APPLICATION FORM
Targeted Community Care (Mental Health) Program
Mental Health Respite: Carer Support (MHR:CS)
New service
Mental Health Respite: Carer Support (MHR:CS) assists carers of people with mental illness to sustain their caring roles and maintain connection with their communities, by providing flexible, innovative carer support services.
Applications are currently sought for service providers to deliver MHR:CS services in specified locations across Australia (see Attachment A to this form).
The Department is seeking to select organisations with the ability to deliver carer-centred services that offer a range of flexible supports to meet the needs of carers of people with mental illness, along with their families.
Service providers will be expected to develop carer support plans in collaboration with carers, to provide a continuum of support for carers and their families, involving a range of assistance to suit their circumstances at different points of time.
Site this Application refers toPlease indicate the site in which you are applying in this form to deliver a new MHR:CS service. Copy the relevant information from AttachmentA. Note that the Department will be seeking maximum service coverage across all the Local Government Areas (LGAs) targeted in the particular site.
State/TerritoryHACC Region
Site Name
Target LGAs
If you wish to apply to deliver MHR:CS in more than one site, a separate application is required for each site. You may only submit one application per site.
Closing Date / Applications must be submitted by 3.00pm (AEDT) Thursday 20December 2012.How to lodge / Applications must be completed and submitted by email to the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) mailbox at , using this form available on the FaHCSIA website.
Applicants experiencing difficulties with the Application Form can email for assistance.
Information and Guidelines / If you are completing this Application Form you should only proceed if you have read Parts A, B and C2 of the Targeted Community Care (Mental Health) Program Guidelines, dated November 2012. Applications will be assessed based on the process outlined in the Guidelines. The Program Guidelines are available at the FaHCSIA website.
If you have any questions regarding your application, please email . Answers to questions received during the Application period will be posted by 5:00 pm (AEDT) every Wednesday on the FaHCSIA website. Questions will not be taken or responded to after Tuesday of the last week of the application period, or at any time during the assessment phase.
National Relay Service (NRS) / If you are deaf or have a hearing or speech impairment, you can use the NRS to contact any of the Department's listed phone numbers.
To access an 1800 FaHCSIA number, NRS users should phone 1800555677 or visit the NRS Website at www.relayservice.com.au.
Use of Information / Please note that FaHCSIA may use successful applicants’ information, other than personal information that has been provided in the applicants’ applications, to assist FaHCSIA to:
(a) comply with the Australian Government requirement to publish the names of all funding recipients on the FaHCSIA website
(b) inform staff negotiating and establishing funding agreements, of risks and issues which need to be addressed in the agreement for that program
(c) inform future assessments for applications in the same program, or
(d) inform assessments for applications for other programs.
Please indicate whether you understand that the Department may use the information (not personal information) you have provided in your application for the purposes listed at (a), (b), (c) and (d) above.
I have read and understand how the Department may use information in this Application
Part 1 Eligibility
**Tips for completing this form
· Save the application form to your computer. Once you have completed the form and signed the Declaration at Part 7, scan the form and attach it to an email to . If you are unable to scan the document, you may email the unsigned Word document from your organisation’s email address. This will be considered your agreement to the Declaration. Receipts of applications will be acknowledged after the closing date and by 5pm on Friday 5 January 2013.
· The application form specifies word limits for several selection criteria. Text beyond the word limits will not be considered as a part of the assessment process.
· Do not provide documents with your applications unless they have been specifically requested. Any attachments to the application form which are not specifically requested in the application form will not be considered as part of the assessment process.
1 Organisation type and financial statusIs your organisation non-government?
Yes
No. Only some government bodies are eligible to apply. Please refer to the program guidelines for information about eligibility.
2 Is your organisation not-for-profit?
Yes
No. For-profit bodies are eligible to apply but should check the program guidelines to ensure their applications are for eligible activities.
3 What is your organisation entity type?
Please tick √ all applicable boxes.
