Office Use Only
TRIM: ___________________
Government of Western Australia
Grant No: _____________________
Department of Sport and Recreation
Project Coordinator._____________
CSRFF Small Grants Application Form
For projects up to $150,000 to be acquitted by 15 June 2012
You MUST discuss your project with an officer from your nearest Department of Sport and
Recreation office before completing and submitting your application to your Local Government
Authority. Failure to do so will render your project ineligible.
DSR Contact: Chris Thompson / Samantha
Date: 05/08/2011
Office: Great Southern
Stevens
Applicant’s Details:
Organisation
Shire of Jerramungup
Name:
Postal Address:
PO Box 92
Suburb:
Jerramungup
Street Address:
8 Vasey Street
Suburb:
Jerramungup
State:
WA
Postcode:
6337
State:
WA
Postcode:
6337
Preferred Contact Person:
All application correspondence will be directed to this person
Name:
Brent Bailey
Position Held:
Deputy CEO
Business Phone:
Mobile Phone:
Title:
0898351022
0429204538
Dr
Mr
Mrs
Ms
Facsimile:
08 98351161
Email:
[email protected]
Organisation Business Details:
Yes
No
Does your organisation have an
ABN?
Is your organisation registered for
GST?
Is your organisation not-for-profit?
Yes
No
Yes
No
Is your organisation incorporated?
Yes
Bank details:
Bank: Bankwest
No
ABN: 45 742 432 975
* Note, in order to be eligible for
funding you must attach a copy of the
Incorporation Certificate
Incorporation #:
BSB: 306056
*
A/c: 5332607
Local Government Authority Details:
LGA:
Shire of Jerramungup
Contact:
As above
Title:
Dr
Mr
Mrs
Ms
Position Held:
Business Phone:
Facsimile:
Mobile Phone:
Email:
Application Form
CSRFF
PROJECT DETAILS
Project Description:
Development of a synthetic multi-sport / recreation surface in Roe Park Jerramungup. The surface will
include line delineations for soccer, hockey, baseball, cricket, hopscotch etc and provide an open playing
surface for other sports that a larger space permits.
The facility will be within the main park in Jerramungup which the Shire has recently invested funds in to
provide a suitable playground and associated landscaping. The synthetic playing surface will ensure that a
green, safe and playable surface is available year-round which is not reliant on the town water supply.
Currently Roe Park is reticulated and due to soil types and lack of additional rainfall there is little to no
natural grass cover to provide open space recreation opportunities. Under this project the Council is
seeking funding from the Department of Sport and Recreation to be applied to the sporting areas
specifically (i.e. baseball, soccer, golf pitches etc). The Shire of Jerramungup and other grant funds will
contribute the remainder of the costs of the sporting surfaces plus provide the additional landscaping
synthetic grass to link the areas.
How did you establish a need for your project?
Currently the town of Jerramungup is serviced well for organised recreation at the Jerramungup Sports
Complex. This complex is at the most Southern part of town but generally unsupervised outside of fixtured
sports days and training times.
There is no other recreation facility apart from the playground which provides sport and recreation
opportunities outside of fixtured times. This playground does not cater for ages 12+ which for this project is
the key target. The current town park lacks a suitable grassed surface due to water restrictions and soil
conditions. The need for this project is thus to accommodate sport and recreation in a supervised
environment after school and on weekends where fixtured sport is not provided at the Jerramungup Sport
s Complex. It also seeks to provide activities for older children and young adults who are currently
inadequately catered for in a recreation sense in Jerramungup.
Project location:
Roe Park Jerramungup
Land ownership:
Who owns the land on which your facility will be located? Shire of
Application Form
CSRFF
Jerramungup
Lease Expiry (if applicable):
Planning approvals
Where applicable, has planning permission been granted? Yes
No
Have other approvals been granted, ie building Heritage,
Indigenous and Swan River Trust?
