SCG 2016-2019 / Call for Proposals September 2017 / Application Form
Application Form
Scheme of Capital Grants for Community
Facilities & Amenities 2016-2019
Call for Proposals September 2017
Date Received(please ensure form is officially date stamped)
Signature of person who received the form
Municipal District
Application Reference No.
PPN No.
Agresso ID No.
Community, Sports or Arts/Cultural
Section 1: GENERAL INFORMATION
1.1 / Promoter’s Registered Name
(As per CRO, if applicable)
1.2 / Contact Person’s Name
1.3 / Promoter’s address for correspondence / Address:
Eircode:
1.4 / Contact Details / Mobile No. (daytime):
Mobile No.(evening):
Landline:
E-mail Address:
Web address if Applicable:
1.5 / Promoter Type/Status
- Please Type “X” in the appropriate Box
- Supporting governing documents should be provided e.g. Constitution, etc.
Club
Community Council
Other (Please specify)
1.6 / Tax Clearance
Provide your eTax details for verification / Tax Reference No.
Access No. (TCAN)
1.7 / VAT Registration Number
(If Applicable) / VAT No.
If you are NOT registered for VAT, you MUST provide a letter from Revenue stating that you are not registered for VAT
1.8 / Group/Club/Community Council Details
- Supporting documents should be provided e.g. minutes of last AGM, most recent annual Accounts,insurances, etc.
If affiliated to national governing body, identify the body
Name of Chairperson
Name of Secretary
Name of Treasurer
Describe your main activities
Date of last AGM
Year of most recent annual Accounts
Tipperary PPN membership no.
Level of insurances in place (e.g. on buildings, public)
Is the group/club/council open to all members, without discrimination, from the area you serve?
1.9 / If the application involves other groups/clubs/councils as partners, please identify them
1.10 / Have these groups/clubs/councils worked together before, and how?
SECTION 2: PROPOSED PROJECT DETAILS
2.1 / Name of proposed project
2.2 / Location of proposed project / Address:
Eircode:
GPS Co-ordinates:
2.3 / Please give a detailed and clear description of the project for which you are seeking funding. Please provide as much information as possible to allow us to fully evaluate your proposal (if the proposal relates to a phased development, provide full details)
2.4 / Please indicate which Priority(s) the proposed project is addressing
- See Section 2, Page 4 of Guidance Notes for List of Priorities
- More than one Priority may be chosen
2.5 / Please provide details of any experience, skills and training that the promoter has that may be relevant to the delivery of this project, in particular, the overall management and financial management of the project
2.6 / Demonstrate the need for your project
- E.g. refer to research carried out, give reasons why the project is required, does the proposal fit into the plans of relevant state/development agencies, etc.)
- Provide hard-copy or link to any research, reports, etc.
2.7 / Describe the area/territorythat the proposed project will serve?
2.8 / Detail the users, benefits and/or impacts resulting from the proposed project
2.9 / How will this project “add value” to what the groups/clubs/councils are already doing?
2.10 / Describe how the proposed project is supported by the “wider community” and how it will benefit from the project?
2.11 / Project Timescale
i.e. time required to deliver the project once grant aid has been approved, if approved
2.12 / Will the project proceed without grant aid?
E.g. if grant aid is not approved will you be forced to abandon the project, or elements of it? Please give details / Yes
No
Please give reason / rationale:
2.13 / Is your project likely to compete with a similar local Facility/Activity?
Please give details of nearby similar facilities / activities that operate in your sector and outline how duplication/displacement will be avoided
2.14 / Local Impacts
Outline any impacts that your proposal may have on the local economy, culture, heritage or community
2.15 / Environment, Climate Change and Energy Efficiency
Describe how environmental considerations were considered when developing your project proposal
2.16 / Value for Money
Please briefly outline the steps taken or to be taken to ensure value for money for the project proposal, particularly in terms of procurement
2.17 / Financial Sustainability
a)Please confirm that you have the necessary financial capability to carry project expenditure before grant funding is paid.
b)Please outline what procedures are in place to ensure the ongoing viability and sustainability of your project, once completed / a)
b)
2.18 / Technical Advice
An accredited technical advisor, architect, engineer or equivalent.Please identify and outline his/her role in the proposed project / Yes
No
2.19 / Social Inclusion
a)What arrangements have been made to ensure there is equal opportunity for access for all in the “wider community” to your existing facilities/activities?
b)What arrangements will be made for equal opportunity of access for all in the “wider community” to the output/result of this proposed project?
c)How will the proposed project be accessible to persons with disabilities? / a)
b)
c)
2.20 / Playground Specific Question
If the proposed application relates to a playground, detail how it is line with TCC’s County Tipperary Playground Policy 2017
2.21 / I/WE HAVE (Add Yes/No/Not Required as appropriate) / Planning Permission
Architects Specification / Plans
Match Funding
Business Plan/ Development Plan (Ensure plan is signed by the promoter)
Insurances
SECTION 3: SITE STATUS
3.1 / SITE STATUS: (Please indicate by placing ‘Yes’ in the appropriate row and provide further details where relevant)
Note: Promoters may apply for grant aid subject to signing a lease agreement.However all details of the proposed lease, including cost and duration must be provided with your application to allow us to properly evaluate your proposal. / Promoter Owned
(please provide certified copy of folio & map showing promoter as full owner)
Leased
Copy of lease to be provided: (it must be signed by the lessor and promoter, appropriately witnessed, accompanied by map and stipulate period of lease which must be a minimum of 10 years from the date of final payment of grant.
