Illawarra Region Innovation and Investment Fund - Sample Application Form

Commercial-in-confidence

Total number of pages contained in this application including attachments:

Illawarra Region Innovation and Investment Fund (IRIIF)

Grant Application Form

Deadlines apply to this program

All applications must be submitted by the program closing time.

Privacy and confidentiality

Applications will be treated as 'commercial-in-confidence'. Applicant information will only be publicly disclosed in accordance with the IRIIF Guide for Applicants or if the Department of Industry, Innovation, ,Science, Research and Tertiary Education is required or permitted by law to make such a disclosure. The Department may also disclose information with your consent. The Department may disclose any information to Commonwealth or state agencies for law enforcement or audit purposes.

Completing an application

Information on IRIIF is available in the IRIIF Guide for Applicants. Applicants should familiarise themselves with the Guide for Applicants prior to completing this application. An AusIndustryrepresentative can help explain program requirements (contact the AusIndustry hotline on 13 28 46). When completing an application, applicants are advised to be factual and concise in all responses.

Applications must be provided electronically by e-mail to or on a CD to the address below.

IRIIF
AusIndustry
GPO Box 9839
SYDNEY NSW 2001

If you wish to submit a hard copy of your application it should be sent to the above address.

Part A - Applicant Details

A1Name of applicant (For applicant eligibility requirements refer to Section 6 of the IRIIF Guide for Applicants.)

Registered business name
Trading name (if trading under a name other than the registered business name)

Is the applicant applying as a trustee on behalf of a trust?

If ‘Yes’, please complete Section A4

Is the applicant part of a group?

If ‘Yes’, please complete group financial information in Section A8

Applicant business address

Provide the registered business street address of the applicant.

Address / Suburb/town / State/territory ACTNSWNTQLDSATASVICWA
Postcode

Applicant postal address

Provide the postal address of the applicant if different to street address.

Address / Suburb/town / State/territory ACTNSWNTQLDSATASVICWA
Postcode

Project street address (where project activities will be undertaken)

Address / Suburb/town / State/territory ACTNSWNTQLDSATASVICWA
Postcode

Note: The applicant must be an entity that is able to enter into a funding agreement. In particular the applicant must:

be liable to pay income tax
have its own ABN and be able to issue tax invoices; and
acquire and own any plant and equipment covered by the funding agreement and capitalise these items in its own accounts

A2Applicant business registrations

To be eligible to apply for funding, an applicant must be incorporated.

Note: ABN and ACN must both belong to the same entity.

Australian Business Number (ABN) / Australian Company Number (ACN) / Date of incorporation
(dd/mm/yyyy)

Is the applicant registered for GST?

A3Joint applicant (where applicable)

Registered business name
Trading name (if trading under a name other than the registered business name)

Business address

Provide the registered business street address of the joint applicant.

Address / Suburb/town / State/territory ACTNSWNTQLDSATASVICWA
Postcode

A4Trustee applying on behalf of a trust (where applicable)

Name of trust
ABN used by the applicant in its role as trustee* for the trust
ACN of the trustee for the trust

*The trustee must be incorporated to be eligible to apply.

* A copy of the Deed of Trust must be provided

A5Applicant’s primary contact

Title / MrMrsMsDrAssoc. ProfProfOther
If Other, please specify:
Name
Position

Alternative contact

Name
Phone number
E mail address

A6Primary contact’s details

Address
Suburb/town
State/territory / ACTNSWNTQLDSATASVICWA / Postcode
Telephone number
Mobile telephone number
Fax number
E-mail address

A7Primary contact’s relationship to applicant

Is the applicant the contact’s employer? ('Yes' or 'No') / YesNo
If no, please describe the contact's relationship to the applicant

A8Applicant organisation background

If you have a business or marketing plan or company profile, please attach it to the application.

How long has your business been in operation?

Applicant financial information

Please complete the following table.

Note: The information provided must agree with the financial statements provided by the applicant.