Yes
No
How will your project increase physical activity? This project will increase physical activity by providing a
new playing surface for predominantly children and teenagers, facilitating after school hours activity in a
supervised location. Because of the location parents will be more willing to allow children to use the facility
and it will also combine with the barbeque and playground area which have recently been constructed in
December 2010.
This project will also provide a small soccer field which is not currently available in Jerramungup. Soccer is a
popular sport at the School during school hours and an out of school facility may promote a formal youth
competition. The Jerramungup District High School are strongly supportive of the project as they can also
use the facility during school hours and offer a wider range of physical education programs.
The synthetic facility will also permit physical activity and light training during times when the Sports
Complex oval is too wet for sports.
Do you share your facility with other groups? Yes
public.
No
If so, who:
Roe Park is open to the
List the main sport and recreation activities (maximum of 3) which will benefit from your proposal. Please
indicate the approximate % usage of the facility (or part of the facility relating to this proposal).
Sport/community organisation
% use of the facility
Hours per week
Soccer
15%
10
General running and “children’s play”
30%
20
Hockey
10%
5
Activity/sport membership numbers over the past three years relevant to your project. For example, if a
bowls project, golf members not relevant; social membership numbers not applicable.
Note: if membership is not applicable, ie recreation facility or aquatic centre, please enter the number of
users of the facility.
2008/09
161 – ABS
Children in
Jerramungup
2009/10
158 - ABS Children in
Jerramungup
2010/11 Not Available
What is the name of the State Sporting Association for your activity/sport? N/a
n/a
Application Form
CSRFF
Have you discussed your project with your State Sporting Association? n/a
Yes
No
Contact Name:
Date of contact:
PROJECT DELIVERY
Task
Date
Council approvals
August 2011
Preparation of tender/quotes
October 2011
Issuing of tender
December 2011
Site works commence
January 2012
Construction starts
January 2012
Project 50% complete
February 2012
Project completed
March 2012
Handover – final inspections
April 2012
Project Acquitted
April 2012
GST
Grant payments are payable to the applicant/grantee only. This may have taxation implications for
grantees. If grantees wish specific advice relating to their grant, this can be obtained from the Australian
Taxation Office (ATO). Please note depending upon the value of the project and/or grant, the ATO may
require an organisation be registered for GST. If the applicant is registered for GST, the grant is grossed up
with the GST amount.
PRIVACY STATEMENT AND STATEMENT OF DISCLOSURE
The Organisation acknowledges and agrees that this Application and information regarding it is subject to
the Freedom of Information Act 1992 and that the Grantor may publicly disclose information in relation to
this Application, including its terms and the details of the Organisation.
Any information provided by you to DSR can be accessed by you during standard office hours and updated
by writing to DSR or calling (08) 9492 9700. All information provided on this form and gathered throughout
the assessment process will be stored on a database that will only be accessed by authorised departmental
personnel and is subject to privacy restrictions.
DSR may wish to provide certain information to the media for promotional purposes. The information will
only include the applicant’s club name, sport, location, grant purpose and grant amount.
APPLICANT’S CERTIFICATION
I certify that the information supplied is to the best of my knowledge, true and correct.
Name:
Position Held:
Signature:
Date:
Application Form
Brent Bailey
Deputy CEO
__________________________________________________________
CSRFF
LODGEMENT OF YOUR APPLICATION
•
Applications should be stapled or clipped at the top left-hand corner. Please do not bind.
•
It is recommended that you photocopy your completed application form, including attachments for
your own records and future audit purposes.
•
All attachments and supporting documentation (see next section) should be clearly identified and
securely attached to the application form.
•
Applications must be submitted to your Local Government Authority by the Local Government’s
advertised cut off date.
The following documentation must be included with your application. Applicants may wish to supply
additional RELEVANT information.
Grants up to $50,000:
Application form.
Incorporation Certificate.
Two written quotes.
If your project involves the upgrade of an existing facility, include photograph/s of this facility.
