APPLICATION FORM

Respondents must complete this ApplicationForm as a compulsory element of their Invitation to Apply for a Grant for the Assisted Private Rental Pilot.Relevant information should be submitted to address each of the following selection criteria:

  1. suitability of proposed service delivery model (60%); and
  2. demonstrated capacity and experience (40%)

as well as the mandatory criteria and pricing schedule.

Respondents are requested to download this ApplicationFormand type directly into the spaces provided. Additional information / documents can be attached separately if required.

Submission Checklist

Respondents are encouraged to:

Attend a non-compulsory briefing, as detailed in section 7.3.2 of the Invitation.

Register their details on the Housing Authority website to receive updates and additional information (e.g. Addenda) about the Invitation

Read the Invitation document thoroughly

Check the Housing Authority website for any updates on the Invitation

Complete the Application Form and prepare any other documents that will be submitted

If submitting by post or hand:

Make five copies of the submission, one marked “original” and four marked “copy”

Make an electronic copy of the submission and save it to a CD-ROM, DVD or USB memory stick in the same order as the original version

Submit all relevant information prior to theclosing date and time to:

Tendering Services – Tender Box

Ground Floor

Housing Authority

99 Plain Street

EAST PERTH WA 6004

Note: If submitting by post, Respondents are responsible for ensuring that the documents are posted with sufficient time for delivery prior to the closing date.

  1. Respondent Details

1.1Contact Details

Required Information / Respondent to Complete
  1. Name of legal entity:
/ [Insert information here]
  1. ACN:
/ [Insert information here]
  1. Business name:
/ [Insert information here]
  1. ABN (if applicable):
/ [Insert information here]
  1. Contact person:
/ [Insert information here]
  1. Contact person position title:
/ [Insert information here]
  1. Registered address or address of principal place of business:
/ [Insert information here]
  1. Email:
/ [Insert information here]
  1. Telephone number:
/ [Insert information here]
  1. Physical address for service of contractual notices:
/ [Insert information here]

Note: Consortium bids must identify the principal provider and/or contact person. The relationship with other parties must be described in section 1.3.

1.2Lead Organisation Information

Required Information / Respondent to Complete
  1. How would you describe the primary purpose of your organisation?
/ Please select one of the following:
☐Support Service Provider
☐Community Housing Provider
☐Other (please specify)
  1. Is your organisation a not-for-profit entity?[1]
/ ☐ Yes ☐No
  1. Is your organisation a Local Government Authority?
/ ☐ Yes ☐No
  1. Approximately how many staff do you have (including volunteers)?
/ [Please specify]

1.3Consortia Bids and Partnerships

Required Information / Respondent to Complete
  1. Do you propose to deliver this service in partnership with another organisation?
/ ☐ Yes ☐No
  1. If Yes to the above, please identify the organisation/s you propose to work with.
/ Please provide the name of any organisations you propose to work with to deliver the required services.
  1. Describe the relationships between the parties submitting this application (e.g. consortia bid / lead agency model / sub-contracting arrangement):
[Insert information here]
  1. Outline your organisation’s experience working with this organisation/s:
[Insert information here]

1.4Warranties

Required Information / Respondent to Complete
  1. I/We have read, understood and accept the material contained in the Invitation.
/ ☐ Yes ☐No
  1. I/We warrant that I/We:
  • am not/are not an entity:
  • who is bankrupt or in the process of being wound up;
  • whose affairs are being administered by the court;
  • who has entered into an arrangement with creditors;
  • who has suspended business activities; or
  • who is in any analogous situation arising from a similar procedure under national laws and regulations;
  • am not/are not the subject of proceedings for:
  • declaration of bankruptcy;
  • an order for compulsory winding up or administration by a court;
  • an arrangement with creditors; or
  • any other similar proceedings under national laws or regulations;
  • have not been convicted of an offence concerning professional conduct by a judgement, which has the force of law;
  • have not been guilty of grave professional misconduct proved by any means, which the contracting authorities can justify; or
  • are not guilty of a serious misrepresentation in supplying or failing to supply the information required.
/ ☐ Yes ☐No

1.5Financial and Compliance Requirements

In the event that the Respondent’s Submission is assessed as suitable, Housing reserves the right to request or perform security or financial (including credit) checks in relation to the Respondent, its partners, associates, or related entities including consortium members and their officers or employees. For further information please refer to section 8.17.1 of the Invitation.

