• Please save a copy of this form on your own PC
  • Once completed, print two copies, one for yourself, the other for Neighbourhood Support NZ
  • Ensure your District Representative signs the final page
  • Post or email a copy to our office (details below)
  • Please remember to include ALL supporting documents

Neighbourhood Support New Zealand invites applications that help achieve the following objectives:

  1. Projects that empower communities eg. Emergency Preparedness projects
  2. Projects that reduce crime
  3. Projects that reduce fear of crime
  4. Projects that increase safety and/ or perception of safety in the community
  5. Projects that address existing and emerging community needs and issues
  6. Projects that identify and encourage inclusion of vulnerable communities
  7. Projects that are delivered in collaboration with partners including but not limited to Neighbourhood Policing

Teams

NSNZ INDICATORS

The above indicators correspond with the 7 project objectivesabove and are the NSNZ ‘Population Outcome Framework’ aligned to the ‘Government Better Public Service Targets’.

You may download the ‘Application Information Notes' from our website.

Please ensure that all answer boxes are completed and that all required documents are attached.

PART ONE: ORGANISATION / GROUP DETAILS
Organisation Name: / District:
Postal Address: / Phone:
Street Address: / Post Code:
Email:
Website:
DETAILS OF KEY CONTACT PERSON
Name / Phone
Position: / Mobile
DETAILS OF SECOND KEY CONTACT PERSON - must be either Chairperson or Treasurer
Name / Phone
Position: / Mobile
BANK ACCOUNT DETAILS
Name of Account
Account Number:
PLEASE ENTER ALL RELEVANT DETAILS:
Legal Status / Please Tick / Number
Incorporated Society:
Charitable Trust
Other: ie umbrella group, 3rd Party; Please specify
GST Registered
1.1 TELL US ABOUT YOUR ORGANISATION
1.2NUMBER OF PEOPLE
PAID / Full-time
# required / Part-time
# required
VOLUNTEERS / Hours / week
# required
PART TWO: PROJECT DETAILS
2.1 / Project Title: Short Description (50 words)
2.2 / What is the problem you want to address?
2.3 / What are the specific objectives of your project and how does this meet the Population Outcome Framework? e.g. Increasing Neighbourhood Support in area by %
2.4 / How will you monitor progress of the project?
2.5 / How will you measure and evaluate the success of the project? How much did we do? How well did we do it? Is anyone better off?
2.6 / Who will you collaborate / partner with for this project?
2.7 / Explain your capacity (resources) to carry out this project ie Personnel, Volunteers, Funding.
2.8 / Staff Salaries(If funding request is for staff salaries, please refer to Information Notes)
2.9 / What are the options and alternatives available to your organisation if your donation request is declined?
PART THREE: FINANCES
3.1 Project Costs
Please list in dollar amounts only / Project Funding
Please list in dollar amounts only
The full costs of this project are: / How will you fund the project?
PROJECT ITEM / COST / PROJECTED INCOME
A
B
C
D
E
F
NSNZ Funding Request
(This must be completed)
Total Cost of Project / Total Funding of Project

Add additional lines as required.

Total Project Costs MUST equal Total Funding Income

3.2 PREVIOUS FUNDING FROM NSNZ:(List the last 3 donations with the most recent year first)
Year / Amount / Reason / Accountability
Completed
Failure to lodge an accountability may result in your current application not being considered
3.3Funding Assistance from other Organisations
Please list the organisations, how much has been requested, what has been confirmed. Please note: Include only figures for this particular project.
Funding Source / Requested For / Amount
requested / Expected confirmation date / Confirmed Funding
TOTAL $
3.4FINANCIAL SNAPSHOT: (State in words what you believe your financial position to be, indicate your current position and how this related to the request. What are your financial control systems in place?)
PART FOUR: Checklist
4.1 CHECKLIST OF ENCLOSURES(Please tick off included documents)
* If you made an application in the Feburary 2017 funding round this documnet does not need to be re-submitted.
Audited / Reviewed Accounts* / {required}
Budget / {required}
Chairperson Annual Report* / {required}
Coordinators (Managers) Annual Report* / {required}
Copy of Certificate of Incorporation* / {required for new applicants}
Charities Commission Certificate* / {required for new applicants}
Trust Deed / Constitution* / {required for new applicants}
Plans, Charts, Photos, Programme etc / {required}
Letters of Support / {optional}
Newspaper Articles / {optional}
Marketing Plan / {optional}
Terms & Conditions Signed / {required}
Other: please specify
4.1HOW WILL YOU ACKNOWLEDGE THE NZ POLICE AND NEIGHBOURHOOD SUPPORT NEW ZEALAND IF THIS APPLICATION IS SUCCESSFUL?
4.2AGREEMENT:
I have read and agree to the terms and conditions outlined below
Applicant Declaration: I ______{full name} declare that this application form has been completed accurately and I am authorised to lodge this application on behalf of the Organisation;
If this application is successful, this organisation will abide by the conditions of the funding.
Name: / Signature:
Date:
5SIGNED BY DISTRICT REPRESENTATIVE
Name: / Signature:
Date: / District:

