PO Box 1321 Katherine NT 0851

Tel: (08) 8972 9038 Fax: (08) 8971 2429

Email: Web:

Community Grants

Application forMajor Grant (up to $3,000)

APPLICANT DETAILS:

  1. Name of organisation: ______
  1. Postal address: ______
  1. Physical location of organisation: ______
  1. Contact person name and position:______
  1. Day time contact: (H) ______(W) ______(Fax) ______
  1. Contact person email address: ______
  1. Is your organisation supported by an Incorporated Association that accepts legal and financial responsibility for the grant? Yes No

(If Yes details to be provided at end of application)

  1. ABN:

If no ABN, please supply a copy of the Statement by a Supplier form.

  1. Which category does your organisation service?

SportFestival Religion/Culture

 Education Charity Other : please specify______

______

  1. Time organisation has been providing services in the Roper Gulf Region: ______
  1. What activities and services does your organisation usually provide?Please explain how the organisation is an eligible organisation for RGRC Community Grants Program? (Please refer to the guidelines)
  1. Name of Project:______
  1. Purpose of the grant. (Please indicate what you want to use the funding for and tell us who will receive the main benefit from it).
  1. When are you going to run this project? ______
  1. Will your project help to support:

Local culture Local community

Families Environment

  1. How does the project support the goals and outcomes of Roper Gulf RegionalCouncil?(The Regional Plan can be found on the Councilwebsite Limit - 100 words)
  1. How does the project encourage collaboration between different groups? (Word Limit - 100 words)
  1. How does the project build knowledge, skills or confidence in Council residents?(Word Limit - 100 words)
  1. Please provide how the outcomes of the project provide maximum community benefit?(Word Limit - 100 words)
  1. Detail your project budget below:

PROJECT INCOME

Amount / Funding Confirmed
Roper Gulf RegionalCouncilCommunity Grant / Yes No
Volunteer labour
(Calculate @ $20 per hour) / Yes No
Your organisation’scontribution / Yes No
Sponsorship / Yes No
Fundraising / Yes No
Other government funds / Yes No
Other / Yes No
Total anticipated funds:
$ / Total funds confirmed:
$

PROJECT EXPENSES

Expenditure Items / Amount / Quotes Supplied
Yes No
Yes No
Yes No
Yes No
Total Expenditure

Will the project still proceed with less money? Yes No

Successful grant will be paid by electronic funds transfer (EFT) to a nominated account. Please show account details for your organisation or sponsor as applicable.

Account Name:
BSB No:
Account No:
Bank/Financial Institution
Bank/Financial Institution Address

TERMS & CONDITIONS

If a funding application is approved, your organisation (or sponsor, where applicable) agrees to the following Terms and Conditions:

  1. The grant will be used for the purpose for which it was given and will be spent in accordance with the Letter of Offer (prior to30 September2016),unless otherwise agreed in writing.
  1. Acquittal documents will be returned to the Roper Gulf Regional Council within three (3) months, of the event being held or project completed.
  1. Unspent funds greater than ten (10) percent of the grant amount will be refunded to the Roper Gulf Regional Council within three (3) months, of the event being held or project completed, unless otherwise agreed in writing.
  1. If there is to be any delay in spending the grant, a written request will be made seeking approval for the extension of time. This will be done no later than one month after completion date originally nominated of receiving formal notification of grant approval.
  1. The project, or part of the project relevant to this grant, will not be started before formal notification of grant approval has been received. If, for any reason, the project is to be started before notification, the organisation will contact the Council before the project starts.
  1. It is the responsibility of the organisation or sponsor to ensure adequate insurance cover for the project. A copy of your certificate of currency for Public Liability Insurance must be supplied with the major grant application.
  1. The organisation will acknowledge the contribution of the Roper Gulf Regional Council Community Grant. Please contact Council for an electronic copy of Council’s logo.
  1. Any special conditions that are attached to the grant will be met.
  1. All relevant records of the grant will be kept for a period of seven (7) years, and will be made available for audit at any time.
  1. Roper Gulf Regional Council reserves the right to use media, photographs and other documents relevant to the project to promote the Council or the Community Grants Program.

I have read and agreed to the Terms and Conditions set out above.I certify that all the information provided is current and correct and I give permission to the Council to contact any persons or organisations relevant to the processing of this application.

Signed for and on behalf of the organisation or sponsor. Only the Public Officer, President or Chairperson (or another officer formally delegated such authority) of the incorporated organisation which is to receive the grant is to sign.

Signed: ______

Name:______

Position: ______

We verify that the following organisation has agreed to manage this Community Grant Funding on our behalf: (Only applicable if you are not an Incorporated Association)

Organisation name
Contact person name/position
Organisation Chairperson/President name
Daytime telephone
Postal address
Organisation physical location
Organisation ABN
Organisation Certificate of Incorporation No.