Recent Trading Performance / FY 2009/10 / FY 2010/11 / FY 2011/12 YTD
Month: (mm/yy)
Annual Sales / $ / $ / $
Earnings before Interest and Tax (EBIT) / $ / $ / $
Current Assets / $ / $ / $
Total Assets / $ / $ / $
Current Liabilities / $ / $ / $
Total Liabilities / $ / $ / $
Net Assets / $ / $ / $
Full Time Equivalent Staff (FTE) *as at 30 June
Salaries / $ / $ / $

Group financial information

If you are part of a group, please complete the following table for the group and provide a copy of the group structure (see Part D for list of attachments required).

Note: The information provided must agree with the group financial statements provided.

Recent Trading Performance / FY 2009/10 / FY 2010/11 / FY 2011/12 YTD
Month: (mm/yy)
Annual Sales / $ / $ / $
Earnings before Interest and Tax (EBIT) / $ / $ / $
Current Assets / $ / $ / $
Total Assets / $ / $ / $
Current Liabilities / $ / $ / $
Total Liabilities / $ / $ / $
Net Assets / $ / $ / $
Full Time Equivalent Staff (FTE)* as at 30 June
Salaries / $ / $ / $

*Note: FTE is measure of the total level of staff resources used. The FTE of a full-time staff member (e.g. 37.5 hours per week) is equal to 1.0. The calculation of FTE for part-time staff is based on the proportion of time worked compared to that worked by full-time staff. For example, a staff member working 2 days per week, at 7.5 hours per day, is equivalent to 0.4 FTE

What is the core business of your organisation?

Describe your product or service?
Who are your major customers?

ANZSIC Code (refer to Appendix B)

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Part B - Project Details

B1Project Title (maximum 10 words)

(Note: If the application is successful, this title will be used by the Australian and NSW Governments in published material.)

Project Summary (maximum 50 words)

(Note: If the application is successful, this summary will be used by the Australian and NSW governments in published material.)

Number of FTE jobs expected to be created by project

A. Expected ongoing direct employees at project conclusion

B. Expected indirect ongoing jobs resulting from project

C. Expected FTE jobs during construction/preparation phase

B2Overview of the Investment Proposal

Detailed description of the investment proposal you wish to undertake with the assistance of IRIIF grant funding. Include:

Key activities (eg a new product, purchase of new equipment etc)?
Expected outcomes (eg expanded business, new product/service, increased employment etc)?
What is the demand for your proposed project (product/service) from the target market?
Have you undertaken research to support the projected demand?

Approvals

Are all required approvals in place? ('Yes', 'No' or ‘N/A’) / YesNoN/A
If no, please provide details on status of, and anticipated timeframe for approval.

B3Grant amount sought

All amounts must be GST exclusive. Please note that the minimum grant size is $50,000 and the applicant’s contribution must be at least equal to the grant amount sought.

Note: Evidence of matching funding must be provided.

A. Applicant’s contribution / $
B. Grant amount sought / $
C. Other funding (if relevant) * / $
D. Total expenditure for project (A+B+C) / $0

*C. Other funding

Please provide a breakdown of other funding sources

$
$
$
Total other funding / $0

B4Project Timeline

Please provide the proposed start and end dates for your project.

Note: Grant funding is available for project activities up to 30 June 2014.

Start date (mm/yy):End date (mm/yy):

B5Project Milestones and Major Activities

Please outline the applicant’s key milestones and describe the major activities to be undertaken to achieve each milestone. Please ensure that the start date of Milestone 1 and the end date of the last Milestone match the start and end date as stated in B4 of the application.

Key Milestones and Related Major Activities / Start Date
(mm/yy) / End Date
(mm/yy) / Estimated expenditure
Milestone 1: / $
Activities:
Milestone 2: / $
Activities:
Milestone 3: / $
Activities:
Milestone 4: / $
Activities:
Total costs / $

B6Other government assistance

Has the applicant received or applied for any Commonwealth/State government assistance (including the R&D Tax Concession) in the last 5 financial years?YesNo

If yes, provide details of the source, timing and amount of other government assistance (include current applications, grants received and unsuccessful applications)

Assistance source (program and agency) / From
(mm/yy) / To
(mm/yy) / Amount / P (pending)
S (successful)
U (unsuccessful)
$ / PSU
$ / PSU
$ / PSU

B7Project budget

a)Please complete the table below detailing the total costs and key activities of the project under the three expenditure types. All amounts must be GST exclusive. Refer to Appendix 1 of the Applicant Guide for detailed information on eligible expenditure.

