COMMUNITY
GRANTS
APPLICATION
Organisation Name:
Organisation
Name:
ABN:
ABN:
ACNC Registration:
Yes
No
ACNC
Postal Registration:
Address:
provide
Registration
Number:
Please
Physical
Address (if different):
Postal
Address:
Physical
Address (if different):
Website Address:
Contact Telephone(s):
Website
Address:
Fax number:
Contact
Telephone(s):
Email:
Fax
number:
Skype:
Email:
Skype:
Primary Contact:
Name:
Position:
Name: Primary Contact:
Total income
income and
andexpenditure
e􀀾penditure for
for the
the last
Total
last
financial
year
financial year or attach a copy of the
(please income
include the and
dollar amount
and attachfor
a copy
of last
your
Total
expenditure
the
latest
annual report:
most recent audited financial report)
financial year or attach a copy of the
latest
annual
report:
Number
of staff:
(equivalent full time)
Number of staff:
Requested
grant amount: (not to exceed
(equivalent
full time)
25% total organisation budget):
Requested grant amount: (not to exceed
If
other
funding
is anticipated
for this
25%
total
organisation
budget):
work, please indicate other funding
If
other funding
is anticipated for this
sources
and amounts:
work, please indicate other funding
sources and amounts:
COMMUNITY
GRANTS APPLICATION
Please provide Registration Number:
Yes
No
Position: Income: AU$ Income:
AU$ AU$
Expenditure:
Expenditure:
Employed: AU$
Volunteers:
Employed: Volunteers:
AU$ AU$ AU$ AU$ COMMUNITY GRANTS
APPLICATION
Which States in
Australia do you
operate:
currently
Which States in
Victoria
Tasmania
Northern
Territory
Western
Australia
Positive Action Community Grants are available to support Non Government and Community Organisations in
Australia
do you
PLHIV
New
South
Wales
initiatives
Queensland
that
aim
to
achieve
South
Australia
90:90:90
(UNAids).
ACT
their work to improve the lives of
including
currently
operate:
We will support programmes that are innovative, sustainable and produce tangible results. To this end, the
following priority areas have been identified.
Positive Action Community Grants are available to support Non Government and Community Organisations
Organisations in
in
their
work
to
improve
the
lives
of
PLHIV
including
initiatives
that
aim
to
achieve
90:90:90
(UNAids)􀀆and beyond.
their work to improve the lives of PLHIV including initiatives that aim to achieve 90:90:90 (UNAids).
Which
of the following
We will
will support
support
programmes
that are
are
innovative􀀅sustainable and results. this end, Initiatives
that facilitate
increased
access
totangible community-based
peer
to
peerthe testing
We
programmes that
innovative,
sustainable
andproduce produce
tangible
results.To To
this
end,
the
Positive
Action
following
priority
areas
have
been
identified.􀀆
among key populations.
following priority areas have been identified.
programme priorities
does your project
Which
following
intend of
to the
address?
Positive Action
(choose only one)
programme priorities
does your project
intend to address?
(choose only one)
Number of beneficiaries
expected:
Projects that strengthen the capacity of community organisations to improve linkage
Initiatives
thatand
facilitate
increased
community-based
to treatment
support
retentionaccess
in caretofor
people living withpeer
HIV.to peer testing
Stigma
and discrimination
among
key populations.
Projects that enhance the quality of life of people living with HIV.
Testing
and /or linkage
to treatment
andorganisations
care
Projects
that strengthen
the capacity
of community
to improve linkage
to treatment and
support methods
retention to
in address
care for people
livingproduce
with HIV.
Development
of effective
stigma and
achievable
outcomes.
Quality of Life
Projects that enhance the quality of life of people living with HIV.
Indirect: Development of effective methods to address stigma and produce achievable
outcomes.
Direct: Project Duration:
Number
beneficiaries
(include of
start
and finish dates)
expected:
Total Project Cost
Project Duration:
(include start and finish dates)
Indirect: Direct: AU$ $0.00
Total Project Cost
AU$ $0.00
COMMUNITY
GRANTS APPLICATION
COMMUNITY GRANTS
APPLICATION
Project Title:
$0.00
Project summary please provide a brief description of your proposed project.
Further details are requested below.
Please provide a brief description of the target population your project seeks to serve. Include
any age, identity, or demographic information that can help us understand your proposed
beneficiaries:
COMMUNITY
GRANTS APPLICATION
COMMUNITY GRANTS
APPLICATION
Section 6:
6: Budget
Budget
Section
Please use
use the
the following
following table
table to
to provide
provide estimated
estimated budget
budget in
in AU$
AU$ for
for your
your
Please
Section
6:
Budget
proposed programme
proposed
programme
Please use
the following table to provide estimated budget in AU$ for your
proposed programme
Budget Line
Line
Budget
Budget Line
Specification
Specification
Specification
A. Salaries
Salaries and
and Fees
Fees
A.
A. Salaries and Fees
Budget
Budget
Budget
Amount
Amount
Amount
(Total
Budget
(Total
(Total
project)
Amount
project)
project)
(Total
project)
Subtotals
Subtotals
B. Administrative
Administrative Costs
Costs (should
(should not
not exceed
exceed 15%
15% total
total budget
budget request)
request)
B.
Subtotals
B. Administrative Costs (should not exceed 15% total budget request)
Subtotals
Subtotals
C. Materials/Supplies
Materials/Supplies
C.
Subtotals
C. Materials/Supplies
Subtotals
Subtotals
D. Workshops/Trainings
Workshops/Trainings
D.
Subtotals
D. Workshops/Trainings
Subtotals
Subtotals
E. Travel
Travel
E.
Subtotals
E. Travel
Subtotals
Subtotals
F. Other
Other (please
(please specify)
specify)
F.
Subtotals
F. Other (please specify)
Subtotals
Subtotals
Total amounts
amounts
Total
Subtotals
Total amounts
GRANTS APPLICATION
COMMUNITY
Secured
Secured
Secured
Amount
Amount
Amount
(from
Secured
(from
(from
other
Amount
other
other
sources)
(from
sources)
sources)
other
sources)
Requested
Requested
Requested
Amount
Amount
Amount
Requested
Amount
COMMUNITY GRANTS
APPLICATION
Questions
Q1.
Why this project is needed – what issue is it expected to address?
Q2.
How does the project respond to the need you outlined in Q1 and align with the
priorities of the Positive Action community grants?
Q3.
What are your projects Main Objectives and Core Activities?
Q4.
What is the anticipated impact of this program? What does success look like and how
will you measure it?
COMMUNITY
GRANTS APPLICATION
COMMUNITY GRANTS
APPLICATION
Final Checklist
Proof of registration:
Proof of NGO/Charity status:
A copy of your most recent annual report:
Does your organisation focus (at least 75% activity and spend) on HIV
and PLHIV:
Grant request less than 25% total organisation income:
List Company Directors/board members attached:
ViiVHealthcarePtyLtd.Level4,436JohnstonSt,AbbotsfordVIC3067,ACN138687448.ForinformationonViiVproductsor
toreportanadverseeventinvolvingaViiVproduct,pleasecontactViiVMedicalInformationon1800499226.Dateof
preparation:October2015|AUS/HIV/0016/13(1)d.6116Vii ViiV Healthcare Pty Ltd. Level 3, 436 Johnston St, Abbotsford VIC 3067, ACN 138 687 448. For information on ViiV products or to report an adverse event involving
a ViiV product, please contact GSK Medical Information on 1800 499 226. Date of Preparation: March 2017. AUSHIV002017
COMMUNITY
GRANTS APPLICATION