7 Brockman Street

GINGIN WA 6503

Tel: 08 9575 5100

Email:

ABN: 85 679 704 946

2017/18 Community Grants Application Form

Project Summary(please complete)

Applicant:

Project Title:

Sum requested from the Shire of Gingin:

Own Contribution: Cash In-Kind

Third Party(s) Contribution:

Total Project Cost:

Only complete application packages will be considered.

Please ensure that:(please tick)

You are using our most recent Application Form, available at

You have read the 2017/18 Community Grants Information sheet;

Your attachments to this application on email is no larger than 4MB; and

You complete all application requirements.

The completed Application Form should be sent to:

By email:Signed and scanned Applications to:

By post:Shire of Gingin

Community Funding Scheme

PO Box 510

GINGIN WA 6503

In person:Shire of Gingin Administration Centre

7 Brockman Street

GINGIN WA 6503

Or

Shire of Gingin Lancelin Office

255 Vins Way

LANCELIN WA 6044

1Application Information

Organisation name:
Street Address:
Suburb / Postcode:
Postal Address:
Suburb / Postcode:
Contact person: / Role:
Telephone: / Mobile:
Fax: / Email:
Website address: / Incorporated: Yes No
ABN: (if applicable) / GST Registered: Yes No

2Auspicing Organisation Details

Organisation name:
Street Address:
Postcode:
Postal Address:
Postcode:
Contact person: / Role:
Telephone: / Mobile:
Fax: / Email:
Website address: / Incorporated: Yes No
ABN: (if applicable) / GST Registered: Yes No

* Please provide confirmation correspondence from the Auspicing Organisation.

3Information about your Organisation

(What it does, for whom and where?)

What is the primary purpose of your organisation?

What is your main target group?

How many people receive services directly from your organisation per year?
How many additional people, in the wider community, receive an indirect benefit from your organisation (per year)?
When was your organisation established (year)?
Number of members (if relevant): / Membership fee:
Who is eligible for membership?
Number of paid staff: / Number of volunteers:
Who owns the premises from which you operate your service?
Has the Shire of Gingin previously assisted your organisation within the past two financial years?
This may be a Community Grant and/or Mid-Year Grant(Small Project/Event)(see below) Please attach additional pages if space is insufficient / Yes No
Community Grant 2015/16: / Yes No
Amount: / $
Project Name:
Community Grant 2016/17: / Yes No
Amount: / $
Project Name:
Mid-Year Community Grant 2015/16: / Yes No
Amount: / $
Project Name:
Mid-Year Community Grant 2016/17: / Yes No
Amount: / $
Project Name:
Were all grants properly acquitted?
-Failure to acquit grants will jeopardise future grant applications. / Yes No
Has your organisation changed its name since your last request? / Yes No
If so, please state previous official name:

4.Your Organisation's Income

Please provide information on your funding sources. Attach a list if there is insufficient space to identify all sources of income.

Operating Costs / Capital
Federal Govt Dept of / $ / $
Contact: / Tel:
State Govt Dept of / $ / $
Contact: / Tel:
Local Government area of / $ / $
Contact: / Tel:
Income from other sources
e.g. fees, fundraising - please specify
$ / $
$ / $
$ / $
$ / $

5.Your Request

5.1What is the name or title of this project?

5.2Please estimate how many people will benefit from the activity for which you are seeking this grant.

5.3When will the activity take place?

5.4What is the issue that you would like to address with this project?

5.5Why is this issue important?

5.6What are you going to do?

5.7How do you know that this is the best approach?Stakeholder/Community support

5.8Why is your organisation the most appropriate to undertake/lead this project?

5.9How will you know that the project objectives have been achieved? How will they be measured?

5.10How will you acknowledge the Shire of Gingin’s contribution?*Mandatory

This could be by public acknowledgement at an opening or Shire branding on any printed/digital information for the project

6.Proposed Budget

Please outline your proposal’s total cost in the table below or by attaching a table of your own.

Item(s) description / Item cost $ / Requested
$ / $
$ / $
$ / $
$ / $
$ / $
Total $ cost of items / $ / $

* Attach copies of either two (2) written quotations or written estimates for all items and three (3) written quotations for projects over $50,000. Low value, miscellaneous items can be grouped together (to $500).

* For any project requiring a Building Permit, the costs associated with securing the Certificate of Design Compliance must be included in the proposed budget.

* Public Liability Insurance must have $20M cover.

Own contribution / $ Cash / In Kind
$ / $
Total / $

If funding for the project/event is being obtained from other contributors, please identify below

Other contributor’s name / Amount / Confirmed yes/no / Contact details
$ / Yes No
$ / Yes No
$ / Yes No
$ / Yes No
$ / Yes No

* Please provide confirmation correspondence from the other contributor/s.

Note: Any Shire of Gingin funding will not be released until all additional funding contributions have been confirmed.

Summary / Amount
Request from the Shire of Gingin / $
Your organisation’s contribution / $
Other contributions/contributors / $
Total $ cost of items / $
In-kind contributions estimated value / $

6.1If applicable, where will significant items purchased be stored:

7.Organisational and Financial Stability

In addition to your completed Application Form we require the following:

  • Copy of the current Certificate of Incorporation;
  • Most recent audited financial statement;
  • Copies of insurance certificates of currency; and

If successful,

  • The approved funds are contingent upon actual expenditure. Any unused funds must be returned via cheque. Cheque to be made out to Shire of Gingin.
  • Receipt of funding will be contingent upon individual requirements and will be negotiated with successful applicants; and
  • There will be a requirement to undertake an acquittal for your approved funds.

8.Organisation Declaration

This Declaration is made by the applicant and, if applicable, the Auspicing Organisation.

  • I declare that all the information is true and correct.
  • I give permission to the Shire of Gingin to contact any persons or organisations in the assessment of the application and understand that information may be provided to other agencies, as appropriate.

Applicant Signature: / Date:
Chairperson/President/Authorised Person
Print Name: / Title:
Position:
Name of
Organisation:
Address:
Telephone: / Mobile:
Witness name:
Witness signature:
Auspicing Signature: / Date:
Chairperson/President/Authorised Person
Print Name: / Title:
Position:
Name of
Organisation:
Address:
Telephone: / Mobile:
Witness name:
Witness signature: