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4.3 PROJECT MANAGEMENT AND DELIVERY
4.3.1 Explain who within your organisation will be responsible for managing and delivering the
actions outlined.
Provide a justification for any new role(s) which will be supported by this funding.
8,000 characters (mandatory)
4.3.2 Attach job description(s) template for any new role(s) which will be supported by this funding.
Facility to upload JOB DESCRIPTION TEMPLATES HERE.
4.3.3 Explain how local branches of your organisation, your regional offices will be involved in the
delivery of the actions outlined in this application
8,000 characters (mandatory)
4.3.4 Explain what other organisations, local groups or other stakeholders will be involved in the delivery of the
actions outlined in the application. Describe their role and responsibilities. (If applicable).
8.000 characters (optional)
4.3.5 Estimate the total number of unique (individual) carers who will benefit from your project
proposal.
Enter whole number, mandatory
4.4 NEED FOR THE PROJECT
Explain how the need was identified for the specific actions outlined in this proposal, including
consultations with carers and any evidence based research by your organisation or independently;
Maximum 8,000 characters
9
4.5 MEASURE OUTPUTS and OUTCOMES
Select the expected outputs and outcomes for your project proposal in the table below. Your response must include at
least one of the measure outputs and outcomes included in the application guidelines.
Measure outputs
Target numbers for each
output
Measure outcomes
Select a minimum of one
output
Options:
 Number of preactivation coaching
programmes for post
caring carers
 Number of post caring
carers in coaching and
support programmes by
age, gender and level
of job-skills
 Number of post caring
carers who completed
training by gender and
by age
 Number of publications
or information
resources developed
and number distributed
 Number of information
and awareness
sessions delivered per
year
 Number of networks
supported per year
 Number of trainers
trained per year
Select a minimum of one
outcome
Options:
 Readiness to engage
with employment
activation support
services
 Readiness for new
learning and training
 Post care transition and
successful new role
development where
those who wish are
empowered to
participate fully in the
labour market.
 Facilitate carers to
improve their mental
health management
and promote a healthy
lifestyles:
Option to add in project
specific outputs
Option to add in project
specific outcomes
Target numbers for each
outcome
Explanatory Notes:
1. When you select an output from the dropdown list it is mandatory for you to enter a number under the target for
each output. This should be a realistic and achievable figure.
2. When you select an output you must select an outcome from the dropdown list that your output will contribute
to. You may select the same outcome for a number of outputs.
3. When you select an outcome you are also asked to provide a target. The target should be realistic and
achievable. The target inserted for the outcome may be less than output target. For example, 40 individuals
will have attended pre-activation coaching however the corresponding outcome may be that 25 are ready for
new learning and training.
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4.6 MEETING THE MEASURE CRITERIA
4.6.1 Explain how your proposal will provide support for former carers in dealing with the loss of caring, their
loss and will proactively support carers to plan a new life at home, work and within their community
Maximum characters 8,000
4.6.2 Explain the extent and impact of the information sharing and networking activities in relation to a “life
after caring”.
Maximum characters 8,000
4.6.3 Explain the extent and impact of “train the trainer programmes” to support former carers.
Maximum characters 8,000
4.6.4 Provide evidence that your proposal is not possible without Dormant Accounts Funding.
Maximum characters 8,000
4.6.5 Explain how the proposal is compatible with government policy for supporting carers.
Maximum characters 8,000
4.6.6 Outline how the proposal will address social and economic disadvantage.
Maximum characters 8,000
4.7 SUSTAINABILITY
Outline how learning and/or any actions will be sustained beyond the end date of your proposed project.
Maximum 8,000 characters
4.8 MONITORING
How will you monitor and record progress in relation to your project?
Maximum 8,000 characters
4.9 ANY OTHER RELEVANT INFORMATION
Please provide any other information which you think is relevant to this application
Maximum 8,000 characters
Facility add supporting documents (not mandatory)
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SECTION 5
FINANCES
5.1 What is the total cost of your project
5.2 What is the grant amount you are
seeking from the Dormant Accounts
Fund?
5.3 If the project costs are greater than
amount applied for, please explain how
you will fund the additional costs.
€
€ 5.2 MAY EQUAL 5.1, amount cannot be greater than €350,000 for
M2; prefills from Q1.4
Maximum 8,000 characters
VAT
5.4 Is your organisation registered for
Y/N
VAT?
5.4.1 If yes, is the VAT recoverable for the
Y/N
costs included in this project?
5.4.2 If no, complete the VAT Not
Recoverable Template
Attach VAT Not Recoverable Template
Click this link to download the VAT Not Recoverable
Template
If Yes to Q5.4, VAT must be excluded from the costs outlined in the Budget Template.
5.5 What is the proposed start date for
your project?
The earliest start date for your project will be 1st December 2017 and the latest end date will be
the 31st December 2018. Your project can start or finish any time between these dates.
5.6 What is your proposed end date for
the project?
5.7 PROJECT BUDGET

