Completing the Funding Submission Form

ABN: 38 872 506 567

D4 Funding Submission Short Form / D4 V2
Service Number:
Office Use Only / Date Submission received:
Office Use Only / Submission Number:
Office Use Only
Seniors Week 2012
Name of Organisation:
Name of Project/Event:

Tick the box below to mark this Funding Submission Form as:
Original / Do not bind or use staples. Paper clips and bull dog clips accepted.
Copy 1
Copy 2
Contents

Completing the funding submission form
Organisation details and eligibility criteria
Proposed project / event details
Selection criteria
Organisation agreement
Lodging the submission
Submission Checklist

1.Completing the Funding Submission Form

Before completing this form, ensure that you have obtained and read:

the Seniors Week Funding Information Paper and
the Department of Communities’ Small Grant Service Agreement.

These documents are contained in the Seniors Week Funding Information Package, which is available from your local departmental regional office or can be accessed on the departmental website at:
Eligibility
Applications must be eligible to receive funding from the Department of Communities. Refer to Section 2, Organisational Details and Eligibility Criteria.
Assessment
Applicants will be assessed according to:

how well they meet the Selection Criteria (Section 3); and
local needs and existing service provision.

All selection criteria are to be addressed unless the submission is for $300 or less. If the submission is for $300 or less, only address Selection Criteria One.
Completing the Funding Submission Form

All sections of this Funding Submission Form must be completed.
Fill in all the organisational details.
Keep your answers conciseby observing the word limits on selection criteria (no more than 200 words)

Lodging the submission

Lodge your submission in hard copy, ensuring that an original and two copies (including all supporting material) are provided. The submission marked original must be unbound.
If you complete this form electronically, click on the grey fields to enter your information. Use the tab key to move to the next field. The format, content and table templates of the funding submission form must not be altered in any way (except where additional space is required to answer the question). Attach additional pages as required.
If using the printed version of this document, attach additional pages sufficient to provide adequate information. Individually address each selection criterion clearly. If completing your Submission by hand, print and use a black pen.
Note this Funding Submission Form is for one event or project only. A separate Funding Submission Form must be completed for each event or project for which the organisation is seeking funding.

Enquiry Contact Details
Please contact your closest regional Department of Communities office listed on the second last page of this submission for additional information.
Privacy Notice
The Department of Communities is collecting information, including personal information, on this form for the purpose of assessing this submission. Your personal information will only be accessed by authorised departmental officers for purposes directly related to assessing this submission. Your personal information will be managed in accordance with the Information Privacy Principles outlined in the Information Privacy Act 2009. The department generally provides local Members of Parliament with the contact details of organisations approved for funding. Your personal information will not be disclosed to any other third party or used for any other purpose without your consent, unless required by law or for other authorised purposes described in the Information Privacy Act 2009.
2. Organisational details and eligibility criteria
2.1 A Organisation name and contact details
Name of organisation:
Address of the organisation:
Organisation’s email address:
Organisation’s fax number:
2.1 B Organisational legal status and contacts
Is your organisation a corporation?
By law, only incorporated bodies and Local Government Authorities may be funded.
Attach a copy of your organisation’s Certificate of Incorporation.
State run entities such as schools and hospitals cannot be funded. However, state school Parents and Citizens Associations can be funded.
If your organisation is non-incorporated and you would like to applying for funding you may either

seek incorporation, or
approach an incorporated community organisation to auspice your project. The incorporated organisation takes full responsibility for the legal and financial accountability of the proposed project.

/ Yes No
Yes, attached Already captured in OASIS
Australian Business Number (ABN): / State if you do not have an ABN.
GST Registered / Yes No
Does your organisation hold a minimum of $10M Public Liability Insurance for this event?
You may wish to approach a large organisation to auspice the project/event or, obtain insurance for the specific event.
If yes, provide the following details:
Name of the insurance company
Sum insured
Expiry date of policy / Yes No
$
If no, Your organisation will need insurance for any activities funded by the Department of Communities. Provide details on how your organisation plans to obtain insurance. Include details on cost, name/s of provider/s from whom quotes have been obtained and amount to be insured:
The department may contact you to request a copy of your most recent Audited Financial Statement. Where your organisation currently receives funding from the department, financial and performance reports may be taken into account when considering this funding submission. This includes both submitted reports and consideration of outstanding reports.
2.3 Contact officers for this submission
Title
(eg Mr, Mrs, Ms) / Name / Position in Organisation / Telephone
Business Hours
Organisation office bearers and accountable officers(Chairperson, President, Secretary, Treasurer of the incorporated body, or Chief Executive Officer for Local Government Authorities)
Title
(eg Mr, Mrs, Ms) / Name / Position in Organisation / Telephone
Business Hours
Does your organisation currently,or has it in the last two years,received funding from the Department of Communities? / Yes No
If yes, provide service name/s and number/s:
Financial and performance reports may be taken into account when considering this funding submission. This includes both submitted reports and consideration of outstanding reports.

