Royal Borough of Kensington and Chelsea
Adult Social Care
Grant Application 2010/2011
Threshold 2: £10,001 to £20,000
Application Form:
Name of Organisation: ______
Please tell us the amount/s you are applying for:
Business Group – Adult Social Care
Adult Social Care – Social Care / £Adult Social Care –
Transport / £ / Adult Social Care –
Carers / £
Please tell us the amount/s you are applying or have received from another Business Group:
Corporate Services / £ / Family and Children’s Services / £- CONTACT DETAILS
A1 Name of Organisation:
A2 Address of Organisation:
A3 Contact Name and Position Held:
A4 Telephone: / A5 Mobile:
A6 Fax: / A7 Email:
A8 Website:
- LEGAL STATUS
B1 Charity Registration Number:
B2 Limited Company Registration:
B3 Other:
B4 Data Protection Act Registration Number (if applicable):
B5 Are you registered with the Criminal Records Bureau? Yes/No
Or with an Umbrella Body (give name of umbrella body)? Yes/No
Do all staff who have direct contact with children, young people, and/or vulnerable adults have a current CRB disclosure reference? Yes/No
First Stage of Application Form
- YOU MUST PROVIDE THE FOLLOWING INFORMATION WITH THE APPLICATION
Funding for £10,001 to £20,000:
Tick if attachedC1 A copy of the audited accounts (or equivalent) 2008/2009, certified accounts or latest bank statements for 2008/2009
C2 A copy of the Annual Report 2008/2009
C3 List of current Committee Members (include addresses and
telephone numbers)
C4 Minutes of the last Annual General Meeting
C5 Minutes of the last Management Committee Meeting
C6 If you do not currently receive a grant from the Royal Boroughof Kensington and Chelsea, a copy of the Organisation’s governing document
Finance:
Tick if attachedC7 Attach a breakdown of the anticipated income/expenditure
budget 2010/2011for each service and/or separate core costsapplied for. (See section D)
C8 Attach a breakdown budget for the transport and carers grant applications (if applicable).
Policies and Inspection Reports
Please tell us if you have the following policies in place:
Tick if in placeC9 Copy of Financial Policies
C10 Copy of User Consultation Policy
C11 Copy of Complaints Procedure
C12 Copy of Equal Opportunities Policy
If grant application is successful, the Royal Borough of Kensington and Chelsea may request to inspect these policies and procedures. Only tick if the organisation has the relevant policies in place.
Tick if applicableC13 Copy of the latest reports (if applicable)
- OFSTED
- Commission for Social Care Inspection/Care Quality Commission
- Charity Commission reports
C14 Have you signed up to the Compact and Codes Yes/No
of Practice?
D SUMMARY OF COSTS 2010/2011
Business Group – Adult Social Care Only
Give a breakdown of the service/project costs and/or core costs, including expected income from other sources for each service/project.
Service/project description funding breakdown - Income 2010/2011:
Adult Social Care – Social Care / £Name of service/project:
Please provide a funding breakdown of the service/project:
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care:
Funding from other sources:
i)
ii)
iii)
iv)
v)
Total funding from other sources:
Please provide us with a breakdown of the funding your organisation is requesting if it relates to transport.
Adult Social Care - Transport / £Name of service/project:
Please provide a funding breakdown of the service/project:
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care:
Funding from other sources:
i)
ii)
iii)
iv)
v)
Total funding from other sources:
Please provide us with a breakdown of the funding your organisation is requesting if it relates to carers.
Adult Social Care - Carers / £Name of service/project:
Please provide a funding breakdown of the service/project:
i)
ii)
iii)
iv)
v)
Total Requested from Adult Social Care:
Funding from other sources:
i)
ii)
iii)
iv)
v)
Total funding from other sources:
If you want funding for more than one service/project, please photocopy and fill in a new Section D.
E CURRENT FINANCIAL INFORMATION
E1 Do you currently receive an annual grant from the Council (2009/2010)? Yes/NoE2 Value of Grant/s: / Adult Social Care: £
Transport: £
Carers: £
Corporate Services: £ / Family and Children’s Services: £
E3 What was the total income for the organisation in 2008/2009?
£
E4 What was the total expenditure for the organisation in 2008/2009?
