NATIONAL LOTTERY APPLICATION FORM 2017

APPLICATION UNDER NATIONAL LOTTERY GRANT SCHEME 2017

Please tick below to specify if your application relates to National Lottery Funding or Respite Care Grant Scheme.

National Lottery Funding …………………. 

Respite Care Grant Scheme……………… 

Community Healthcare Organisation:

Check information on HSE Website for your CHO Area:

Section 1 Name of Voluntary Organisation/Group:

Name and Address of main contact / liaison person for the organisation

Name of Organisation:

If your Organisation is incorporated please ensure this is the Legal entity name.

Title: Mr Mrs Miss Ms Other

Name of Contact Person: ______

Address: ______

Position Held: ______Tel No: ______


Name and Address of Chairperson Name and Address of Secretary

Name: ______Name: ______

Title: ______Title: ______

Address: ______Address:______

______

Address of Organisation (base/office if applicable)

______

Telephone: Fax: ______

Email: ______Website: ______

Organisation Status/Charitable Status/Tax Clearance Certificate

Please tick all of the following that are relevant to your organisation

Limited Company Yes No Registered Company Number:______

Registered Charity Yes No Registered Charity (CHY) No: ______

Charities Regulatory Number: ______

The Organisation holds a Tax Clearance Certificate Yes No

Tax Reference Number: ______

Tax Clearance Certificate Number:

Certificate expiratory date:

Note: If the Tax Clearance Certificate expires within 3 months of closing date for this scheme a further certificate bearing a later expiry date must be sought and submitted with your application.

When was your organisation established? Year

Organisational Overview
Provide details of the Organisation that is to receive the Grant award. This may include the Organisation’s mission, objectives and current activities.
Aims and Objectives of the Organisation
Describe the Activities of your organisation
Target groups of your organisation (what groups of people benefit from your service)

Please give details of current numbers of paid, voluntary, community employment, and other workers involved in your organisation

Paid Full Time / Paid Part Time / Volunteers / Community Employment / Others / Total

All Details in Section 1 are compulsory

Section 2

Purpose for Use of this funding application:-
Describe the project/service for which grant is now being sought or attach details of project/service on a separate page/document.
Is this Project once off? Yes No
Part of an ongoing operation? Yes No
When did or will the project commence? ______
When is it due to end? ______
Why is this project needed? What is the identified need within this CHO that your organisation is seeking to satisfy (please provide relevant information to support application)
With this project, how do you propose to address the needs of the clients in this CHO?
What are the expected benefits/outcomes of the project to clients of this CHO?
How does this proposal represent value for money?
How will the service/project integrate with other agencies and organisations?

Specify clearly (name) the geographic area in which this project will be delivered

Client Group
Provide details of the target Client group(s) that will benefit from the funding.
Specify clearly (name) the geographic area in which this project will be delivered
(e.g. local community area(s) / DED, electoral area, county/counties, Community Healthcare Organisation (CHO) Area, etc.)
Estimated number of clients in the CHO named above that will benefit from this project?
What category of persons are expected to benefit? (older persons, families, etc.)

State the estimated total cost of the project € ______

State the cost to be incurred in the current year: € ______

State how much the group is contributing to the project € ______

State the amount of grant now sought for the project: € ______

Please outline breakdown of costs associated with the project. Please submit quotations/estimates for all aspects of the project and return with this application form.

______

______

______

______

______

______

______

Has your organisation previously applied for funding from the HSE or another public source? (If yes, please set out details, including details as to any unsuccessful applications)

______

Is your organisation currently or has your organisation previously received funds from private sources? (If yes, please set out details)

______

Has your Organisation/Group made, or does it intend to make an application for funding towards this project to any other source (private or public)?

Yes No

If YES state: Sources, amounts sought and result if any:

______

______

______

Please give details of amount (in €) and source of National Lottery grants received by your organisation from public funds in the following years (if applicable):

2013______

2014______

2015______

2016______

Give details of the amounts (in €) and sources of funds that are available to your Organisation/Group for this project – for example cash in hand, donations, fundraising, other grants, etc,.

______

______

______

Bank Account Details – To receive funding from the HSE you must have a separate Bank Account in the name of your organisation – Please outline your account details below:-
Name of Bank:
Address of Bank:
Name on Bank Account:
Bank Account Number:
IBAN Number:
BIC Number:
Bank Sort Code:
Bank Balance as of ------/------/------
Any comments on account balance
Insurance Details
Please see notes below regarding Insurance requirements. Evidence of the Organisation’s insurance may be sought by the HSE.
Please tick the box if the Organisation is compliant with requirements below
Please confirm that the Organisation will be in a position to comply with the HSE requirements for insurance contained in Section 10.1 of the Grant Aid Agreement as follows:
The Organisation undertakes to have sufficient insurance coverage in respect of all services or activities it delivers when using the Grant. The extent and adequacy of the insurance cover is a matter for the Organisation and its insurance advisors.


DECLARATION

(To be completed by Chairperson, Hon. Treasurer of Organisation/Group)

On behalf of: ______

I,______wish to apply for a grant towards the project/service named above and I declare, that all the information given in this form is true and complete to the best of my knowledge and belief and undertake that upon completion of this project/service named above that a statement will be forwarded to the Executive signed by the CEO or Chairperson of the Board stating that a 2017 National Lottery Grant awarded in respect of this project/service was used for the stated purposes intended.

Signature: ______Date: ______Tel No: ______

Chairperson

Signature: ______Date: ______Tel No: ______

Treasurer


Checklist for National Grant Application

This checklist must be included with applications.

Please ensure that all the accompanying information is provided and this will ensure applications are processed as quickly as possible.

Please note that all incomplete applications will be returned to the organisation/group and will not be regarded as valid until all appropriate information is provided

*A statement signed by the CEO or Chairperson of the Board stating that any National Lottery Grant(s) awarded in 2016 was/were used for the stated purposes intended

Checklist / Yes / No
Annual Report or Chairperson’s Statement
A completion Statement for any 2016 National Lottery Grant(s) received if not already submitted *
Fully completed copy of the Application Form, (per Sections 1 & 2)
signed and dated
Copy of Architects, Contractor’s or other estimates of Projected Costs.
Charitable Status or Tax Clearance Status.
Last Available Audited accounts (or other statutory accounts) or an Income and Expenditure Account certified by the Chairperson of the Organisation must be provided.
Constitutional Document for your Organisation

COMPLETED APPLICATIONS MUST BE SUBMITTED TO THE LOCAL COMMUNITY HEALTHCARE ORGANISATION (See Website for Details) IN A SEALED ENVELOPE AND CLEARLY MARKED “HSE NATIONAL LOTTERY APPLICATION 2017” TO ARRIVE NO LATER THAN 5PM ON 26TH OF MAY 2017

Organisations successful in their Lottery Applications will be required to sign a Grant Aid Agreement and comply with the minimum requirements as outlined in appendix 1:

For Reference purposes the Grant Aid Agreement is available on the Web-link Below:

http://www.hse.ie/eng/services/publications/Non_Statutory_Sector/Grant-Aid-Agreement-Revised-Nov-2016-.pdf

Appendix 1 - Minimum Financial and Governance Requirements
Charity Number or Tax Clearance Certificate is mandatory
Insurance Cover (appropriate to size of agency & nature of activities)
Written Signed Chairperson’s Statement at year end stating Grant was used for the purposes intended. To include declaration on other Exchequer funding if applicable, & whether the total organisation funding from Exchequer is >50%.
Record of Meetings
Need to have formal record of Governing body meetings i.e. Agenda minutes Attendees etc..
Record of Activities undertaken with use of Grant (evidence in the form of annual reports, newsletters etc are sufficient)
Record of Complaints – in line with statement outlined in Constitution (This depends on whether agency is without paid employees and/or have direct involvement with children or vulnerable adults).
Governing Document (i.e. a Constitution or if agency is incorporated a Memorandum & Articles of Association). A Constitution outlines the following and Rules regarding same where applicable:
-  Names of Organisation
-  Aims
-  Members
-  Equal Opportunity (statement sufficient for most small agencies)
-  Committee & Officers
-  AGM & Other Meetings
-  Finances
-  Rules of Procedure
-  Conflict of Interest (statement)
-  Freedom from Abuse & Complaints (statement regarding how to complain, recording & resolution of same sufficient in most small agencies without paid employees and/or direct involvement with children or vulnerable adults). For those involved with children or vulnerable adults it is advised that a Complaints Policy in line with HSE’s ‘Your Service’ Your Say’ is developed.
-  Amendments to the Constitution
-  Dissolution
Note: Information on how to complete a constitutional document is available in the Guide for Small Agencies see web-link below:
http://www.hse.ie/eng/services/publications/Non_Statutory_Sector/Explanatory_Guides.html
Record of Financial Matters and Proper Governance & Accounting Arrangements & Systems including:
-  Having a Bank /Credit Union/Post Office Account in the agency’s own name
-  Income & Expenditure Reports
-  Reporting to Governing Body (if applicable)
-  Payment of taxes & pensions (if applicable)
-  Petty Cash
-  Payment by cheque or Electronic Fund Transfer (EFT) were possible
-  Receipting of cash & income collected
-  Submission of Annual Accounts separately identifying the HSE allocation and Expenditure. (*Of Note* when the total funding of an agency is over €150,000 these accounts must be Audited ).
Comply with legislation regarding the following and have structures & systems in place regarding same:
-  Data Protection & Freedom of Information
-  Equality (statement in Constitution will suffice)
-  Employment Practices (This is not relevant for small Organisation without paid employees).
If your organisation have staff that work with children or vulnerable adults the following applies:-
Compliance with Children First National Guidance for Protection and Welfare of Children 2011
1) Implementation and Compliance Checklist for HSE funded Agencies
http://www.hse.ie/eng/services/list/2/PrimaryCare/childrenfirst/informationresponsibilities/ChildrenFirstImplementationandComplianceChecklistforHSEFundedAgencies2016.pdf.
(If difficulty in accessing the above web link please look at the HSE’s Children’s First Website at: http://www.hse.ie/childrenfirst.
Policies regarding the Safeguarding of Children & Vulnerable Persons
Garda Vetting applicable in these instances.

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