Incorporated association incorporated under Australian State/Territory legislation
Incorporated cooperative incorporated under Australian State/Territory legislation
Aboriginal corporation incorporated under the Corporations (Aboriginal and Torres Strait Islander) Act 2006
Organisation established through specific Commonwealth or State/Territory legislation
Company incorporated under Corporations Act 2001 (Commonwealth of Australia)
Partnerships
Trustee on behalf of a trust
An Australian local government body
If you have not ticked any box from the list above, your organisation may not be able to apply for funding. Youshould refer to the program guidelines.
4 If this application is successful, could your organisation begin to deliver services within six months of signing an agreement with FaHCSIA?
Yes
No. FaHCSIA may not assess your application. Please refer to the Part C2 of the TCC Program Guidelines.
Part 2 Applicant details
5 What is the legal name of your organisation?This is the name that appears on all official documents and legal papers. It may be different to your trading name.
6 What is the trading name of your organisation?
This is the name your organisation trades or provides services under.
7 What is the physical business address and main contact details of your organisation?
Physical address (must not be a PO Box)
Building/Floor
Street no. and Name
Suburb/Town
State / Postcode
Main Telephone
Email Address
8 What is the postal address of your organisation?
Same as above
or
Building/Floor
Street no. and Name, or PO Box
Suburb/Town
State/Territory / Postcode
9 Who are the authorised Contact Persons for this application?
/Preferred contact
/Alternative contact
Title
/ /First name
/ /Surname
/ /Position in organisation
/ /Telephone number
/ /Mobile number
/ /Email address
/ /10 What is the local service name under which you will deliver MHR:CS, if your application is successful?
11 Provide a brief description of your organisation including its mission, key activities and history. Limit response to 150 words.
12 Are you a Lead Agency applying on behalf of a consortium to deliver MHR:CS?
No. Go to Question 13
Yes
If ‘Yes’, please list all consortium members including their legal names, ABNs, business addresses, and descriptions of their roles in delivering the proposed project.
Legal Name / ABN / Business Address
(include full address details) / Role in consortium arrangement
Note: FaHCSIA will only contract with a single legal entity. Applicants may determine that efficient or effective service delivery is best achieved through the use of a network of providers through aconsortium arrangement. If successful, the legal entity specified in Part 2 will be offered a funding agreement by FaHCSIA as the Lead Agency and will be held liable for all obligations contained in the terms and conditions of the funding agreement. This includes monitoring, management, financial performance, service outcomes, and specifically insurance coverage. Theconsortium members, other than the Lead Agency, do not sign any funding agreement with the Department.
Include a scanned, signed statement by the proposed consortium members with the email containing your application form. The signed statement must show:
- that they intend to enter into a consortium arrangement for the purposes of this funding,
- the nature of the legal relationship that will occur between parties if the application is successful, and
- how the arrangements between the consortium members will be managed and overseen by the Lead Agency.
If you experience difficulties attaching documents with the application form, please email
for instructions.
The Department will not accept later changes to consortium arrangements that, in the opinion of the Department, represent a material change to the application. Further evidence of the consortium arrangements may be sought from successful applicants prior to the signing of funding agreements.
13 Does your organisation plan to subcontract or broker any or all of the service provision, if this application is successful?
No. Go to Question 14
Yes.
If ‘Yes’, please describe how your organisation will manage the subcontracting or brokerage arrangements to ensure its obligations under the funding agreement are met. Describe how your organisation will ensure that appropriate ‘duty-of-care’ arrangements are in place, and that subcontractors will provide services in accordance with the obligations of your organisation relating to confidentiality, permitted disclosure, insurance requirements, privacy of information, and all relevant legislation. Limit response to 300 words.
Part 3 Financial details
Information provided in Part 3 will be used if your application for funding is successful.14 Does your organisation have an Australian Business Number (ABN)?
Yes
No
If yes, what is the ABN of your organisation?
If your organisation has an ABN branch number, please provide it here.
15 Is your organisation GST-registered?
(Questions on GST requirements should be addressed to the Australian Taxation Office.)
Yes
No
16 Please provide details of your organisation’s bank account for payment should your application be successful.
Record the account details of the organisation listed at Q3 only. FaHCSIA will not make cheque payments or payments to a third party.