6APPLICATION TO BE SUBMITTED TO THE FOLLOWING EMAIL OR POSTAL ADDRESS

Send completed Application to:

If sending a hard copy application, please post the signed original application to:

NSNZ Contestable Funding

Neighbourhood Support New Zealand

c/- Police National Headquarters

P O Box 3017

Wellington 6140

Applications close on Friday, 26 May at 5.00pm

Please allow sufficient time to complete this application before the final submission date as late applications WILL NOT BE accepted. Once your application is lodged, you will receive a confirmation email.

Incomplete applications will not be accepted.

The NSNZ Funding Panel decision is final and no correspondence will be entered into

NSNZ Contestable Funding Program – TermsandConditions

The terms and conditions of this contestable funding program are as follows:

  1. Neighbourhood Support NZ (NSNZ) will provide the successful applicant(s) (‘Fund Recipient’) with a one-off contestable funding grant in the amount determined by NSNZ in its sole and absolute discretion.
  2. The fund recipient confirms this is not a respective application.
  3. Recipients of funding must enter into and comply with a Funding Agreement accepting the fund payment in accordance with these guidelines. Once complete, the FundingAgreement is a legal contract between NSNZ and the FundRecipient and sets out the obligations of each party.
  4. Funding granted must be used and applied solely for the purpose of the project stated in the application and as approved by NSNZ.
  5. Should the actual total project costs be more than the proposed project costs, NSNZ will not be responsible or obligated to pay any monies additional to the notified grant amount.
  6. All financial and operational reporting requirements must be completed within the specified timeframe. This includes, but is not limited to, completing and lodging a final project report and financial accountability.
  7. In the event of cancellation of a funded activity, the Fund Recipient must notify NSNZ in writing. A change of purpose may be applied for or the unspent money returned immediately.
  8. A fund may be terminated and money returned immediately if, in the opinion of NSNZ, any of the following apply:
  9. The project is not being carried out to the satisfaction of NSNZ
  10. The terms and conditions and the Funding Agreement are breached
  11. Any special conditions attached to the funding are breached, and/or
  12. The Fund Recipient fails to provide information concerning administrative or financial aspects of the project in response to a reasonable request.
  13. All promotional material must acknowledge funding from ‘Neighbourhood Support New Zealand’and ‘NZ Police’. Requests to use the NSNZ logo must be submitted to and approved by the FundingAdministrator prior to production and release.
  14. The Fund Recipient must remain the Fund Recipient of the funded project for the duration of the Funding Agreement and not transfer funds to a third party.
  15. NSNZ will promote and report on the Project to its partners, stakeholders and the community through internal and external communication channels including the media.
  16. NSNZ project grants are subject to the Goods and Services Tax (GST). Where an organisation funded by NSNZ is liable to pay GST, the amount payable by NSNZ, will be decreased by the amount of the GST liability, and provided to that organisation:
  17. The Fund Recipient will provide NSNZ with a valid Tax Invoice
  18. All successful applicants may be subject to a random audit process.
  19. The committee may consult with any outside organisation; including government authorities or relevant police regarding your application.

Signed / Dated
Full Name / Position

Application Form: Contestable Funding Program May 17 Page 1 of 6