Required Information / Respondent to Complete
  1. Is your organisation willing and able to provide full financial statements or such other information required to assess the Respondent’s financial and organisational capacity and capability?
/ ☐ Yes ☐No
If No, please provide details.
  1. Is your organisation’s financial information available via the Australian Charities and Not-For-Profit’s Commissions (ACNC) Register, and does the Respondent agree that Housing can use this information to assess the Submission?
Note: Respondents are responsible for ensuring that the information available via the ACNC Register is correct and that no material changes to the information have occurred since it was reported to the ACNC. / ☐ Yes ☐No
  1. Does your organisation have public liability, professional indemnity and workers compensation insurance?
If No, would you be willing to acquire insurance to cover your activities under this Grant Agreement? / ☐ Yes ☐No
Value
Public Liability
Professional Indemnity
Workers Compensation
☐ Yes ☐No
  1. Have any of the following:
  • the Respondent; or
  • any Director or other Officer of the Respondent; or
  • any Specified Personnel,
  • been convicted of a criminal offence that is punishable by imprisonment or detention?
[The Respondent need not disclose convictions that are spent convictions under the Spent Convictions Act 1988 (WA) or equivalent legislation of another State or Territory of Australia]. / ☐ Yes ☐No
If Yes, please provide details:
  1. Are there any actual, potential or perceived conflicts of interest associated with your organisation delivering this service?
/ ☐ Yes ☐No
If Yes, please detail how the actual, potential or perceived conflict of interest arises and strategies for managing it below.
  1. MANDATORY REQUIREMENTS

Housing will not consider any Application that does not meet the following Mandatory Requirements:

Required Information / Respondent to Complete
  1. Do you warrant that the grant funding will notconstitute the sole source of funding for the Respondent organisation/consortia?
/ ☐ Yes ☐No
  1. Are you willing to participate in a Pilot Steering Committee?
/ ☐ Yes ☐No
  1. Are you willing to work collaboratively with Housing and any other Successful Respondent(s) to undertake ongoing evaluation, data collection and reporting in accordance with agreed frameworks and processes?
/ ☐ Yes ☐No
  1. Are you willing to share financial and other data with Housing to develop an understanding of the true service costs and outcomes achieved?
/ ☐ Yes ☐No
  1. Are you willing to undertake action research activities with Housing and others, including End Users, to improve services and deliver outcomes?
/ ☐ Yes ☐No
  1. Are you willing to share learnings with Housing and other Community Services Organisations to achieve better outcomes for End Users and the community?
/ ☐ Yes ☐No

For context and further information please refer to section 6.2 of the Invitation.

  1. Proposed approach and Service delivery model (60%)

Respondents must outline a service model that achieves the desired outcomes set out in Section 4 of the Invitation, within the scope of services outlined in Section 5 of the Invitation. Note that Housing is receptive to new ideas and welcomes innovation, provided that this will support the achievement of Pilot objectives and outcomes.

3.1.Service Model Overview

Required Information / Respondent to Complete
  1. What services do you propose to supply to the Housing Authority?
Note: Housing will commence identifying participants prior to the Invitation process being completed. Successful Respondents may be required to provide assistance services to clients identified through this process. / Please select one of the following:
☐An Integrated Property Leasing and Individualised Assistance Solution
☐An Individualised Assistance Only Solution
[Refer to section 5.1 of the Invitation]
  1. Which locations do you propose to service?
/ Please select all that apply:
☐Metro North
☐Metro South-East
☐Metro Fremantle
☐South West (Bunbury)
☐Great Southern (Albany)
  1. What is the maximum number of participants you have capacity to provide individualised assistance to by 30 June 2017?
/ Please specify.
  1. If you are proposing an Integrated Property Leasing and Individualised Assistance Solution, how many participants do you have capacity to house in private rental accommodation by 30 June 2017?
/ Please specify.
  1. Which target group do you propose to work with?
/ Please select one of the following:
☐Waitlist Applicants (including Priority Waitlist)
☐Over-Income Tenants
☐Both of the above
  1. Do you propose to target a sub-set of these groups (e.g. families with children on the priority waitlist, victims of family and domestic violence, other)?
/ ☐ Yes ☐No
If Yes, please specify.
  1. Do you anticipate the need to recruit additional staff to deliver your proposed service model?
/ ☐ Yes ☐No
  1. If you were provided with grant funding in September 2016, when do you estimate that you could commence working with clients?
/ Please specify.

