Quairading Community Grants Application Form

*Closing Date: Friday 11th May 2018 at 4.00pm

SECTION 1 - Applicant Information
Name of Club/ Organisation
ABN
Postal Address
Contact Person
Position
Phone / Email
1.1 Is your organisation an incorporated body? / Yes / No
1.2 Financial Information –
Please attach a copy of the /annual financial statement for the last Financial Year/Season.
1.3 Has Council previously assisted your organisation? / Yes / No
Year / Amount $
SECTION 2 - General Information about your Club/Organisation
2.1 Where you are operating from?
2.2 What are the main services/activities the Club/Organisation provides?
2.3 Describe how your organisation operates i.e. by volunteers, paid staff, combination of both, etc
Please indicate how many staff and volunteers you have.
2.4 If not clearly specified in your financial statements, describe your main funding sources e.g.
government grants (please state source), fundraising, members fees, fees for services, etc.
2.5 Please provide membership numbers for adults and juniors for the previous financial year.
Adults / Juniors
2.6 If you are requesting a grant for capital works for a building, please indicate who owns the
premises & land? Provide evidence support for your project from the owner.
SECTION 3 - Request Summary
3.1 Please select what type of project you are requiring assistance with:-
One-off small Grant > $500 (equipment, event etc.)
Capital Grant >$2,500
3.2 Provide a description of the purpose or activity for which you are seeking assistance.
You should also include:-
• Why the funding assistance is necessary;
• How the community, and/or target groups will benefit;
• Timeframe for your project to be delivered;
• Who will be involved in the project;
• How your organisation will manage the project and funding;
• How the project aligns with the Shire Stragetic Plans and Policies; and
• Attach photos, plans or diagrams to illustrate your request if relevant.
3.3 Would it be possible to share with another group?
(i.e. Is your proposal duplicating an existing service?) / Yes / No
Please Comment
3.4 Describe how you have the full support of your members for your funding application.
E.g. Attach minutes of meeting where project funding was discussed/letters of support/ etc.
SECTION 4 - Project Cost - Please ensure all relevant quotes are attached to your application.
Item/Activity
e.g. Purchase of Water Fountain
Volunteer labour for installation / Description
e.g. 1 fountain@ $650
2 people x 1 day @ $20/hr / Council Funding
(ex GST) / Club& External Funding
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
$ / $
Sub-Total Budget / $ / $
Total Budget / $
Other Funding–Grants / Loans / Donations
Please list the details of any other funding your group has applied for or received that will contribute to this project:
Name of organisation/funding source/type / Amount / Status
(e.g. Received, pending)
$
$
$
Budget Breakdown:
Description / Funding amount
(ex GST) / Percentage
(%)
Club / organisation / $
External Funding (Grants / Loans / Donations) / $
Council (Community Grant Request) / $
Total / $ / 100%
SECTION 5 – Authorisation/Declaration
5.1 I certify that I am authorised to submit this application on behalf of the organisation. I declare
that I have read and accept the Shire of Quairading Community Grants Guidelines.
Signature / Name / Position / Date
5.2 Please list all attachments to your application and ensure you have included the following:-
Annual Financial Statement
Quotes
Photos, plans or diagrams (if relevant)
Meeting minutes and letters of support (if relevant)
Project support from owner of land (if relevant)
Additional Attachments
Submission Information
All applications to be received BEFORE 4pm on the 11th May 2018. Late applications will not be accepted.
Please forward your application form and all attachments to:
The Chief Executive Officer
Email:
Or post to: PO Box 38, Quairading WA 6383.
Contact
For further information or assistance with the Application Form, please contact the Grants & Projects Officer Mrs Jen Green on ph. 9645 1607 or email

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