Councillor Community Grant Scheme Application Form 2017 - 2018

Please read the attached application guidance and contact your ward councillor to discuss your project before submitting your application.

The deadline for the receipt of applications is 5pm on Friday 16th February 2018

1. Name of Organisation: ______

2. Applicant details:

Name
Position in organisation
Telephone
Email
Address
Post code

3. Organisation details:

Address
(if different from above)
Phone (if different from above)
Email (if different from above)
Bank Account Details
(must be group account, we can not pay individuals)
Registered Charity? / Y/N / Charity Number:
Voluntary / Community Group? / Y/N
Company Ltd by Guarantee? / Y/N / Company Number:
Self help group/ forum? / Y/N
What is the main purpose of your organisation?

4. Amount requested for your Project:

£

5. Please describe your project:

6. What value will your project add to the local community?

7. Who will benefit from your project? How many people?


8. Where will your project be delivered?

9. How can you demonstrate there is a need for this project?

10. Project Cost Breakdown

Item or Activity - please give a breakdown of costs / Cost
Total Project Cost:
(This figure should match the ‘Total Funding’ figure at the bottom of this table)
Funding from other sources or grants
(Please specify, e.g. club funds, other grants)
Other “in-kind” contributions
(non financial, such as volunteer time)
Amount requested from the Councillor Community Grant Scheme Fund
Total Funding for the Project:

Additional information & Declaration


Publicity & Promotion

A monitoring form will be sent to successful applicants six months after funding is awarded. It is a condition of the grant that this form is completed and returned, along with the required evidence of expenditure.

All projects are required to invite the councillor who approved the grant to visit the project, and for photographs to be taken which can be used for publicity purposes. Photographs may be published in council publications, including on social media and websites so please ensure the people in the photo have given their consent. If you do not feel this would be appropriate for your project, please include a short explanation along with your application.

Details of the successful applications may be published on Havant Borough Council’s website in accordance with government policy. No personal information will be published. We may also supply a list of grants awarded to the local media who may want to contact you about your project.

Declaration

I certify that all the particulars given in the form are correct, I understand how the Council may use our information and photographs,and that any grant money received must used for purposes stated in this form within 6 months of being awarded. The Council reserves the right to reclaim any grant not used for the purposes stated on this form.

If successful, I agree to complete and return the monitoring form, and to submit the required photos and evidence of expenditure.

Name: ______

Date: ______

Position: ______

Next Steps

Please now forward this application form to your councillor who will countersign and pass onto the Community Team for approval and processing.

If you have any queries or require further information, please contact Katie Bone on 02392446 495 or email

To be completed by the ward councillor awarding the funding:

Ward
Name
Amount to award / £
Do you have a declaration of interest in this application? Yes/No
If yes, please give details below and ask another ward councillor to countersign the application below.
Details of Interest:
I hereby confirm that I am happy to countersign this application due to the declaration of interest stated above.
Name of Councillor
______
Ward
______/ Signed: ______
Dated: ______
Ward Councillor Approval
I confirm that I support this project and I wish to submit the application for approval and payment, subject to it meeting all qualifying criteria. / Signed: ______
Dated: ______

For office use:

Grant successful: / Yes/No
If not, reason for rejection:
Amount payable: / £
Date money transferred: