2014/2015 Acquittal Form

Community Grants

v  It is recommended that you refer to your copy of the original application sent to Council to assist you in completing this form.

v  You must include photos (in .tiff or .jpg format) of the event and a copy of all receipts.

v  Where auspiced, you must include a letter from the auspicing organisation confirming the grant has been fully expended.

v  Electronic copies of this form are available at www.mitchellshire.vic.gov.au

v  Completed acquittals are to be submitted to Council by 15 May 2015

1.  Grant Details / Grant Year / Grant amount
2014/2015
Project Name
Grant Category
Artistic and Cultural Activities Community Celebrations
Community Development and Wellbeing
2.  Recipient Details / Organisation’s Name
Contact Person’s Name
Business hours no. / Mobile no.
Email
3.  Declaration / ·  To the best of my knowledge I declare that the information in this report is true and correct.
·  The financial accounts are true and fair, and a statement of the balance of the grant funding. The grant funding was expended on the project/activity in accordance with the Grant Funding Agreement signed with the Mitchell Shire Council and as per the original Grant Application.
·  I have returned any unspent grant monies to Council with this report.
I agree to the above declaration
Name / Position in organisation
Date
4.  Project Summary / Please answer all the following questions for this acquittal report to be deemed complete. Please also attach materials developed as part of this project e.g. media coverage, flyers, photos in either .pdf or .tiff or .jpeg format.
1.  Please briefly describe your project and its outcomes. What did you do? How did the community benefit? Who was involved? (Maximum 400 words)
2.  How many people participated in your project?
No of males: / No of females:
No. of children: / No of people of all abilities:
How did the project encourage participation from a wide range of people (People from culturally and linguistically diverse backgrounds, Youth, Seniors, people of all abilities)? (Maximum 200 words)
3.  How many volunteers and partnering organisations worked on your project and in what capacity? (Maximum 100 words)
4.  Was the project successful in the way you expected? If not, how did it differ? What would you do differently next time? (Maximum 300 words)
5.  Statement of Income and Expenditure / Please include a copy of all receipts.
Please note unspent grant funds must be returned to Council with this report.
Actual Income / Actual Expenditure
Income source / Amount / Items purchased with the Mitchell Community Grant / Cost
Mitchell Community Grant (a)
Organisation’s own money contribution
Give details
In-kind contribution including volunteer staff (to be costed at $25 per hour)
Give Details
Project generated income
Give details of sales, tickets etc / Total (b)
Items purchased with other funding sources / Cost
Other grants, sponsorship or donations
Give details of state, federal or private funding received
Any other income
Give details
Total / Total
Mitchell Community Grant amount (a)
Items purchased using Mitchell Community Grant (b)
Total (a) – (b) = surplus or (deficit)

Completed acquittals and attachments are to be submitted by email to:

Community Grants Acquittal Form 2