Locality map, site map and building plans (in relevant constructions projects), including where the
proposed facility is located in relation to other sport and recreation infrastructure.
Income and expenditure statements for the current and next financial years. (LGAs exempted).
Written confirmation of financial commitments from other sources including copies of council
minutes.
For resurfacing projects, a written guarantee from the supplier of the product that clearly
identifies the product’s life expectancy.
Itemised project cost for components and identified on the relevant quote for each (including
cost escalation).
For floodlighting projects, a lighting plan must be supplied showing lux, configuration and
sufficient power supply
Your application will be considered not eligible, if:
•
You have not discussed your project with the Department of Sport and Recreation and your State
Sporting Association.
•
You do not meet the eligibility criteria for the grant category to which you are applying.
•
You have not included with your application all the relevant required supporting documentation. There
is no onus on Department staff to pursue missing documentation.
•
Applicants/projects that have received a CSRFF grant in the past and have not satisfactorily acquitted
that grant. In some cases this may apply to localities where other significant projects have not been
progressed or have not completed a previous project in accordance with the conditions of the grant
provided. An assessment will be made in November and if no physical progress has occurred, new
applications may not be recommended.
•
It is not on the correct application form.
•
The project for which application is made is specifically excluded from receiving CSRFF support.
Application Form
CSRFF
DEVELOPMENT BONUS APPLICANTS ONLY
If you applied for a CSRFF grant for more than one third of the cost of the project, please provide evidence of meeting
at least one of the following criteria.
You MUST contact your local DSR office to determine eligibility before applying.
Category
Details
Regional/Remote location
Geographical location
Growth Local Government
Co-location
New
Existing
Water saving
Sustainability initiative
Energy reduction
Other
New participants
Increased participation
Existing participants –
higher level
Special interest
Other
Application Form
This project will deliver a range of sporting
opportunities in one location which has ample
supervision from the surrounding
neighbourhood. It also allows parents with
young and older children to be supervised from
a central location.
This project will deliver a recreational park in
synthetic grass and will be one of the first
projects of its kind in Great Southern Local
Governments. The water savings will be
significant as Roe Park is currently fully
reticulated. As a result of taking Roe Park off
the reticulated supply the Water Corporation
has advised that they can accommodate
additional industrial lots in Jerramungup which
is not currently available due to water
shortages. The reticulation system will be
reduced to only the garden areas which are on
dripper systems.
The provision of soccer and baseball sporting
opportunities is a new sporting area for
Jerramungup and will attract additional
participation across a variety of age-groups. It
will also provide the local High School with
access to better facilities for their physical
education programs.
CSRFF
PROJECT BUDGET
ESTIMATED EXPENDITURE
Please itemise the components of your project in the table below, indicating their cost and which quote or part of quote was used to estimate this. Quantity Surveyor
costs will be accepted however the responsibility lies with the applicant to ensure the validity of the information. A contingency allowance is considered an acceptable
component.
Project Description
(detailed breakdown of project to be supplied
ie Electrical Works
Construction and installation of multisport facility
by contractor
Refer to quote for additional detail.
$ Cost ex GST
Quote Used
(list company name and quote no)
27,500 B & S Electrical
$ Cost inc GST
25,000
$149,650
Donated materials
0
Volunteer expenses
0
Sub Total
$149,650
Cost escalation
$0
$164,615 Green Planet Grass
$164,615
Any escalation will be covered by the Shire however we have
$0 commitment on the quote given and the project will be a
fixed price tender once approval is provided.
$164,615
a)
Total project expenditure
$149,650
• At least two written quotes are required for each component.
• If your project is a floodlighting installation or upgrades, please ensure that the power supply is sufficient and no upgrade will be required. If upgrade is required and
not budgeted for, the grant will immediately be withdrawn. A lighting plan must be supplied showing lux and configuration.
• Projects that do not meet Australian Design Standards are ineligible for funding.
