Pacific Hydro

Sustainable Communities Fund

Application Form for projects that will benefit the Portland and District Community 2012-2013

Please read the Sustainable Community Fund application guidelines before commencing the application.

A. Contact Details

Please complete all fields:

Contact (Name and Title) ……………………………………...... …………………………

Position ……………………………………...... …………………………

Organisation/Community group name: …………………………...... …………………………

Name on cheque: ……………………………………...... …………………………

ABN: ……………………………………...... …………………………

Physical address: …...... …………………………

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Postal address (if different from above:

…...... …………………………………...... …………………………

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Phone numbers: ……………………………………...... …………………………

E-mail address: ……………………………………...... …………………………

Pacific Hydro aims to limit our environmental footprint wherever we can. If you would prefer all correspondence regarding the Sustainable Communities Fund to be sent via email, please tick this box.

Pacific Hydro aims to ensure all community groups are aware of the Sustainable Communities Fund. By answering this question, it helps us to ascertain if we are promoting the Fund in the correct places.

Where did you hear about the Fund?

ð  Portland Observer

ð  Radio

ð  Poster/flyer

ð  Word of mouth

ð  Direct notification

ð  Other ………………………………………………………………

Applications must be made by a representative or member of the organisation applying for funding. Third party applications will not be accepted.

Please sign this declaration and submit with your application.

I (Name) ______declare that I am a representative or member of (Organisation) ______and I will not personally receive any commission or any part of any funding awarded as a result of this application.

Signed: ______(If applying electronically, please type your name)

Date: ______

B. Brief history of the organisation

Please provide a brief history of the organisation including how long it has been operating?

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What are the objectives of the organisation?

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What are the services and activities of the organisation?

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Is the organisation not-for-profit?

Yes No (If not, please describe why the organisation is seeking funding for the project?)

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If available, please provide the latest annual report or accounts of the organisation.

What tax concessions does the organisation have from the Australian Taxation Office (ATO)?

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Please attach copies of your endorsement notices as a Tax Concession Charity (TCC) (previously known as Income Tax Exempt Charity (ITEC)) and Deductible Gift Recipient (DGR) if you have them. Neither endorsement is necessary to be eligible, but they may assist in the evaluation process.

C. Project Details

Project name.

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Summary of the proposed project for which you are seeking funding: What do you want to do?

(NB: The Sustainable Communities Fund will not grant funding for individual pursuits, salaries, political campaigns or organisations, religious organisation for religions purposes, fundraising events, producing or distributing printed material or advertising materials, one off events, public schools (unless good reason is indicated) or Government projects. Please see the Sustainable Communities Fund guidelines for a full list).

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What are the principal objectives of the project?

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What are the predicted outcomes of the project? How will it benefit and who?
(Please be as specific as possible)

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Describe the impact the project will have on the problem / issue it addresses and benefit(s) it will create for the community. What need is the project fulfilling?

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How do you know the need exists?

(Please include research, community consultation, ABS data or any other relevant information)

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Who else is providing this service?

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Why is your organisation best placed to undertake this work?

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Who will be the principal beneficiaries?

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How many people will be directly affected by the project?
Please be as accurate as possible

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Where will the project be located? Local or Regional (Please specify)
NB: Applications outside of Portland, Cape Bridgewater, Cape Nelson, Gorae, Narrawong, Tyrendarra and Heywood must show why they believe they are eligible for the Portland Fund.

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What contribution will the community make towards the project? (e.g. labour, materials, other funds – please be specific)

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Please attach two letters of support for your organisation and this project.

Referees must not be associated with Pacific Hydro (this means Landholders of the Cape Bridgewater and Cape Nelson South wind farms are excluded from providing a reference). They should be familiar with your organisation, the project and this application. It is preferable that support letters are from community members who will use your services. Local council references are not necessary as we consult with them during the selection process.

D. Project Management

Please list the key members of your organisation’s executive management and Board

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How will the project be managed and by whom?

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What is the schedule for implementation of the project? Include or attach a timetable of activities or a list of milestones.

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E. Evaluation and Reporting

Please provide 3-4 key indicators that will be measured to determine the success of the project.

1. ______

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2. ______

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3. ______

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4. ______

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Pacific Hydro requires a ‘report back form’ to be completed at the end of the six month project implementation period. If Pacific Hydro does not receive the report back form your organisation may be disqualified from funding in future rounds.

Do you agree to provide this form? Yes No

Pacific Hydro requires a ‘Sponsorship Agreement’ to be completed, if you are successful, before receiving the grant cheque. This is an agreement between you and Pacific Hydro outlining your agreement to spend the funds in line with your application form and letter confirming success.

Do you agree to provide this form? Yes No

F. Financial Management

Please attach:

·  Information about your organisation’s financial status; and

·  A specific budget for this community project, including projection of revenue from all sources and expenditure

How much money is being sought from Pacific Hydro (in total)?

Requests of $10,000 or less are more easily accommodated under the grants program. For transparency and auditing purposes Pacific Hydro requires fund distribution to be specific, please attach a written quote and a breakdown of where funding is going.

$

For annual events, how many years do you require the funding?

1 year

2 years

3 years

When is the project due to be implemented?

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Is this project seen as a priority for the funds available in your budget?

Yes

No If not please explain why

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Will the amount requested see the project fully funded? (If not, please tell us how you intend to fund the project. Projects must be completed within six months of receiving the grant unless prior arrangement is made with Pacific Hydro)

Yes

No - If no, please tell us how you intend to fund the project.

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What other sources of funding are, or may be, involved? (Please list names and amounts. If funding has not been sought on any Government level, please explain why not. Please also indicate if funds have been approved or your organisation is still waiting on approval.)

Local Government

State Government

Federal Government

Philanthropic trusts

Other companies or organisations

None – please explain why no other funding has been sought.

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Please do not send videos, sound cassettes, photos, or original documents as we cannot guarantee their safe return.

Thank you for taking the time to complete this application. Pacific Hydro will consider all applications that fit within the guidelines of the Sustainable Communities Fund. Requests of $10,000 or less are generally more easily accommodated due to the large numbers of requests we receive.

Please direct any queries about your application or the Fund to Community Engagement Coordinator, Chloe Carpenter on (03) 8621 6428 or community@pacifichydro.com.au.

We wish you every success with your application.