3.2.Service Model Detail

3.2.1.Description of Model

Required Information [Respondent to Complete]
  1. Outline the philosophy, approach andkey elements of your proposed service delivery model, including but not limited to:
  • what role, if any, you will have in sourcing properties and negotiating leases with the private sector, and your preferred leasing arrangements;
  • what role, if any, you will have in providing or procuring Property Related Services [refer to section 5.6 of Invitation];
  • the legal and financial relationships between stakeholders including any revenue sources other than Grant funding provided by Housing; and
  • any distinguishing or innovative elements of your model, including the contribution or leverage of other resources and/or services.
[Insert information here]
  1. Describe how the proposed service model will contribute to achieving the required outcomes:
[Insert information here]

3.2.2.ParticipantAssessment and Monitoring

Required Information [Respondent to Complete]
  1. Outline the approach and process that will be used to assess Participants’ suitability to participate in the Pilot, including:
  • What strategies/methods will you use to identify Participants with the aspiration and capacity to succeed in the Pilot?
[Insert information here]
  1. Outline the approach and process that will be used to assess Participants’aspirations, capacity and support needs, including:
  • How will you work holistically with Participants to identify the core factors that are inhibiting their capacity to sustain mainstream housing, including any enablers and restraints?
[Insert information here]
  1. Outline the approach and process that will be used to partner with Participants to monitor and respond to theirongoing needs, including:
  • Individual planning approaches
  • Contingency plans to address changing needs?
[Insert information here]

3.2.3.Individualised Assistance

Required Information [Respondent to Complete]
  1. Describe the approach and processes you will use to gain and maintain participant commitment, and enable Participants to access and connect to services and/or supports, resulting in them achieving intended Pilot outcomes, including:
  • The support services to be provided by the Respondent
  • The existing support services participants will be linked to
  • The peer and community support services that will be established or utilised
  • How you propose to maximisethe use of pre-existing services and community supports, to avoid service duplication.
[Insert information here]
  1. Existing support services may have limited capacity to assist Pilot Participants. Outline how this issue will be managed:
[Insert information here]
  1. Use examples to illustrate how you propose to work with Participants to help them build personal and financial capacity so they can become independent from support services and rental subsidies, giving consideration to:
  • The nature and level of services or supportsprovided;
  • How you propose to support Participants to prepare for reducing rental subsidies and to successfully exit the Pilot; and
  • How you will seek to ensure that Participants are not under or over-serviced.
[Insert information here]

3.2.4.Collaboration and Evaluation

Required Information [Respondent to Complete]
  1. As this Pilot has a strong formative evaluation element and, noting the mandatory requirements,outline your proposed approach and process for working collaboratively with Housing, other Successful Respondent/s and End Users:
[Insert information here]
  1. Outline the proposed arrangements for collecting and reporting the required data:
[Insert information here]

3.3.Risk Management

Required Information [Respondent to Complete]
  1. Outline what you consider to be the main risks in delivering the outcomes within the required timeframes and the proposed risk management mechanisms:
[Insert information here]
  1. demonstrated capability, Capacity and Experience (40%)

Respondents must demonstrate that they have the organisational capacity, capability and experience to perform the requirements of the grant agreement and deliver the scope of services detailed in Section 5 of the Invitation.

