Iwi/Hapū Management Plan Fund

Application Form

1.  This is an application for (select the option that best applies)

The development of a new Iwi/Hapū Management Plan

The update or review of an existing Iwi/Hapū Management Plan

Name of Existing Iwi/Hapū Management Plan:

2.  Contact Details

Iwi/Hapū group applying for the fund

Name:
Postal address:
Telephone: / Email:
Mobile: / Post code:

Does your Iwi/Hapū have a signed Protocol Agreement with the Tauranga City Council?

Yes No

Description of Iwi/Hapū areas of interest/boundaries and statutory acknowledgement areas (if applicable). Please include map if possible.

Two key people involved in this project:

Name:
Postal address:
Post code:
Telephone: / Email:
Mobile: / Fax:
Name:
Postal address:
Post code:
Telephone: / Email:
Mobile: / Fax:


Relevant Iwi Authority to verify the plan:

Name of Iwi Authority:
Details of Authorised Iwi Representative:
Postal address:
Post code:
Telephone: / Email:
Mobile: / Fax:
Signature: By typing your name in the space provided you are electronically signing this application form. / Designation:

3.  Evidence to show the plan being developed has the approval from a wide representation of the Iwi/Hapū. Please provide the following:

Copy of minutes of meeting in which the plan development was mandated

Letter of confirmation from the chairperson of the Iwi/Hapū.

Other form of confirmation (please provide details)

4.  Project Plan/Methodology:

(Describe the purpose of the plan, process for development of the plan, and desired outcomes)

What is the key purpose of the plan?
Who will be developing the plan? (include relevant qualification and/or experience):
Will the plan be developed in stages? Yes No
(If yes, please outline stages and proposed timeframes)
What are your desired outcomes from completing your plan?

5)  Plan Development estimated costs:
(This information may be provided as a separate attachment, however, please include the headings identified below and any additional ones you may have).

Please provide details beneath the headings below / Estimated Costs
Consultation Hui: / $
Research: / $
Administration: / $
Site Visit/Field Trip: / $
Workshops: / $
Consultants/Contractor Fee: / $
Other: / $
Estimated Total Cost / $
Contribution from Tauranga City Council / $
Other sources of funding / $

Other sources of funding

Our group, organisation and/or business has applied for funding from other sources (If yes please fill in details below) Yes No

Other sources of funding / Type of Funding / Amount / Pending/Received

How will the Iwi/Hapū contribute to the development of the plan? (Include details about any financial or in-kind assistance)

How would you like to work with Tauranga City Council in developing your plan?

5.  Bank Account Details (Please provide a pre-printed bank deposit slip to the application. GST will only be paid if the organisation is GST registered)

Bank Name:
Branch:
Account Name:
Account Number:
GST Number:

6.  Official lodgement of the final plan

Please note that successful applications will be required to officially lodge their plan with the Tauranga City Council (see Iwi/ Hapū Management Plan Fund Guidelines). The plan will become a public document, and may be placed on Council’s website.

7.  Authorised signature(s) for application:

Name: / Role:
Postal address:
Telephone: / Email:
Name: / Role:
Postal address:
Telephone: / Email:

Declaration

I declare that I have the authority to sign this application form, provide information and apply for funding on behalf of the organisation.

I declare that to the best of my knowledge the information supplied in the application form, or provided in support of our application, is complete, true and correct.

Name:
Signature: By typing your name in the space provided you are electronically signing this application form. / Date:

8.  Please send applications by Friday 14 March 2014 to:

Kaiarahi Māori

Tauranga City Council

Private Bag 12022

TAURANGA 3143

Phone: 07 577 7142

Email:

TCC Ref: 6328861