BSB number
Account number
Account name
17 Provide the email address for payment advice to be sent to.
If this is left blank RCTIs will be sent to the preferred contact email address at Q9.
Part 4 Application and Funding Details
No. Go to Question 19.
Yes.
If ‘Yes’, please show details of FaHCSIA funding your organisation has applied for since 1December 2011.
FaHCSIA program name / Date of Application / Amount of Funding / Period of Funding
19 Has your organisation applied for, or received, funding from any other source to deliver the same services covered by this application?
No. Go to Question 20.
Yes.
If ‘Yes’, please show details of other funding your organisation has received, or has applied for, to deliver the services.
Program or funding source name / Date of Application / Application Approved
20 Does your organisation already receive funding from FaHCSIA?
Yes. Go to Question 23.
No
Part 5 Financial Viability, Governance and Activity Funding
Yes No
Two most recent audited financial statements
Current financial statement (does not need to be audited)
An income and expense budget for the 2012–13 financial year (excluding the funding being applied for in this application)
If you answered ‘No’ to any of the above, or your organisation's financial statements are not fully compliant with Australian accounting standards, please explain why. Limit response to 150 words.
21 22 Does your organisation have the following documents and are you able to provide copies of them to FaHCSIA within seven days if requested:
Yes No
an organisation chart
duty statements for all positions
financial policy and procedures (systems manual)
delegations (authorised financial delegates or decision makers)
business plan
risk management plan
minutes of board meetings.
23 Do any of the following legal situations apply to your organisation?
Any litigation, threatened litigation or allegations of or investigations into inappropriate or illegal conduct during the past three years.
Any significant financial matter which may impact on the organisation e.g. insolvency or voluntary administration.
Future commitments or contingent liabilities that might materially affect the organisation.
If you answered ‘Yes’ to any of the above, please provide a brief explanation. If your organisation has settled a claim on confidential terms, please indicate this in your response. FaHCSIA may request further information as part of the application assessment process.
24 a. Outline an estimated budget for the service you propose to deliver.
For information on eligible and ineligible activities please refer to the TCC Program Guidelines – Part C2 Mental Health Respite: Carer Support.
Budget Item / Sub Items / Budget Amount ($) / Totals ($)
Assets / Purchase/lease of vehicles
Purchase of office equipment
Sub-total - Assets
Running costs/Administration / Rent of premises
Utilities
Telephone expenses
Computer/IT expenses
Office consumables
Vehicle maintenance
Fuel for vehicles
Insurances
Auditor costs
Legal fees
Sub-total – Running costs/Administration
Staff costs / Salaries and on-costs
Staff training and development
Sub-total – Staff costs
Operational costs / Brokerage of services
Travel
Research
Promotion and marketing
Venue hire
Catering
Sub-total – Operational costs
Other expenses (please specify)
Sub-total – Other expenses
Total expenses
24 b. Please note that the Department may select more than one provider to deliver MHR:CS services in this site. Should this situation occur, please indicate the willingness of your organisation to revise this budget and your service model if a smaller level of funding is available.
Yes, my organisation would still be interested in applying for funding
No, my organisation would no longer be interested in applying for funding.
25 If your application is successful, do you intend to ask clients to contribute to the costs of services or activities? Please refer to the TCC Program Guidelines Part C2.
Yes
No
26 Please provide information on how financial governance for the service will operate, including mechanisms for monitoring the budget. Limit response to 300 words.
27 Do you have any existing outlets which service the area from which you propose to deliver this service?
Yes
No
28 Provide outlet names and addresses.
Physical address (not a PO Box)
Building/floor
Street no. and Name
Suburb/Town
State/Territory / Postcode
Physical address (not a PO Box)
Building/floor
Street no. and Name
Suburb/Town
State/Territory / Postcode
Physical address (not a PO Box)
Building/floor
Street no. and Name
Suburb/Town
State/Territory / Postcode
Part 6 Responses to selection criteria
29 The extent to which the applicant demonstrates an understanding of the need for a Mental Health Respite: Carer Support service in the particular Coverage Area. (Please limit your response to 600 words).