Ref: 16.48318
Special Community Projects
and
Events Funding
APPLICATION FORM
INSTRUCTIONS FOR APPLICANTS:
1.
Refer to the Guidelines and Information for Applicants for eligibility criteria, funding
categories, and selection guidelines. Close observation of this document will assist
you with your application. Funding decisions are made by the Council, based on
this information. Please allow three (3) months from the date of your application to
allow for a report to be presented to Council and a response to be provided.
2.
If you wish to apply for more than one project a separate Application Form must be
completed for each project. Extra copies of both the Application Form and Guidelines
and Information for Applicants are available on the Council’s website at
www.mitchamcouncil.sa.gov.au/communitygrants. If you wish to use a word copy or
would like a copy posted to you, please contact the Council on 8372 8899.
Please forward completed applications to:
City of Mitcham
PO Box 21
Mitcham Shopping Centre
TORRENS PARK SA 5062
Fax: 8372 8101
Or via email [email protected]
3.
If you have any queries/comments regarding completing this application form please
contact the Council by telephoning 8372 8899.
Special Community Projects & Events Funding - Application Form – January 2017
SECTION A:
APPLICANT DETAILS
Name of group or organisation
undertaking the project:
Organisation’s Postal address:
Postcode:
Telephone Number:
Email address:
Does your organisation have an ABN Yes
No
If NOT a representative of the organisation will be required to complete an Australian Tax
Office – “Statement by a Supplier” form, which will be provided to successful applicants to
complete at a later date.
ABN:
CONTACT PERSON FOR THIS PROJECT:
Name:
Daytime Contact number:
Email Address:
DESCRIPTION OF GROUP OR ORGANISATION
In summary, what is the primary aim
or goal of the group or organisation?
Any further details of the group or
organisation?
Number of members currently
involved in the group or
organisation?
What procedures are used by your
group to ensure your income and
expenditure is fully and accurately
accounted for?
Does your group or organisation
benefit from the use of Council
grounds and/or buildings, through a
lease or other hire arrangement
and/or have the use of grounds which
are regularly maintained by the City
of Mitcham?
Yes
No
If YES, please provide details (ie annual
lease or hire cost to group, annual
maintenance cost to group, etc).
Special Community Projects & Events Funding - Application Form – January 2017
2
Has your group or organisation
previously received a Community
Development Grant from Council?
Yes
No
Yes
No
If you have previously received
grant(s) from this Council have
Statements of Expenditure been
submitted?
Yes
No
Is the Organisation Incorporated?
Yes
No
If NO, are you auspiced by an
Incorporated Organisation?
Yes
No
If YES, please provide the year and
round funding was provided, the amount
received and the name of the project for
which funding was received:
Did the organisation receive any
other funding from the Council within
the last financial year?
If YES, please provide the date, the
amount received and the purpose of the
funding:
Please provide the name of the
auspicing organisation:
SECTION B:
DESCRIPTION OF THE PROJECT
Project Title:
Amount applied for
Project funding category
Refer to the ‘Guidelines’, ‘Funding
Categories’, and choose the Category
that best describes the aims of the
project for which the grant is being
sought (not the general focus of your
group or organisation):
$
Please tick one only:
Community Projects:
Community & Cultural Development
Recreation
Sport
Community Health & Safety
Environmental Improvement
Community Event
(please attach a copy of Public Liability Insurance
cover)
Facilities Upgrade & Equipment Purchase
(Quotations must be attached to this application
and prior approval sought from Council for any
proposed improvement to Council owned
property.)
Special Community Projects & Events Funding - Application Form – January 2017
3
In summary, what is the primary aim
or goal of the project and what
outcomes will be achieved?
Any further detail of the project (ie
how is it: innovative, of value to the
community, meeting a need within the
community, number of people who
will benefit, etc)?
How did you decide the project was
needed?
How was demand for the project
identified?
Does your project seek to:
Target a recognised community need or
identified gap
To foster community engagement and
participation
Primarily benefit residents of the City of
Mitcham and the Mitcham community (refer
to question below)
Encourage a strong sense of community
wellbeing that supports learning,
participation, inclusiveness, healthy
lifestyles and environmental sustainability.
What percentage (approximately) of
the Mitcham Community will benefit?
.%
If residents from another Council area
will benefit, are funds being sought
from that Council? If so, please
provide details.
Special Community Projects & Events Funding - Application Form – January 2017
4
Target Group:
Youth
(Please indicate which group(s) within
the community is most likely to benefit)
People with a Disability
Aged
Socially Isolated
Culturally Diverse
Disadvantaged
Other (please list):
Yes
No
Could your project proceed if you
only received partial funding?
If YES, how?
Yes
No
Are written quotations attached?
Yes
No
Do any similar projects exist within
the City of Mitcham?
Please provide details:
How does your project encourage
and support the involvement of
volunteers? (ie coordination,
planning, training)
How will you promote your project in
the community (ie Mitcham
Community News or Messenger,
which groups will be targets for
promotion, leaflets, flyers, etc.)?
How will Council’s contribution to
this project be acknowledged?
(If Council’s logo is to be used please
contact the Council)
How did you hear about Council’s
Community Development Grant
Scheme?
Messenger Press
Community News
Council Website
Other (please specify):
Special Community Projects & Events Funding - Application Form – January 2017
5
Any further information which you
think is relevant to your application?
You may wish to attach further information –
please ensure it is unbound and A4 to
enable it to be photocopied.
Is it likely that your project may
involve the submission of
applications for further Council
permits or Development Applications
prior to being implemented?
Such projects may involve the following:
• Construction or modification on Council
property
• Erection of banner or moveable sign
• Events (including road events, street
parties, marches, parades)
• Erection of trading tables
• Property Development - for details of
what is classified as property
development, refer to Council’s website
at
http://www.mitchamcouncil.sa.gov.au/sit
e/page.cfm?u=1135
Yes
No
If YES, please note that in the event of your application
being successful, funding will not be provided if the
required approvals are not given.
Special Community Projects & Events Funding - Application Form – January 2017
6
SECTION C:
PROJECT BUDGET & DECLARATION
INCOME:
What contributions will your organisation be making to the total cost of the project, what
contribution are you requesting from the Community Development Grants scheme, and will
you be sourcing other funding?
Funding Source
Amount
Confirmed
Requested from Council
$
Cash Sponsorships
$
Yes / No
Other Government Funding (Federal or State)
$
Yes / No
Organisation’s cash contribution
$
Yes / No
In Kind Contributions
$
Yes / No
Total Project Income (excluding GST)
$
EXPENDITURE
How the money will be spent (attach quotes if possible):
Item
Amount
$
$
$
$
$
Total Project Expenditure (excluding GST)
$
DECLARATION:
I,
on behalf of
(name of Organisation)
declare that, if our application for funding is successful, I will forward to the City of Mitcham a
written assessment of the project and a statement of expenditure signed by the Treasurer of
the organisation after the monies provided as a donation have been expended.
In accepting a grant for the project
our organisation agrees to indemnify and to keep
indemnified the Council, its servants and agents and each of them from and against all
actions, costs, claims, charges and expenses whatsoever which may be brought or made or
claimed against them or any of them arising out of or in relation to this project. The Council
bears no responsibility for the management of the project prior to, during and after finalisation
and makes clear that the financial contribution is for funding purposes only.
SIGNATURE:
POSITION:
DATE:
Special Community Projects & Events Funding - Application Form – January 2017
7