Application Form

Glenelg Shire Council

Community Grants (Round 2) 2015-2016

Please Note: An organisation can make more than one application but the total amount of funding received by an organisation or group will NOT exceed $5,000 in any financial year.

Which category of the GSC Community Grants are you applying for?
Recreation Arts, Culture and Heritage
Public Halls Community Plan Support
Tourism Community Support

Section 1 – Organisation Information

Part A: Applicant details

Name of Organisation:
Street Address:
Town / Suburb: / Postcode: / State:
Postal Address (if different from above):
Town / Suburb: / Postcode: / State:
Authorised person (This is the person who is authorised by the organisation to make the application on their behalf)
Title: / First name: / Last name:
Position:
Telephone: / Mobile: / Fax:
Email:
Postal Address (if different from above):
Town / Suburb: / Postcode: / State:


Section 1 – Organisation Information

(continued)

Are you an Incorporated Association?
Yes, please provide your Organisation’s Australian Business Number (ABN):
Please go straight to Section 2 - Project Overview. You do not require an auspice organisation.
No, please complete Part B: Auspice Organisation Details below. You require an incorporated association, (an auspice organisation), to manage the grant funds on your behalf. NB if the proposed organisation has an outstanding Community Grant acquittal itself, it is ineligible to auspice another organisation’s application. Please check.
Has your organisation previously received funding from us? Yes No
If Yes. Please provide further details Year: Amount: $ 0.00 and Project Name:

Part B: Auspice Organisation details

Name of Auspice Organisation:
Street Address:
Town / Suburb: / Postcode: / State:
Postal Address (if different from above):
Town / Suburb: / Postcode: / State:
Authorised person:
Title: / First name: / Last name:
Position:
Telephone: / Mobile: / Fax:
Email:
Type of Organisation: Incorporated Association Other
Auspice Organisation’s Australian Business Number (ABN):
Please note that a signed LETTER OF AGREEMENT from the ELIGIBLE auspice organisation must be included with this application form for your application to be considered.
The Letter of Agreement from the auspice organisation is attached to this application? Yes No

Section 2 – Project Overview

Project name / We will use this name on all correspondence. Please use 10 words or less.
Project Description / Describe the project in 50 words or less. We will use this in reports and other publications.
Council Officer contact?
Discussion of your project idea is required for all applications. Please indicate the name of the relevant GSC officer you have discussed your proposal with. Please refer to staff listing on page 9 for relevant officer’s contact details.
Who will benefit from this project? Is this project for the benefit of the whole community or directed toward a particular group i.e. people with a disability, women, men, indigenous, youth, seniors, disadvantaged etc. Please use 50 words or less.
When will your project take place?
Anticipated project start date: D/M/Y
Anticipated project completion date: D/M/Y
Which township/community will benefit from your project?

Section 3 – Weighted Selection Criteria

Please indicate how your project addresses the following assessment criteria: community involvement, community benefit, evidence of need, capacity building, financial issues and economic impact, sustainability and environmental. Please refer to the ‘Community Grants Guidelines (Round 2) – ’ 2015-2016 (page 7) for detailed criteria information. Responses to each question should be no more than 50 words. Attach additional pages if required.

Community involvement (participation/inclusiveness) – 20% (50 words maximum)
Which community groups will be involved?
Community benefit – 20% (50 words maximum)
What will the project achieve?
Evidence of need – 15% (50 words maximum)
Why is the project needed?


Section 3 – Weighted Selection Criteria

(continued)

Capacity building – 15% (50 words maximum)
How will it strengthen or develop the participants, organisations and the shire?
Financial issues and economic impact – 10% (50 words maximum)
Is the project financially viable and will it bring economic benefit to the shire?
Sustainability – 10% (50 words maximum)
How will the project strengthen the community and its resources? Is the project achievable and sustainable?
Environmental – 10% (50 words maximum)
Have environmental issues been considered and is the project environmentally friendly?

Section 4 – Project Budget

Please provide details of the income and expenditure for your project. Note the total income amount MUST EQUAL the total expenditure amount. You are required to submit your budget using the categories provided, which are relevant to your project. If you cannot provide enough details in this section, please provide a summary here and provide the details on a separate sheet using the categories.