Application Form
CSRFF
PROJECT FUNDING
$ Amount
ex GST
Source of funding
Local government
$ Amount
inc GST
24650
Funding confirmed
Y/N
27500 LGA cash and in-kind
Applicant cash
Yes
Organisation’s cash
Cannot exceed applicant cash
and LGA contribution – max
$50,000
Cannot exceed applicant cash
and LGA contribution
Volunteer labour
Donated materials
Other State Government funding
50000
Comments to support claim
(please attach relevant support)
2011/2012 Budget
Yes
55000
No
GSDC Regional Grants Funding
Federal Government funding
Other funding – to be listed
CSRFF requested
Loans, sponsorship etc
50000
Development Bonus
up to 1/3 project cost
55000
25000
27500 Up to ½ project cost
No
No
b) Total project funding
149,650
$164,615
*Note: If the funding approved is less than funding requested for this project, or the project is more expensive than
indicated in this budget, where would the extra funds be sourced from?
Shire of Jerramungup - 2011/2012
budget amendments.
GST
Grant payments are payable to the applicant/grantee only. This may have taxation implications for grantees. If grantees wish specific advice relating to their grant, this
can be obtained from the Australian Taxation Office (ATO). Please note depending upon the value of the project and/or grant, the ATO may require an organisation be
registered for GST. If the applicant is registered for GST, the grant is grossed up with the GST amount.
FINANCIAL SUMMARY
a) Total project expenditure (ex GST)
b) Total project funding
c) Project variance*
$149,650
$149,650
$0
*Balance between a) and b) should be $0
Application Form
CSRFF
________________________club information
PROJECT ASSESSMENT SHEET
This page is for the use of the relevant Local Government Authority to be used for both community and LGA projects.
Please attach copies of council minutes relevant to the project approval.
Name of Local Government Authority: Shire of Jerramungup
Name of Applicant: Shire of Jerramungup
Note: The applicant’s name cannot be changed once the application is lodged at DSR.
Section A
The CSRFF principles have been considered and the following assessment is provided:
(Please include below your assessment of how the applicant has addressed the following criteria)
All applications
Satisfactory
Unsatisfactory
Not relevant
Satisfactory
Unsatisfactory
Not relevant
Project justification
Planned approach
Community input
Management planning
Access and opportunity
Design
Financial viability
Co-ordination
Potential to increase Physical activity
Sustainability
Development applications only
Location
Sustainability
Co-Location
Increased Participation
Section B
LGA – priority ranking of this project
Priority ranking of no of applications received
1
1
of 1
applications received
Regional Plan
State Plan
Local Plan
Is this project consistent with the
Have all planning and building approvals been
given for this project?
If no, what approvals are still outstanding?
Application Form
This project is beyond the scope of the Shire of Jerramungup
local recreation plan as it is Council driven and seeks to deliver
recreation opportunities beyond formal Sports Clubs and
associations which the Local Recreation Plan is based on.
Yes
No
N/A
CSRFF
Project Rating (Please tick the most appropriate box to describe the project)
A
Well planned and needed by municipality
B
Well planned and needed by applicant
C
Needed by municipality, more planning required
D
Needed by applicant, more planning required
E
Idea has merit, more planning work needed
F
Not recommended
LGA comments: This project is a ground breaking approach for the provision of sustainable Park infrastructure in a
local government environment. The installation of a multi-sport synthetic area will not only provide new and
additional sports areas for the residents and visitors of Jerramungup but also contribute to the financial viability of
the Shire by reducing maintenance costs. The installation of a synthetic surface will also provide a year round high
quality surface which is unattainable in the current location due to climate and soil conditions.
This project is an important step forward for the Shire of Jerramungup and the Local Government industry.
Signed
Position Chief Executive Officer
Date
Applications for CSRFF funding must be submitted to your Department of Sport and Recreation office by 4pm on the
last working day in August. Late applications cannot be accepted in any circumstances.
Application Form
CSRFF