Community Grants Submission Form

District Council of Yankalilla’s (DCY)

NEW/REPLACEMENT EQUIPMENT

Applicant Details

Organisation/Group Name:......

Address of organisation:......

Postal Address:......

ABN:...... Registered for GST? YES □ NO □

How are you funded?......

......

Contact Person Information

Title.....First Name...... Given Name......

Position at organisation/group:......

Postal Address......

Email Address ......

Daytime contact phone number......

Number of submissions this financial year

Are you making multiple submissions for this year’s Community Grant?YES □ NO □

If so, what priority are you allocating to this submission when comparing to the others

...... out of...... (ie: 2 out of 3)

Eligibility information

You are NOT eligible to apply for a grant if: you are a Political Party, State or Federal Government Department or Service (excluding school), Employee or Elected Member of DCY, a Union, a Professional Association, an organisation registered as a company limited by shares, an organisation who is not eligible to apply for a grant on behalf of another eligible organisation, an individual who is not a resident or rate payer of DCY or a commercial/profit-making organisation.

Are you a not for profit community group/organisationYES □ NO □

Do you operate in the District Council of Yankalilla (DCY) boundaries and

serve its residents?YES □ NO □

Are you situated outside the DCY boundaries yet provide service to DCY residents?YES □ NO □

Is your organisation/group eligible to make a submission as detailed in the

Community Grants Policy?YES □ NO □

If you are a local school, provide name ......

Details of New/Replacement Equipment

Details on the equipment seeking funding for:......

......

Is this a new piece of equipment being introduced?YES □ NO □

Is the equipment to replace an existing item?YES □ NO □

Please provide details on how the equipment will add value to the applicant ......

......

If to replace existing equipment, how old is the current equipment and why does it need replacing

......

How many quotes for the equipment are you including with the submission......

Summary of Funding New or Replacement Equipment:

Council only funds (1) a maximum of $2,500 which must be (2) no more than 50% of the total value of the equipment. Examples:

or equipment costing $7,000. 50% of the purchase cost is $3,500. Council will only provide a maximum of $2,500. You should demonstrate how the remaining funds are being sourced (self, other sponsorship etc)
for equipment costing $4,000. The maximum amount Council will fund for this purchase is $2,000 and you should demonstrate how the remaining funds are being sourced (ie self, in-kind, other sponsorship etc)

Total Cost of Purchase / From Applicant / From Other

Total amount being requested from Council$......

Declare other financial assistance being offered for the equipment:

From whom......

Amount $......

I confirm the funding amount requested is NOT more than $2,500YES □

I confirm that providing an acquittal by 30 June next year is an essential requirement YES □

I confirm funding amount sought is NOT more than 50% of the total equipment costYES □

I confirm the funding will not be used to pay a salary or wageYES □

Declare if Council is providing any other financial assistance to the applicant (within this current financial year) not relating to this submission (ie discretionary rate rebate):

What...... Amount$......

Demonstrate how DCY will be acknowledge and recognised for its grant......

......

Previous Community Grants from Council

Last Year’s Community Grant Funding:

Did you receive Community Grant funding from DCY in 2016/17YES □ NO □

If yes:

What was the funding for......

What funding was received $......

Date you returned acquittal to Council for the funding......

How did you acknowledge and recognise Council for its contribution......

......

Further information:

Would you like to provide any further information for the Panel to consider?

......

Payment details

(Please provide details to enable payment to be forwarded directly to your bank account)

Banking Institution Name......

Account in the Name of......

BSB Number...... Account Number......

OR if you require a cheque:

Name of person/club/group or organisation cheque is to be made out to:

......

Address......

......

Signature

Have you read and reviewed the Community Grants PolicyYES □ NO □

Are you able to meet the conditions of the grant as detailed in Policy? YES □ NO □

The following support documents are attached to this submission:

Audited financial statement for the current financial year YES □ NO □
Public Liability Insurance ($20 million) YES □ NO □
Quotations for the equipment
Any other supporting documentation

Signature of Applicant......

Name of Applicant......

Position at Organisation......

Date of Application......

Sending a Submission

All submissions are to be received by Council by 5pmFriday 29 September 2017. Late submissions cannot be accepted.

All submissions must be made on the appropriate Submission Form and be completed fully. If you are unsure about any question please ask for assistance.

Submissions can be made:

via email to
in person at the Council Chambers, 1 Charles Street, Yankalilla
by mailing to the District Council of Yankalilla, PO Box 9, Yankalilla, SA 5203, or
by faxing to (08) 8558 2022

Need Assistance?

If you would like to discuss your submission with Council prior to submitting, please contact Gemma Russell, General Manager Customer and Community Development.

Email:

Phone: 08 8558 0200

ASSESSMENT BY COMMUNITY GRANTS PANEL– TO BE COMPLETED BY DCY STAFF ONLY

Notes on submission’s complianceYES □ NO □

(See Community Grants Policy)

If not, reasons why not:......

......

Notes if recommended for funding YES □ NO □

If not, reasons why not:......

......

Notes on amount recommended to be funded $......

......

Notes on any funding variation from submissionYES □ NO □

If yes, why is the submission value not recommended......

......

Other Comments from Panel:......

......

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