Other
Where the promoter cannot obtain a lease, legal documentation confirming the promoter’s authority to carry out the relevant activities (for at least a 10 year period), will suffice. This documentation must be witnessed by a solicitor and signed by a person or body recognised as the person or body in charge of the property. This document cannot be used as contribution-in-kind. Any agreement for a period of less than 10 years may not be eligible for funding.
3.2 / PLANNING PERMISSION (Please give details)
Granted
(please provide copy of grant of planning permission)
Required
(please give details of proposed submission date DD/MM/YY OR the date that the decision on your planning permission is likely DD/MM/YY)
Please provide planning number if already submitted
Not Applicable / Exempt
(If exempted development, provide a Declaration under Section 5 of the Planning and Development Act, 2000 from TCC)
3.3 / Other Notices (if relevant)
Have you a valid Commencement Notice?If yes, provide copy
Have you a valid Fire Safety Certificate? If yes, provide copy
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SCG 2016-2019 / Call for Proposals September 2017 / Application Form
SECTION 4: FINANCIAL ASPECTS4.1 / State which Grant Award Level being applied for / Community/Local Grant Award– projects having an impact at the level of one or more communities; funding at a maximum rate of 75% of the total eligible project cost up to a maximum of €40,000;
Major – projects having an impact at the level of one or more Municipal Districts; funding at a maximum rate of 75% of the total eligible project cost up to a maximum of €100,000; if applying for this grant, you must provide a detailed rationale for this choice
4.2 Please complete the following table in relation to the COST of your project.
All services/works are subject to full compliance with public procurement guidelines detailed in the Application Form Guidance Notes. If procurement has already taken place, please attach copy of the quotes, your advisor’s cost report and/or any other relevant report/documentation.
Description of items / Cost ex. VAT / Cost Inc. VAT
Insert further rows as necessary
Total Project Cost:
4.3 / Conflict of interest:
Are you/your organisationand/or its officers linked in any way to the proposed suppliers/contractors? / Yes
No
If ‘Yes’ please give details:
NOTES
- Voluntary labour can be included as an eligible “cost”. However, no more than €5,000 or half of the minimum 25% promoter’s match-funding financial input into the project, whichever is the lesser, shall be voluntary work in lieu of cash. If including voluntary labour as a project cost, a “Proposed Voluntary Schedule” must be completed and used in support of this particular cost item.
- The donation of land or equipment can be included as part of the project. These must be independently valued by an appropriate expert and a copy of the valuation submitted. The valuation should be included in your project costing above, if relevant.
- Professional fees up to a maximum of 10% of the project cost can be included.
Grant amount sought
(Funding for projects is at a maximum rate of 75% of the total eligible project cost up to a maximum of €40,000 or €100,000 depending on Grant Award Level chosen in 4.1. The minimum grant awarded will be €10,000. Due to the anticipated demand for funding through this Scheme, the funding amount allocated to any project is expected to be less, and perhaps significantly so, than the maximum rate payable and promoters should bear this mind when drawing up their project budget).
If you are NOT registered for VAT, then grant is calculated on the eligible project cost Including VAT / €
Own funds / €
Other public grants, e.g. LEADER, Fáilte Ireland, etc. / €
Bank or credit union loan / €
Voluntary labour, if applicable (complete sheet on appendix 2) / €
Donation of land / equipment, if applicable / €
Other Sources, e.g. funding from governing bodies, etc. / €
TOTAL SOURCE OF FUNDS (This should equal the total project cost as detailed on the table in 4.2) / €
4.5 / Source of Match Funding (give details) / Own Cash
Please attach proof of own cash from financial institution
Bank Loan facility
Please attach proof of bank loan from financial institution
Other sources of funds
Please detail and attach support documentation
Bridging finance
Please attach evidence of necessary bridging finance to deliver the project
4.6 / Do you require phased payment of the grant (tick relevant box) / YES:
NO:
4.7 / Have you applied for funding for this project from another source? / YES:(Please give details in the box opposite including application number if relevant)
NO:
4.8 / Sustainability
Funding obtained through this Scheme will only be for capital works which have not yet taken place. If relevant, please complete the following table to indicate estimated annual running costs for the service/facility, and how it is proposed to fund them. The total for expenditure and funding should equal.