£
E5 Anticipated total income for the organisation in 2010/2011:
£
E6 Anticipated expenditure for the organisation in 2010/2011:
£
F GOVERNANCE
Governance, Management and Finance
F1 The Council needs to ensure the organisation is well governed and has good management and financial systems in placePlease tell us how you demonstrate the following:
(Maximum 200 wordsin total)
a)Leadership:
b)Management Committee meetings (tell us how often meetings are held, how decisions are made, and agenda items discussed, for example, health and safety, staffing and finance):
c)Financial Management:
G If the organisation has not received a grant from the Royal Borough of Kensington and Chelsea within the last two years, give the name of an independent referee who knows about the organisation.
G1 Name:G2 Organisation:
G3 Position:
G4 Address:
G5 Telephone Number: / G6 Email:
G7 Has the referee been told that they will be approached? Yes/ No
Second Stage of Application Form
I Outline the overall aims and objectives of the organisation
I1 Aims and objectives (Maximum 150 words)J Service Description: Describe the service for which funding from Adult Social Care for is being applied for.
Complete a separate Section J for each service/project applied for
J1 Name of Service/Project Description. (Maximum 150 words)Which of the priorities below does the service meet: Tick box (you can tick more than one)
Improved quality of life / Making a positive contribution
Better health and well-being / Dignity and respect
Choice and control / Freedom from discrimination and
harassment
Economic well-being
Describe how the service will meet the priorities that have been ticked. (Maximum of 100 words for each priority)
a)Improved quality of life
b)Better health and well-being
c)Choice and control
d)Economic well-being
e)Making a positive contribution
f)Dignity and respect
g)Freedom from discrimination and harassment
How does the organisation collate this information? (Maximum 100 words)
J2 If funding is sought to meet transport costs, answer all the following questions: (This is if you are applying for a transport grant)
Brief description of transport needs (Maximum 100 words)Give reasons why public transport cannot be used (Maximum 50 words)
Frequency of journeys (e.g. twice daily, weekly)
Do you have your own transport? Yes/No
If no, name the transport provider you intend to use
J3 Give the total number of people expected to use the service
Monthly______
Yearly______
Percentage expected to be Royal Borough of Kensington and Chelsea residents
%______
Which areas of the borough will the service cover:
All Central North South
Monitoring and Evaluation
J4 Describe the ways in which the serviceyou are requesting funding for will be monitored (Maximum 150 words)J5 Describe the ways in which serviceyou are requesting funding for will be evaluated (Maximum 150 words)
i)
ii)
iii)
iv)
Complete a separate Section Jfor each service/project applied for
K User involvement/consultation
K1How does the organisation involve and consult with users? (Maximum 200 words)L Volunteering
L1 How many volunteers work for the organisation (excluding trustees)?MBACS Form
Please ensure that you complete the information below before submitting your application form.
It is the Royal Borough’s policy to make all payments by BACS transfer to reduce administrative costs. Please supply the details of your bank account below so that, if you are successful in your grant application, we can make payments quickly by direct bank transfer.
Please send a copy of the most recent bank statement with the BACS form.
Organisation Name:______
Organisation Address:______
Fax No______
Tel. No______
Payee’s Bank Account Name______
_ / _Bank Sort Code
Bank Account
Number
Bank Name and Branch______
Bank Address______
______
Postcode______
Signature______Date______
Print Name______
Job Title______
Office Use Only:
One World Supplier Number:
N DECLARATION
On behalf of the organisation, we the undersigned certify the following:
- The organisation wishes to apply for Grant Funding from the Council;
- If funding is approved we will adhere to the Funding Agreement and Mandatory Conditions of Funding;
- Monitoring information will be provided as required, returned on time, and we acknowledge the Council may impose penalties if this is not done;
- To the best of our knowledge the information included in the form is true. We understand that if false statements are made the Council may reduce or withdraw funding and that the Council will treat fraud as a legal matter;
- We understand that the contents of the completed application form are confidential between the Council and ourselves and that disclosure to third parties can only be done with permission of the Council and ourselves.
Signed: ______Date: ______
Position: ______
Signed: ______Date: ______
Position: ______
One signatory should be an officer of the Management Committee for example, Chairman, Treasurer and the other an appropriate member of staff, for example Executive Director or Manager.
O RETURNING THE APPLICATION FORM
Voluntary Sector Grant Applications 2010/11
Royal Borough of Kensington and Chelsea
Room 139
The Town Hall
Hornton Street
London
W8 7NX
Or email to
Remember to
Apply by the deadline: 23 September 2009 by 12 noon
Complete all sections
Keep a copy of the application for your files
Ensure all the additional information listed in Section C is enclosed with the application form. We will require a hard copy of signature page and BACS form.
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