Royalties for Regions

Country Local Government Fund

Application Form

2010-11

Regional Groups of Local Governments

To receive funding under the CLGF groups are required to complete this form and submit it together with a business case for an eligible project. Groups are required to complete a separate form and business case for each project they wish to undertake.

Forms must be signed by the Chief Executive Officer of each of the local governments within the group.

RDL will liaise with the nominated managing legal entity, as per this application form, in regards to the Financial Assistance Agreement, funding payments and reporting requirements.

A copy of this form, the business case template and the CLGF guidelines can be found at: www.royaltiesforregions.wa.gov.au.

Please complete all sections of the form.

The mailing address for returning this form is:

Manager, Reporting and Evaluation

Department of Regional Development and Lands

Regional Investment Division

PO Box 1143

WEST PERTH WA 6872

If you require more information or help to complete this form please contact
Matthew Marsh on telephone (08) 9217 1689 or Freecall 1800 620 511 or email .

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ROYALTIES FOR REGIONS

COUNTRY LOCAL GOVERNMENT FUND (CLGF)

REGIONAL GROUPS APPLICATION FORM – 2010-11

1.  GROUP DETAILS:

Name of group:
Member local governments:

2.  PROJECT DETAILS:

Project / Brief Description / Est Start Date of Project / Est Completion Date of Project / Est No. Jobs Required for Project / Est No. Ongoing Jobs Created

Please attach more information if insufficient space.

3.  EXPENDITURE DETAILS:

CLGF Funds Available to Group (ex GST): / $

3.1 $ are to be allocated to the above infrastructure project – as supported by the attached business case

3.2 Individual Local Government Contributions:

[Please show the amount that each local government is contributing to this project from its 2010-11 CLGF Regional Groupings Allocation]

Local Government / Total 2010-11 CLGF Regional Groupings Allocation / Contribution to this Project from 2010-11 CLGF Regional Groupings Allocation

[Please add more rows if more local governments are members of the group.]

4.  GOVERNANCE ARRANGEMENTS

4.1 Details of who will manage and deliver the project(s):

Name of legal entity:
ABN: / GST Registered: / Yes No
Address:
Postal Address:
Web Address:
Contact Person:
Position/Title:
Telephone: / Fax:
Email:

5.  DECLARATION

[This section must be signed by the CEO of each local government in the group]

We the undersigned declare:

That we are authorised to supply this information on behalf of the local governments identified in section one (1) above.

That the nominated project accurately reflects the group’s regional priorities as supported by the attached business case.

That all the information supplied in this form is, to the best of my knowledge, accurate and complete and that the Department of Regional Development and Lands will be notified of any change to the information supplied and any other information or circumstances arising that may affect this project(s) proposal.

Below are my details and signature, acknowledging the above:

Name
Title / Chief Executive Officer
Organisation

Signature: ______Date: ______

Name
Title / Chief Executive Officer
Organisation

Signature: ______Date: ______

Name
Title / Chief Executive Officer
Organisation

Signature: ______Date: ______

Name
Title / Chief Executive Officer
Organisation

Signature: ______Date: ______

[Please add more if more local governments are members of the group.]

Please print, sign and return this original form to RDL.

Manager, Reporting and Evaluation

Department of Regional Development and Lands

Regional Investment Division

PO Box 1143

WEST PERTH WA 6872

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