/ Active Citizens Fund
Application Form
COVENTRY

Please tick the box relating to the funding you are applying for

Community Projects Fund
[Maximum level of funding £25,000] / Small Enterprise Grants
[Maximum level of funding £2000]
  1. About you and your organisation/group

Project name:
Name of organisation/group: / Organisation/group address:
Project contact/owner: / Position in organisation: / Contact details:
Daytime telephone number(s)
Fax
Email
Does your organisationhave a constitution or
set of rules?For more information, please speak to Partnerships Team / A separate bank account which has at least two signatories?
If you have not previously applied to us, please submit a copy
  1. Please list the names, addresses and position held of all members of your organisation’s management committee or board of directors. Continue on a separate sheet if necessary.

Name / Address / Position
  1. Please tell us about allprevious West Midlands Police / Office of the West Midlands Police and Crime Commissioner funding you have received

Project / Funding programme / Amount awarded / Financial year awarded
  1. About the project

Which community(s) will this project take place inand which community priority(s) will it meet?
Project/activities proposed:
Provide a brief outline of the activity/project and explain why your organisation is best placed to deliver this.
Provide enough information so that those unfamiliar with the activity/project understand what is being proposed. What are the objectives of the project? What will the project achieve and where will it take place? Who is the target audience for the project/activity? How will you advertise/ promote this project to your target audience? How will your project/activity contribute to promoting equalities and diversity in the target area? Include any particular benefits identified for groups such as children and young people, elderly people, disabled people, women, different faith groups and black minority ethnic (BME) communities.
Evidence of need / Baseline Evidence / Local Consultation:
Provide detailed information about the problem the project/ activity is seeking to address.
Provide evidence of the local need for your project, and how it addresses gaps in existing services/Community needs. What are the key issues the project is seeking to address? Use evidence of your own that is relevant to the project. How will your project have an impact on these problems?
  1. Outputs and outcomes

Outputs to be delivered:
Use this section to describe what outputs will be delivered and who will benefit. Explain how you will measure the success of the project as it is being delivered.Outputs are products ,services or facilities that result from an organisations or projects activities
Example 1: running 10 sessions of a homework club between September and December.
Example 2: 30 people participating in after school club and attending 75% of the sessions run.
Outcome evidence:
Outcomes are the changes and achievements resulting from your project/activity.
Provide information about what do you want to achieve by delivering this project/activity and what difference you expect it to make within the local community.
Example 1: 30 people attaining x’ standard or attaining ‘y’ qualification.
Example 2: 10 per cent reduction in anti-social behaviour in the area as evidenced by monitoring of graffiti levels over the six month period January – June.
Your track record:
Has your organisation run a similar type of project activity before?Who will be involved in running this project and what experience do they have of doing this? (i.e. which individuals or organisation(s) will deliver the project on your behalf?)
  1. Timescales

Project start date: / Project end date:
Timescale
(day/week/month) /
Key milestones and activities to be undertaken
  1. Project costs and funding

Itemised breakdown
of costs* / (A) Amount requested from Active Citizens Fund / (B) Amount contributed from other funding
(identify source**) /
(A+B) Total cost
Example 1: wheelchairs / £500 / £500 (Big Lottery) / £1,000
Example 2: volunteer time / £0 / £300 in kind (£7.20 per hour x 10 hours x 6 volunteers) / £300
TOTAL: / £ / £ / £
  1. Funding will normally be released in stages. Please indicate below how much you will need in order to start the project, and the dates when remaining funds will be required

Stage / Date / Amount required
Start up date
Next relevant stage (ie Quarter 1)
Next relevant stage (ie Quarter 2)
And so on . . .
  1. Please include any photographs or documents which you consider would help to explain the project more clearly.

When you have completed the application, please read and sign below. You must provide a written or scanned electronic signature.

I certify that the information supplied is accurate to the best of my knowledge. I understand and accept that providing deliberate false information could result in legal action being taken against me and withdrawal of funds awarded.

Signed for and on behalf of: ……..…………..………………………………………………………..

[your organisation name here]

Name: …………………….……………………………………………………………………………………

Position: …………………….……………………………………………………………………….………..

Date: …………………….……………………………………………………………………………………..

Please send completed application form to:

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To be completed by Neighbourhood Policing Unit Commander

I have assessed the information provided in this application and I approve this project for funding by the Active Citizens Fund. I have confidence in the legitimacy of this project and organisation. The reputation of this organisation and its leaders is well known to local police and does not give me any cause for concern.

Signed …………………………………………...... Date …………………………………………
Print name and job title …………………………………………………………………………………….

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