3. ProposedProject/Event Details

Project/event name:
Address of premises from which the project/event will be provided:
(insert if applicable – do not enter if premises are a women’s refuge)
Postal address:
Telephone number:
Email address:(if any)
Fax number:(if any)
Address of premises from which the project/event will be coordinated:
(if different from above)
Postal address: (if different from above)
Telephone number: (if different from above)
Email address:(if different from above)
Fax number:(if different from above)

4. Selection Criteria

Submissions must provide written responses to all the following selection criteria.
Note that there are three (3) selection criteria and that equal weighting is assigned to each.
In completing the submission ensure you:

address each criterion on its own. Do not referto other sections of the Funding Submission Form;
address each ‘supporting evidence’ dot point. These are used to assess your submission;
do not use attachments as part of your responses to selection criteria (letters from Collaborative Partners are accepted). Applicants may quote from other documents or summarise documents within selection criteria responses.
Keep to the word limits.

Selection Criterion 1 Project/Event description (equal weighting, 300 words max)
Describethe proposed event or project, including the activities to be provided, and how the event or project contributes to:

promotion of positive community attitudes towards older people and ageing
encouraging the participation of older people, and
building community connections between people of different ages, cultures and backgrounds.

Include details of theproposed dates and time/s ofthe event or project and the geographic areayou wish to cover.
Tick which of the target groups, or who will benefit from the event or project if this is different, below.
Aboriginal people
Torres Strait Islander people
Australian South Sea Islander people
People from culturally and linguistically diverse backgrounds
Children
Young people /Students
Families
Seniors (tick relevant box) 60 years & under 61-70 71-80 80 years & over
Carers
Gay/lesbian/bisexual and transgender people
People from rural, remote or isolated areas
Other
Address the Selection Criteria and supporting evidence here
Selection Criterion 2Budget (equal weighting, 200 words max)
Demonstrate how you propose to use the grant to provide the event/project, and demonstrate how the activity provides value for money.
Eligible costs include:

Salaries, including salary on-costs (eg: workers’ compensation, leave loading, superannuation, payroll tax, long service leave) for staff directly involved in administration and coordination of the funded event. Salaries should be paid in accordance with the applicable industrial award or registered industrial agreement.

Operating costs specifically related to the provision of the event such as:

Running expenses (eg: gas, electricity, hire of premises, etc)
Administrative expenses (eg: postage, stationery, printing, telephone, cleaning, book-keeping/audit fees)
Insurance expenses
Travel/transport expenses (eg: fares, vehicle allowances)
Incidental expenses incurred by volunteers and staff in carrying out their work
Training expenses, including volunteer training
Advertising and publicity costs for fostering community awareness and involvement
Catering costs (should not exceed 50% of total event budget)
Sessional, tutor or consultants fees
Performance fees for example, entertainers

Ineligible costs include:

costs other than those listed above unless approved in writing by the Office for Seniors.
catering equipment purchase
purchase of prizes, gifts or incentives

events which are solely of a culinary nature (eg: barbeques, morning teas) are limited to an expenditure of not more that 50% of the event budget on food and beverages.

Key information to consider when planning your budget:
The minimum funding amount available is $1 000 and the maximum amount available is $5 000 per event or project.
(*Minimum funding amounts are provided as a preferred guide but submissions for amounts under $1 000 may be accepted and assessed, however they may not be considered a high priority status).
If you are receiving in-kind or other financial assistance, attach a budget outlining this support. Note that grant funds may only be expended on "eligible costs".
Funds available for Seniors Week project/events are provided on a one-off basis and there will be no further funding.
Respond here
Selection Criterion 3(equal weighting, 200 words max)
Describe how your project will collaborate with other organisations in the area that have agreed to work with the proposed project to meet the aims of the Seniors Week Funding Initiative.
Supporting information may include:

Letters from the collaborating partner organisationswhich must detailtheir contribution to the project/event. Letters of general support are not required.
Letters should include the name and details of a contact person in the collaborative partner organisation.
Be sure to include any collaborative partners you have with significant cultural groups that enhance your service delivery to these communities, for example the Aboriginal and Torres Strait Islander community, including traditional owners.

Address the Selection Criteria and supporting evidence here
Number of letters from collaborative partners attached:

4. Organisation Agreement

Organisations that are successful in obtaining funding will be required to:

comply with the Department of Communities’ Small Grants Agreement and complete an event report at the end of their event or project.

I declare that:

I am authorised by the applicant organisation to submit the submission;
the details in the submission are accurate; and
sufficient control mechanisms are in place to ensure that all monies can be managed and accounted for appropriately.

On behalf of the organisation: must be a person who has authority to sign on behalf of the corporation.
Signed:
Name:
Organisation position: (authorised officer)
Date:

5.Lodging the Submission

Closing date: All submissions must be lodged by 4:00pm on Monday, 14 November 2011.

Late submissions may not be accepted and, where accepted,may only be considered after assessment of all other submissions received by the deadline. If you live in a remote area which does not have a daily mail service and you believe that your submission may not arrive by the closing date, telephone the contact officer whose details appear below, prior to the closing date, to arrange an alternative means of lodgement. The original must still also be lodged.

Submission requirements: Copies of the following documents must be included in your submission. Check the box to indicate that the documents are attached:
a completed, original, unboundFunding Submission Form signed by an appropriate office holder;
a copy of the organisation’s Certificate of Incorporation if your organisation is not an Approved Service Provider;
letters of support from Collaborative Partner organisations (where relevant);
any additional relevant information to support the submission; and
two additional copies of the full submission and its attachments.
Enquiries:
Should you require further information to assist you in developing your funding submission, please contact your local Department of Communities regional office.

ABN: 38 872 506 567

LODGING SUBMISSIONS
Submissions can be lodgedat the regional office in which the event or project will be located. The addresses for all regional offices are listed below.
Region / RegionalCommunity Capacity and Service Quality Service Centres
South East Region / Gold Coast CCSQ Service Centre
Department of Communities
PO Box 4387
ROBINA TOWN CENTRE
QLD 4230
Level 2, Campus Alpha
2 Investigator Drive, Robina, 4226
Ph:07 5656 5868
Fax: 07 5575 7970 / Logan and Redland CCSQ Service Centre
Department of Communities
PO Box236
WOODRIDGE
QLD 4114
Level 1
6 Ewing Road
WOODRIDGE QLD 4114
Ph:3884 7804
Fax: 3884 7832
South West Region / South West CCSQ -Toowoomba Service Centre
Department of Communities
PO Box 2427
TOOWOOMBA Q 4350 / Level 6, Easternwell Centre
10 Russell Street
Toowoomba QLD 4350
Brisbane Region / Brisbane CCSQ – Windsor Service Centre
Department of Communities
PO Box 2186
WINDSOR Q 4030 / Level 2 Muruk Haus
230 Lutwyche Road (cnr Eildon Road)
WINDSOR Q 4030
Ph: 3109 0620
Fax: 3872 0666
NorthCoast Region / NorthCoast CCSQ Service Centre
Department of Communities
PO Box 3008
Maroochydore Qld 4558 / Level 3, 12 First Avenue
Maroochydore
Ph: 07 5352 7291
Fax: 07 5352 7308
Central Queensland Region / Central Queensland CCSQ – HerveyBay Service Centre
Department of Communities
PO Box 1490
HERVEY BAY Q 4655
Level 1 BrendanHansenBuilding
50-54 Main Street
HERVEY BAY Q 4655
Ph: 4125 9398
Fax: 4125 9396 / Central Queensland CCSQ - Rockhampton Service Centre
Department of Communities
PO Box 1503
ROCKHAMPTON Q 4700
36 East Street
ROCKHAMPTON Q 4700
Ph: 4938 4235
Fax: 4938 4236
North Queensland
Region / North Queensland CCSQ -
Mackay Service Centre
Department of Communities
PO Box 858
Mackay Q 4740
Level 2 HealthpointPharmacyBuilding
67-69 Sydney Street
Mackay Q 4740
Phone: 4967 4420
Fax:4967 4424 / North Queensland CCSQ -Townsville Service Centre
Department of Communities
PO Box 588
TOWNSVILLE MAIL CENTRE Q 4810
Level 2SuncorpPlazaBuilding
61 Sturt Street
TOWNSVILLE Q 4810
Ph: 4760 7300
Fax: 4760 7305 / North Queensland CCSQ – MountIsa Service Centre
Department of Communities
PO Box 1843
MOUNT ISA Q 4825
Suite 5B, MountIsa House, Cnr Camooweal & Mary Sts
MOUNT ISA Q 4825
Ph: 4747 3499
Fax: 4747 3466
Far North Queensland / Far North Queensland CCSQ Service Centre
Department of Communities
PO Box 1696
CAIRNS Q 4870
Please call the office first to arrange collection on 4036 5400 / Level 2, 5B Sheridan Street
CAIRNS Q 4870
Ph. 4036 5400
Fax:4036 5572
Hand delivered packages by prior arrangement only

Section 8

Checklist

The purpose of this checklist is to help you ensure you have answered all the questions in the Funding Submission Form and have attached the required supporting evidence.

Ensure you have completed all sections of the Funding Submission Form

Section 1 – Completing the Funding Submission Form

Have you completed one funding submission form for each Project/Event you are seeking funding for?

Section 2 – Organisational details

Defined Term funding only: Have you provided your ASP number?

Have you attached a copy of your organisation’s Certificate of Incorporation AND provided your ABN?

Have you provided details of contact officers for this submission?

Have you provided details of the organisations’ office bearers?

Have you provided details of the public liability insurance held by your organisation?

Section 3 -Selection Criteria

Have you provided full responses to each selection criterion?

Section 4 – Organisation Agreement

Has the funding submission form been signed by an authorised officer?

Section 5 – Lodging the Submission

Have you provided an original and two additional copies of the full submission and its attachments?

Have you kept a copy of your application for your records?