Expenditure type / Total Project Costs
Plant and equipment costs, including buildings / $
Salaries of employees working directly on the project / $
Other costs, including contractors and audit report / $
Total costs / $0

b)Provide a breakdown of eligible plant and equipment cost

(Additional rows automatically appear when you hit 'Tab' at end of last row of table)

Plant item / What will it be used for in the project? / Estimated Cost ($) / Expected procurement date
(mm/yy)
$

IRIIF – Application FormMarch 2012Page 1 of 19

Add more rows as needed

c)Provide a breakdown of eligiblesalary costs

Position title / Role in project / Anticipated annual salary / Anticipated Start date
(mm/yy) / Anticipated End date
(mm/yy) / Estimated eligible salary cost
$ / $
Add more rows as needed

d)Provide a breakdown of eligibleother costs

Expenditure item / Role in project / Estimated project cost
$
Add more rows as needed

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B8Applicant Sales / Profit Projections

Financial Year / FY 2011/12 YTD Actual
Month / 2012/2013 / 2013/2014 / 2014/2015
Estimated sales / $ / $ / $ / $
Estimated percentage of sales exported
Estimated net profit (after tax) / $ / $ / $ / $
Full Time Equivalent Staff (FTE)* as at 30 June
Salaries / $ / $ / $ / $

Provide details of sales forecasts. What are estimated sales resulting from the project?

Group Sales / Profit Projections (if applicable)

Provide details of sales forecasts. What are estimated sales resulting from the project?

B9Project impacts

a)Does the project involve:

a new market?

and/or

a new product?

and/or

a new service?

and/or

a new process?

b)How will the project contribute to the company’s growth?

c)How will the project contribute to the company’s competitiveness?

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Part C - Assessment Criteria

Provide information detailing how your project meets each of the assessment criteria.

Note: Foreach criterion you must address each of the points under the criterion description.

C1The level of net economic benefit the proposal project will bring to the Illawarra Region including:

Number of sustainable, new jobs generated through the project. Note:

The number, type and timeline for the creation of the new jobs. Include estimated or average salaries for new positions (refer to data provided in B1).
Where will the workforce for the project be sourced.
The employment impact on other businesses.
Estimate of indirect employment benefit.

The contribution of the project towards diversifying the region’s economy:

A new economic activity, an expansion of an existing activity or diversification of existing businesses.
Describe the input and output impacts on your supply chain, including where the inputs for the investment proposal will be sourced.
The generation of further investment.
Trade impacts on other businesses in the Illawarra (including competitors)
The extent to which the project will service market inside/outside Illawarra.

C2The demonstrated capacity of the applicant(s) to successfully undertake the project outlining the skills, experience and resources to which they will have access.

Details of management experience required for the project, including the applicant’s track record, or if outside prior business activities, outline the expertise and capabilities to successfully implement the new project (ensure CVs are attached).
Details of the technologies involved in the investment proposal should be provided. Was the applicant involved in the development of these technologies?
Has the applicant accessed customers and sourced distributors or relevant supply chains relating to the investment proposal?

C3The demonstrated capacity of the applicant to provide matching funding for the project.

An explanation of how the investment proposal will be funded and:

The level of funds likely to be generated from each source
The type of funding (e.g. debt and/or equity) must be provided.

Applicants are expected to provide documentary evidence of their ability to provide matched funding, which may include:

for internal funding sources - cash flow forecasts, evidence of existing sales pipelines and/or sales contracts; and
for external funding sources such as equity investments or loans - evidence of the commitment and capacity from the investor or finance provider.

C4Sustainability of the project over the longer term without the need for ongoing government support.

Has private sector funding for the investment proposal been secured or evidence of significant progress in negotiations for funding should be provided, including details of any special conditions applying to the provision of funding.
The likelihood of funding from the private sector.
List and detail funding relating to the investment proposal from other government agencies, including unsuccessful applications, applications still in progress or funding received for the proposal from all government agencies including Commonwealth, state and local governments should be provided.
Discuss industry trends, market size and competitors in the medium to long-term.

