Community Grants Program

2017/2018

Round ONE

Applications Open August 2017
Close 5.00pm Wednesday27September 2017

Please complete this application on a computer and type your responses, or request an electronic document from Chloe: 8391 7238,
SUMMARY INFORMATION

Name of Project/Activity
Name of Organisation / Click here to enter text. /
Contact Person for project / Click here to enter text. /
Position / Click here to enter text. /
Postal Address / Click here to enter text. /
Phone / Click here to enter text. /
Fax / Click here to enter text. /
Email / Click here to enter text. /
ABN / Click here to enter text.
Registered for GST: ☐ Yes ☐ No
Bank Details / Account Name:Click here to enter text.
BSB:Click here to enter text.
Account:Click here to enter text.
Total cost of project/activity / $Click here to enter text.
Amount requested from Council / $Click here to enter text.

Please complete this application on a computer and type your responses, or request an electronic document from Chloe: 8391 7238,

  1. A brief description of the proposed project

Click here to enter text.
  1. How will your project benefit the community?

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  1. Key tasks & dates for your project. (Include completion dates)

All organisations receiving Community Grants will be required to claim, expend and acquit the grant within twelve months of the grant being approved at an Ordinary Council meeting.

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  1. Who are your partners in this project?

Include which stakeholders, organisations and community members have been consulted about this project/activity, why and how they support the project/activity and other information to demonstrate community support.

Please supply letters of support

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  1. Is the project sustainable beyond this project?

Outline how you will ensure sustainability of the project/activity (for on-going projects/activities) and/or the outcomes to be achieved (for on-going and one-off projects/activities).

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  1. Is Council approval required?

☐Yes☐No

  1. Is a Development Application required?

If licences, permits or approvals have been approved or are being sought please attach copies of applications and approvals.

☐Yes☐No

  1. Can your initiative or components of the project / product be delivered if only part funding was granted?

☐Yes☐No

Referees:

Please list the name and contact details of two people who can act as referees for this project or activity.

Click here to enter text. /
Click here to enter text. /

Please attach any additional information about your organisation or project that would support your application including building plans, quotes, financial statements and letters of support from stakeholders

  1. Project Budget: Please include ALL details

Income / $Click here to enter text.
Activity generated income (e.g. ticket sales, merchandise) / Click here to enter text. /
Organisation’s Contribution / Click here to enter text. /
Other Grants (Stipulate who)
State whether Pending or Approved / Click here to enter text. /
Sponsorship (confirmed and unconfirmed) / Click here to enter text. /
Amount requested from MBDC
Community Grant Program / Click here to enter text. /
Other (please specify) / Click here to enter text. /
Total (not including GST) / Click here to enter text. /
Expenditure / $Click here to enter text.
General Administration / Click here to enter text. /
Fees required (e.g. trades, travel, consultancy) / Click here to enter text. /
Equipment (hire of purchase) / Click here to enter text. /
Other (please specify) / Click here to enter text. /
Total (not including GST) / Click here to enter text. /

NOTE: Your total income should equal your total expenditure.

Please attach a copy of your organisation’s most recent profit/ loss statement
Checklist:

Please read, tick the boxes and sign.

☐I acknowledge that I am authorised to make this application on behalf of the organization and that the information in this application is true and correct

☐I acknowledge that I may be required to supply further information prior to consideration of this application by the Mount Barker District Council

☐I have attached the organisation's most recent financial statements

☐I have attached copies of any approved or pending licenses, permits or approvals

☐I acknowledge that I will complete the attached acquittal report and submit it within four weeks of the project/activity completion

☐I acknowledge that the acquittal report must include financial statements along with any media releases, promotional material, reports, statistics or photographs of the project/activity.

☐I provide permission for the Mount Barker District Council to promote this Community Grant proposal as part of any communications and public relations activities.

SignatureClick here to enter text. / DateClick here to enter a date.
Print NameClick here to enter text.