Facility to attach budget template
Click this link to download the Budget
Template
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SECTION 6
Disclaimers
A. Disclosure under the Freedom of Information Act
Under the Freedom of Information Act 2014, the information in this application form and its attachments may
be released on request to third parties.
If you believe that any of the information in your application form is sensitive and should not be disclosed to
a third party, you must identify the sensitive information and provide the reason(s) for its sensitivity.
You will be consulted about the sensitive information before any decision is made to release the information
to a third party.
Please outline the sensitive information and the reason(s) for the sensitivity in the text box below.
Text box (maximum 1,500 characters). Optional.
B. Data Protection
In submitting this application to Pobal, your organisation (and project partners) agree that:

No sensitive personal data should be included on this form.
Sensitive personal data is defined as data relating to a person's racial origin; political opinions or
religious or other beliefs; physical or mental health; sexual life; criminal convictions or the alleged
commission of an offence; trade union membership. In this case, sensitive personal data may also refer
to the inclusion of names, addresses and/or ages of service users or project beneficiaries in your
application form.

Your organisation authorises Pobal to use, process and store the information in this form for the
purposes of assessing your proposal for funding, the administration of any grants awarded by the
Dormant Accounts Fund and the production of internal and external reports relating to the Dormant
Accounts Fund.

In its management of the Dormant Accounts Fund scheme, Pobal may transfer any data it has received
from, and any data it holds relating to your organisation to other persons and bodies, such as the
Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs, the Department of Social
Protection, the Department of Justice and Equality or any other Government Departments sponsoring
the Dormant Accounts Fund.

If a third party is acting on your organisation’s behalf, Pobal is authorised to use, process and store
data received from this third party and to forward to the third party, any data relating to your application,
Pobal’s appraisal of your application and your organisation’s delivery of projects supported by the
Dormant Accounts Fund. Pobal may also procure data from third parties to assess your application.

It is your organisation’s responsibility to ensure that any sensitive personal data submitted is obtained
with the individual’s consent and knowledge that the data will be used for the purposes of this
application. By submitting this application form, your organisation confirms that consent has been
obtained from any individual whose data is disclosed within the application form.
Tick box to confirm that you have read and agree with the above data protection requirements.
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SECTION 7
SUBMISSION OF APPLICATION
Please read carefully before submitting your application.
In submitting this application, the board of directors or management committee:
 Confirms that the application form and attached documents is submitted on their behalf;
 Declares that the information provided in the application form and attached documents are true and
accurate;
 Accepts that Pobal may contact funding organisations or Government Departments to discuss this
application and previous funding awarded, as part of the selection process;
 Has the co-funding in place as described in the application form (if applicable);
 Has a current lease or agreement in place with the owner of the property (if applicable);
 Has the consent of the legal owner of the premises to carry out any refurbishment or to install
machinery (if applicable);
 Has planning permission or applied for planning permission to carry out any refurbishment included in
this application (if applicable);
 Accepts that the Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs, the Department
of Social Protection, the Department of Justice and Equality or Pobal shall not be liable to the
applicant or any other party in respect of any loss, damage or costs of any nature arising directly or
indirectly from:
a) The application or the subject matter of the application;
b) The rejection for any reason of any application.
 Accepts that the Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs, the Department
of Social Protection, the Department of Justice and Equality or Pobal, their servants or agents, shall
not at any time or in any circumstances, be held responsible or liable in relation to any matter
whatsoever arising in connection with the development, planning, construction, operation,
management and or administration of an individual project.
7.1
NAME
7.2
POSITION ON THE BOARD
ACCEPTABLE USE AND PRIVACY STATEMENT – hyperlink to the Pobal policy on our website which outlines
conditions re using online forms and information provided on line.
14