C5The extent to which the project would be unlikely to proceed without support.

Why would the investment proposal not proceed without the grant?
How would the incentive of the grant impact favourably on the scale or timing of the investment proposal?
What other funding options has the applicant pursued to bring this investment proposal to fruition?

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Part D - Attachments

Mandatory attachments (tick box to show that documents are attached)

Note:Applications that do not include mandatory attachments will be deemed incomplete and may not be assessed.

The following documents must be attached in support of your application:

for existing entities, the applicant's three most recent financial statements (audited if available);

interim accounts;

group organisational chart (if applicable);

consolidated group’sthree most recent financial statements (if applicable);

where parent entity providing funding, written undertaking to this effect and evidence of ability to provide funding (eg financial statements);

copy of Deed of Trust (if applicable);

project budget forecast spreadsheet; and

letter from external accountant confirming financial contributions (See Appendix A for template)

Where an applicant is seeking a grant in excess of $100,000, the following additional documents must be provided.

copy of statutory approvals received for planning or building (if applicable);

evidence of loan approval (if applicable);

quotes and estimates for plant and equipment and project costs; and

Additional attachments

Where relevant, you may also wish to provide the following information to further support your application (tick box if attached):

Business plan

Sales contracts or orders

CVs or resumes of key personnel

Letters of support from customers or suppliers

Part E - Declaration

Authorised person declaration

I declare that I am authorised by the applicant to complete this form on behalf of the applicant and to sign and submit this declaration on behalf of the applicant. I understand that I may be requested to provide further clarification or documents to verify the information supplied in this form and the Commonwealth may during the application process consult with other agencies about the applicant’s claims and may also enlist external technical or financial advisers to advise on information provided in the application.

I declare that the information contained in this application is to the best of my knowledge true, accurate and complete.

Applicant’s signature / Name of signatory
Date (dd/mm/yyyy)

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Getting Help

If you wish to obtain advice on your application please contact the AusIndustry hotline on 13 28 46.

We will either provide advice via the phone or e-mail or arrange a suitable time to meet with you.

IRIIF – Application FormMarch 2012Page 1 of 19

Additional information concerning IRIIF can be obtained from the AusIndustry website.

IRIIF – Application FormMarch 2012Page 1 of 19

Submitting your IRIIF – Round 2 application

Completed applications under Round 2should be submittedelectronicallyby5:30pm AEST[date]2012bye-mail to:

IRIIF – Application FormMarch 2012Page 1 of 19

Or, applications on a CDshould be sent to the address below.

IRIIF

AusIndustry

GPO Box 9839

SYDNEY

NSW 2001

If you wish to submit a hard copy of your application it should be sent to the above address.

IRIIF – Application FormMarch 2012Page 1 of 19

Applicant feedback

AusIndustry values your input to the service provided to our customers. Please complete this voluntary questionnaire. Note that this questionnaire is not part of the application or assessment process.

How did you find out about the IRIIF?

(Select one or more of the following.)

Newspaper/magazine article

Internet

Direct mail/e-mail

Industry group

Word of mouth

AusIndustry staff

AusIndustry hotline

NSW Trade & Investment

Other

If ‘Other’, please specify

Please tick this box if information about AusIndustry’s product and services is not required in future

IRIIF – Application FormMarch 2012Page 1 of 19

APPENDIX A

External Accountant Declaration

DECLARATION:

MADE BY:
COMPANY NAME:
ACCOUNTANT’S POSTAL ADDRESS:
ACCOUNTANT’S CONTACT DETAILS: / Phone:
Fax:
Email:
ACCOUNTANT’S RELATIONSHIP TO APPLICANT:
QUALIFICATION: /  Chartered Accountant
 Certified Practicing Accountant
 Association of Chartered Certified Accountants
 National Institute of Accountants
PNA FPNA MNIA FNIA
MEMBERSHIP NUMBER:

I declare that:

On the basis of the evidence [Applicant Name] has supplied to me, I consider that [Applicant Name] is able to fund its share of the cost of the proposed project. This opinion is based on total project expenditure of