Community Asset Grant Scheme2015/16

Application form

Due by: 5 pm 2 October 2015

(9 pages including checklist and approval form)

THIS FORM IS ALSO AVAILABLE ELECTRONICALLY FROM CLARE AND GILBERT VALLEYS COUNCIL AND ON THE WEBSITE:

Community AssetLandowner ______

Council Asset 

  1. Location of project
  1. Title of proposal
  1. Organisation Details

3.1Name of organization

3.2Contact person

  • Name
  • Position in organisation
  • Address (postal)
  • Phone
  • Email
  1. Type of organisation (please circle)
  • Incorporated
  • Community/non- profit
  • Government funded
  • Section 41 committee of Council
  • Other
  1. ABN if applicable
  1. Certificate of incorporation (if applicable) – please attach
  1. Has your organisation received a Clare and Gilbert Valleys Council Asset Grant in the last three years? (circle answer)

YesNo

If yes when?

  1. Detailed description of the project.

Note: if this project is part of a larger development please provide a brief outline of the whole development planned.

Please include/ attach:

  • Maps
  • Photographs
  • Quotes
  • Any additional relevant material
  1. Please provide written evidence that this project is authorised by your committee eg Minutes of a meeting noting project approval or a letter from the Chairperson.
  1. LANDOWNER APPROVAL

10.1COUNCIL OWNED PROPERTY

Please complete the COMMUNITY MANAGED COUNCIL INFRASTRUCTURE – Approval Form which is Page 9 of this application form and submit to Council prior to the submission of your application.

*** NB Approval must be finalised before any applications will be considered for funding.

Forms can be emailed to you upon request separately if preferred.Please contact

Community Liaison Officer on 88426400 or for forms or questions.

10.2COMMUNITY OWNED PROPERTY ONLY

A letter from the Landowner must be provided stating approval for the

project

  1. Do you need any licenses, registrations, or other approvals to undertakethe project?

These applications should meet all statutory requirements i.e. Work Health and Safety Regulations, Building Regulations, Equipment Standards etc.

Licensed Trades People should be used if applicable

YesNo

If yes provide evidence of use of qualified contractors or trades people.

  1. Please list the other community groups that are involved in, or would benefit from your projectand describe their involvement.
  1. Demonstrate the community need for this project and please provide as much evidence as possible.

(i.e. survey forms, letters of support, strategic plan etc)

  1. What results are expected from this project?

1

  1. Detailed outline of costs and expected funding sources

Please include details of any free works (in kind) associated with this project.

eg, labour provided for removal of fences, loan of equipment

(A suggested value for voluntary labour is $25 per hour for unskilled and $50 per hour for skilled)

Item/ Activity / Cost / FUNDING SOURCE
Clare and GilbertValleys Council
(max $2,500) / Your organisation / Other organisations
Cash / In Kind / Name / Cash / In Kind
Sub totals
TOTAL
Inc GST if applicable

1

Please print name ______

Position Held in Organisation Chairperson 

Secretary 

Signature ______

Applications to:

Any of:

Clare and GilbertValleys Council

4 Gleeson Street

CLARE SA 5453

Saddleworth Office

19 Belvidere Road

SADDLEWORTH SA 5413

Riverton Office

21 Torrens Road

RIVERTON SA 5412

Or

By 5pm 2 October 2015

Please phone Community Liaison Officer, Lol Hill on 08 8842 6400

or email on for any information or assistance

Check List for Asset Grants2014/15

The following checklist has been devised to assist in preparing the application; Inclusion of sufficient data for evaluation is necessary to ensure consideration.

Please ensure that:

Application will be postmarked or received by Council by 5pm on 2 October 2015 (can be emailed)

All questions have been answered

The application has been signed by the appropriate person and contact details have been included

The budget has been completed

The financial totals have been placed in the correct budget columns

The Grant amount requested has been placed in the Clare and Gilbert Valleys Council column

If funding is being sourced from “other organisations” these organisations are named

The volunteer hours have been calculated and included

The application has been proof read

And that the following have been included:

Certificate of Incorporation (if applicable)

Evidence of Committee authorisation

Approval for projects on Council property – using the form included OR

Landowner consent for projects on Community owned property

Support letters

Quotes

Photos

Plans and Maps

  • Please submit your application in a single sided format
  • Please secure applications and attachments with a paper clip- do not bind your applications as copies are made
  • A cover page is not necessary

COMMUNITY MANAGED COUNCIL INFRASTRUCTURE
APPROVAL REQUEST
Organisation:
Building /Council Property:
Site Address:
Contact Person / Role:
Ph:
Name: / Mobile:
Email:
Postal Address:
Details of proposed project including placement of units if appropriate:
Other parties involved: (eg plumber/electrician)
Note:
  1. Council preferred contractors only are to be used on Council property - check with Gary if unsure
  2. Other suppliers can gain approval upon application to Council

Funding Source: (eg organisation / grant )
PRIOR TO ANY INSTALLATION PLEASE CONSULT WITH GARY EASTHOPE
Office Use only: / Date:
Approved / Signed
G.Easthope
Facilities, Maintenance, Contracts Supervisor

Not Approved /
Budget consideration
To Manager Infrastructure
for consideration

To CEO for consideration / (Copy of form to Finance Manager)

1