4.1.Organisational Capability

Required Information [Respondent to Complete]
  1. Outline the Respondent’s governance and accountability arrangements(in the case of a consortia application, these arrangements and practices must be detailed for each party to the consortia):
[Insert information here]
  1. Describe the Respondent’s organisational planning and resourcing capability to perform the services requested in Section 5 of the Invitation:
[Insert information here]

4.2.Organisational Capacity

Required Information [Respondent to Complete]
  1. Provide an indicative timeframe for project commencement and service delivery, including projected milestones for:
  • housing Participants under an Integrated Property Leasing and Individualised Assistance Solution; or
  • assessing participants under an Individualised Assistance Only Solution
by 30 June 2017:
[Insert information here]
  1. Outline the proposed staffing arrangements, including qualifications, experience and capacity of key personnel:
[Insert information here]

4.3.Experience

Required Information [Respondent to Complete]
  1. Provide relevant information to demonstrate that the Respondent has experience in delivering services similar to those being proposed in the service model. At a minimum, this should include details of:
  2. Groups targeted;
  3. Services provided;
  4. Outcomes achieved;
  5. Similarities with the current Application; and
  6. Referees contact details.
[Insert information here]
  1. Provide relevant information to demonstrate that the Respondent has experience working collaboratively to improve outcomes for End Users, including any experience in:
  • Evaluation;
  • Data collection;
  • Continuous Improvement;
  • End user co-design; and
  • Action learning.
[Insert information here]
Required Information [Respondent to Completeonly if the Respondent proposes to provide an Integrated Property and Assistance Solution]
  1. Provide relevant information to demonstrate the Respondent’s capacity, capability and experience to efficiently secure and oversee a portfolio of private leases, including proposed systems and processes for doing so:
[Insert information here]
  1. PRICE SCHEDULE
  2. Estimated Annual Cost

Required Information [Respondent to Complete]
  1. Respondents are required to estimate the whole cost of delivering their proposed service model (including administration, overheads etc) over the next two years, indicating how the budget will be distributed across key budget items in the table below.*
* Note that further rows may be added to the table if required.
BUDGET ITEM / Year 1 / Year 2 / TOTAL
[Insert information here] / $ [Insert information here] / $ [Insert information here] / $ [Insert information here]
Administration / $ / $ / $
Staffing / $ / $ / $
Staff On-Costs / $ / $ / $
Travel / $ / $ / $
Brokerage / $ / $ / $
Other / $ / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
TOTAL / $ / $ / $
  1. Outline key assumptions made in preparing the costings above, including:
  • Estimated number of participants to be serviced;
  • Proportion of waitlist applicants to over-income tenants;
  • Proportion of low needs and moderate needs participants;
  • Geographic area serviced;
  • Differences in proposed level of service over the two years; and
  • The scalability of your delivery model and any price sensitivities relating to the number of participants (for example 20, 50, 100)and their varying levels of need, and an explanation for any significant variations.
[Insert information here]
  1. Additional Information

Required Information [Respondent to Complete]
  1. Provide any additional relevant information to support your Application and value proposition.
[Insert information here]
  1. Respondent’s Certification of the Application

Required Information [Respondent to Complete]
This Application is signed by a person or persons duly authorised on the Respondent's behalf.
In the case of a Consortia Application, each party to the Consortia must have a duly authorised person or persons sign below.
Signature 1: ...... WitnessSignature 1: ......
FullName 1: ...... WitnessFullName 1: ......
Date: ...... Date: ......
Signature 2: ...... WitnessSignature 2: ......
FullName 2: ...... WitnessFullName 2: ......
Date: ...... Date: ......
Signature 3: ...... WitnessSignature 3: ......
FullName 3: ...... WitnessFullName 3: ......
Date: ...... Date: ......
Signature 4: ...... WitnessSignature 4: ......
FullName 4: ...... WitnessFullName 4: ......
Date: ...... Date: ......
Signature 1: ...... WitnessSignature 1: ......
FullName 1: ...... WitnessFullName 1: ......
Date: ...... Date: ......

END OF APPLICATION FORM

1

[1] For the purposes of this Invitation process, the Respondent is from the “not-for-profit entity” if its constitution or governing documents prohibit distribution of profits or gains to individual members, both while the Respondent is a going concern and on its dissolution.