ARTS & CULTURAL SPONSORSHIP ACQUITTAL FORM

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The personal information collected on this form will only be used by the City of Perth for the sole purpose of providing requested and related services. Information will be stored securely by the City and will not be disclosed to any third parties without your express written consent.

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I authorise the City of Perth to reproduce any attachments provided with this form for internal purposes only. / City of Perth
Council House
27 St George’s Terrace, Perth
GPO Box C120 Perth
Western Australia 6839
ABN 8378 0118 628
Phone: (08) 9461 3154
Facsimile: (08) 9461 3086

www.perth.wa.gov.au

Instructions: Please print clearly in BLOCK letters, using black pen in the spaces provided. Incomplete, or illegible forms, will not be accepted.

Please complete this acquittal form and attach any relevant support material. For copies of any media/advertising use plain A4 paper stapled at the top left hand corner. Please do not bind your acquittal or use folders.

It is not necessary to provide project expenditure receipts, however it is advisable to keep a copy of your acquittal and any other project documentation including receipts for at least twelve months after the project has been completed.

Please ensure that the information provided is accurate. Some questions on this form may not be applicable, where this is the case please write N/A. Signing this document certifies that the sponsorship funds were used in accordance with the terms of agreement.

For more information:

Please ensure that your acquittal is completed fully and returned within three calendar months of the completion of your funded activity and prior to submitting a further application to:

Business Support and Sponsorship

Attention: Sponsorship Officer

City of Perth

GPO Box C120

PERTH WA 6839

Tel: 9461 3382 Fax: 9461 3086

Email:

1.  APPLICANT DETAILS

Applicant Type: / Individual: / Organisation: / Group:
First Name: / Surname:
Organisation:
Position: / Telephone:
Mobile: / Facsimile:
E-mail:
Street Address:
Postcode:
Postal Address:
Postcode:
ABN: / GST registered:
Website:

2.  PROJECT DETAILS

Under which category are you applying?

Arts Projects Grants High quality local arts projects that encourage creative development
Creative Community Grants Projects that facilitate the public’s access to and participation in the city’s cultural life
Sponsorship A single project or a series of projects that demonstrate artist excellence and/ or significant cultural relevance
Project Name:
Art Form:
Sponsorship Amount: / $ Please complete budget on the last page of this form
Public access Dates: / From: / To:
Public Access Times: / From: / To:
Venue:
If ticketed, please state the ticket prices:
Project Management:
Who coordinated the project?
Creative Personnel:
Project Description:

3.  ATTENDANCE DETAILS

Number of participants:
Participants are those taking part in the event/project / Perth Metro Area
Regional
Interstate
International
Total
Estimate of total numbers in audience:
This figure is an accumulation of audience, spectators & so on / Perth Metro Area
Regional
Interstate
International
Total
Total Seats Available / Total Attendance
Activity
(please specify number) / Paid/Ticket: / Unpaid/Free: / Paid/Ticket: / Unpaid/Free:
Performance
Symposium
Exhibitions
Screenings
Other
How did you arrive at these figures?
Did the actual attendance meet your expectations?
Number of personnel directly involved in the project/activity:
·  Full-time – Paid
·  Full-time – Unpaid
·  Part-time – Paid
·  Part-time – Unpaid

4.  SPONSORSHIP ACKNOWLEDGEMENT

How did you acknowledge the City of Perth’s support for your project?
Please attach copies of promotional material, advertisements etc

5.  ARTISTIC REPORT

What is your personal assessment of the project?
Consider:
Did the project achieve its goals
What were particular strengths/weaknesses
Did you learn anything new or gain unexpected benefits?
What was the response to the project?
Consider:
Audience, media, public
How did the project meet the objectives of the grant category you applied for?

6.  CERTIFICATION

I certify that the cultural sponsorship described above was used for the approved purpose. To the best of my knowledge and belief, the attached financial reports are true and fair.
Name of Applicant:
Signature: / Date:

7.  DISABILITY ACCESS REPORT

Please indicated with outcomes were met and give brief description of how these outcome was met.
Disability Access Implementation Plan Outcome / Outcome met? / Description of how met
1. People with disabilities have the same opportunities as other people to access services and events
2. People with disabilities have the same opportunities as other people to access buildings and other facilities.
3. People with disabilities receive information in a format that will enable them to access information as readily as other people are able to access it.
4. People with disabilities receive the same level and quality of service from staff as other people receive.
5. People with disabilities have the same opportunities as other people to make complaints.
6. People with disabilities have the same opportunities as other people to participate in any public consultation.
If you would like further information regarding this section please contact Emma Landers on 9461 3145.

8.  FINANCIAL REPORT

Please refer to your original application when providing the budget figures.
Income:
Details: / Budget: / Actual:
A- Earned Income: / Box Office / Ticket Sales / $ / $
Other / $ / $
B- Govt Sponsorship/Grant Income: / City of Perth / $ / $
Government / $ / $
C- Corporate Sponsorship / Corporate / $ / $
D- Other: (ie. philanthropy, donations, private support) / $ / $
E- In-Kind Support (cash value ) / Goods and Services / $ / $
(this figure to correspond to L below) / Volunteer Labour / $ / $
Total Income: / $
Expenditure:
Details: / Budget: / Actual:
H- Administration (not staffing) / $ / $
I- Production and Exhibition Costs / $ / $
J- Marketing /Documentation / $ / $
K-Staffing and Labour / Administration / $ / $
Creative / $ / $
Production / $ / $
L-In-Kind Support (cash Value) / Goods and Services / $ / $
(this figure to correspond to E above) / Volunteer Labour / $ / $
M-Other Costs (please specify) / $ / $
Total Expenditure: / $
Surplus / (Deficit):

Acquittal Forms are to be submitted via the following methods only:

Email:

Mail: Attention:

Business Support & Sponsorship Unit

Arts & Cultural Sponsorship Program

City of Perth

GPO Box C120

PERTH WA 6839

In Person: Council House

Ground Floor

27 St George’s Terrace

PERTH WA 6000

Please ensure you have included supporting documents including evidence of acknowledgement of sponsorship, reviews etc.

Please Note: This form is available in alternative languages and formats on request.

City of Perth ACSP Sponsorship Acquittal Form Updated August 2016 - 5 -