NB: Where the Council contribution sought is greater than $1,000 the applicant must demonstrate equal or greater contribution to the project. Please refer to Community Grants Guidelines Page 2 Funding Conditions, dot points 4 & 5. (NB. Not applicable to Community Plan Support applications)

INCOME / $ / EXPENDITURE / $
Cash amount sought from Council’s Community Grants Program / $ / Administration overheads / $
Funds from your organisation / $ / Advertising and Promotion / $
Other Grants / $ / Contingencies and Allowances / $
External Business Contribution / $ / Education and Training / $
Community Fundraising / $ / Labour and Materials / $
IN–KIND SUPPORT / Printing / $
·  Volunteer Labour / $ / Salaries (please detail) / $
·  Materials / $ / Transport / $
·  Facilities / $ / Venue / Meeting room hire / $
Other (please specify)
/ $ / Other incl. in-kind (please specify) / $
Council in-kind support sought (e.g. Council venue hire etc. Max $500) / $ / Other / $
Total Income
(must equal expenditure) / $ / Total Expenditure
(must equal income) / $

Note: The total budget for combined cash grant and Council in-kind support applications must not exceed the maximum amount of $5,000.

Are project incomes confirmed or unconfirmed? (50 words maximum)
Please indicate whether incomes listed in your budget from (a) your organisation; (b) external business contributions; (c) community fundraising; and (d) other grants (please list grant funding body/ies) are confirmed.

Section 4 – Project Budget

(continued)

What could you complete without other income?
If this application were successful but other income you have identified was not received, would you be able to proceed with this project?
Yes No n/a

Declaration

·  I state that the information in this application and its attachments is true and correct to the best of my knowledge.

·  I will notify Glenelg Shire Council (GSC) of any changes to this information and any circumstances that may affect this application.

·  I acknowledge that the GSC may refer this application to external experts or other Government Departments for assessment, reporting, advice, comment or for discussions regarding alternative or collaborative grant funding opportunities.

·  I understand that GSC is subject to the Freedom of Information Act 1982 and that if a Freedom of Information request is made, GSC will consult with the applicant before any decision is made to release the application or supporting documentation.

·  I understand that this is an application only and may not necessarily result in funding approval.

Signature: / Date:
Print name: / Position:
To be signed by a person with delegated authority to apply (i.e.) Chief Executive Officer or Board Chairperson.

Supporting Documents

Please provide relevant documents to support your application. These might include:

·  Letter of Agreement from auspice organisation (if applicable)

·  Letters of support and pledges (includes cash and in-kind)

·  Annual Reports

·  Bank Statements

·  Quotes/estimates

·  Risk Management Plan (If applicable)

·  Public Liability Insurance cover of at least $10million (If applicable)

Other documents may be requested if successful.

Eligibility Checklist
The eligibility checklist below is designed to help groups, clubs or organisations determine their eligibility for the Glenelg Shire Council’s Community Grants. Please note: Groups, clubs or organisations that receive State or Federal Government funding are NOT eligible for funding.

Please answer ‘yes’ or ‘no’ to the following: / Y/N
Is the major emphasis of the project within Glenelg Shire?
Is your organisation incorporated? If not incorporated have you listed an eligible organisation that will auspice on your behalf?
Has the application been discussed in detail with a Council officer?
Is the project start date in the future?
Are you a small to medium non-profit organisation?
Do you, or the incorporated organisation that has agreed to auspice your application, have no outstanding acquittals or debts owing to Council?
If requesting over $1,000, can your organisation match the contribution?
Public Liability - only complete this section if you are applying for a grant of $2,000 or more and/or applying for the use of a Council owned facility.
If you are applying for a grant for $2000 or more and/or applying for the use of a Council owned facility have you provided a copy of your current public liability insurance (minimum $10million) with your application?

Risk Assessment - only complete this section if you are applying for a grant to run an event or if applying for the use of a Council owned facility.

If the project is an event, have you provided a Risk Assessment Plan with your application?

If you have answered YES to all of the above relevant questions you are eligible to apply for the Community Grants Program.


Please note eligibility does not guarantee application success.

Quotes/Estimates
Please note, where possible, quotes and/or estimates should be supplied to support your application.

Contact Details

Grant Category / Council Officer / Contact Details
Recreation / Public Halls / Sharon Bridgewater
Acting Recreation Development Officer / Ph: 5522 2172
Email:
Tourism / Carly Garonne
Economic Development & Tourism Coordinator / Ph: 5522 2239
Email:
Arts, Culture and Heritage / Lynda Cooper
Acting Arts and Culture Manager / Ph: 5522 2301
Email:
Community Plan Support/ Community Support / Ian Moody
Community Development Manager / Ph: 5522 2220
Email:

Submitting Your Application:

In Person: Glenelg Shire Council Customer Service Centres

OR

By Mail: Glenelg Shire Council

“Insert relevant Grant Category”

Community Grants Program (Round 2) 2015/2016

PO Box 152

PORTLAND 3305

OR

Email to:

“Insert relevant Grant Category”

Community Grants Program (Round 2) 2015/2016

Glenelg Shire Council-Community Grants (Round 2) 2015-2016 (Application Form) 1 of 9