Estimated Annual Running Costs
Expenditure / Funding
Type / Amount
€ / Source / Amount
€
Heating / Local fund-raising
Lighting / Donations
Cleaning / Income from use of facility/service
Maintenance/Repairs
Loan Interest (if any)
Staff/Supervision/
Caretaking
Others…..Insert further rows as necessary / Others…..Insert further rows as necessary
Total
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SCG 2016-2019 / Call for Proposals September 2017 / Application Form
DECLARATION
- Ideclarethatall the information given in this form and supporting documentation suppliedinsupportofthisapplicationaretrueandcorrect.I understand that any false information or misrepresentations can lead to disqualification at any stage of processing the proposal.
- Irequestthatassistancebegivenin supportoftheprojectasoutlinedandIundertaketoprovideanyadditionalinformationthatmayberequired.
- I confirmthatthegrantifreceivedwillbeusedsolelyforthepurposeforwhichitisapproved.
- I understand that if sufficient information is not provided by us to allow this application to be assessed, it will automatically lapse
- I understand that if this application is successful we will be required to pay the contractor in advance and all grant criteria must be fulfilled before the grant is paid.
- I understand that grant funding is given on the basis that it may be reviewed if the project receives additional funds from other sources and that funding will lapse if not drawn down within 12 months of approval, or as otherwise agreed in writing with Tipperary County Council.
- I understand that Tipperary County Council will not be liable for any future capital, maintenance or revenue costs unless expressly agreed.
- I understand that any information provided will be held on computer and hard copy format. This information will be used for the administration of your project application and producing monitoring returns. Tipperary County Council may share information with other local authorities, Local Action Groups and government departments/agencies to enable them to prevent fraudulent applications or for detecting crime and to co-ordinate processing of complementary applications. This policy does not affect your rights and your information will be held as prescribed under the Data Protection Acts1988 and 2003.
- I understand that Tipperary County Council is subject to the Freedom of Information Act (FOI) Act, 1997. If an applicant considers that any of the information supplied to the Council is either commercially sensitive or confidential in nature, this should be highlighted and the reasons for its sensitivity specified. In such case the relevant material will, in response to a request under the Act, be examined in the light of the exception provided for in the Act.
Signed On Behalf ofApplicant………………………………………………… Date…………………………………
(This should be the contact person as detailed in Section 1.2)
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SCG 2016-2019 / Call for Proposals September 2017 / Application Form
Appendix 1: DATAPROTECTION-FORMOF CONSENT
Tipperary County Council (TCC) is responsible for delivering a wide range of services to the public.We are required to collect information on individuals and community groups who we assist.
As soon as you contact TCCa record is created in your name for the information you provide. The information will be stored by TCC, where relevant, in paper/electronic form. Information that we then collect, including information that you give us, is added to the record.
- You have the right, given by the Data Protection Act of 1988 and 2003 to a copy of your information at any time.
You should address your request to:
Data Protection Officer,
Tipperary County Council,
Civic Offices,
Clonmel,
Co. Tipperary
The information we record is used only for the following purposes:
- Processing of applications;
- Auditing of applications;
- Compiling statistical information to help us plan and improve our services;
- Analysing information about applicants for other bodies such as various Government Departments;
- Producing our own statistics for publication;
- Publication of promoter and project details (including photography) for publicity and promotional purposes.
Personal information about you will be disclosed only in accordance with TCC’s registration under the Data Protection Act. The purpose for which we hold information and the people to whom we may disclose it are listed in the Register of Data Controllers. This is a public register kept by the Office of the Data Commissioner at the Irish Life Building, Talbot Street, Dublin 1. (Phone 01- 874 8544), and you may inspect it free of charge.
Other information supplied and collected may also be disclosed to people and bodies from time to time. On request you can receive a list of disclosures.
DECLARATION
I have read and understand the above statement and give consent to TCCfor the use and disclosure of data and information as outlined above.
Name:______
Date: ______
Witnessed by: ______
SCG 2016-2019 / Call for Proposals September 2017 / Application Form
APPENDIX 2: PROPOSED VOLUNTARY LABOUR SCHEDULE
This form should only be completed if you are claiming voluntary labour as part of the overall costing of your project
Name of Promoter:
Name of person contributing the labour / Nature of contribution / Estimated number of voluntary hours to be contributed / Value of voluntary labour (number of hours’ x by rate per hour* / Justification for rate “charged” per hour for task*Maximum rate per hour is €14
Signed: ______
Dated: ______
SCG 2016-2019 / Call for Proposals September 2017 / Application Form
Appendix 3: Checklist of Information required
Grant Approval will not be made without consideration of all appropriate documentation relevant to your project.
Requirements will vary depending on the project.
Required Information
Applications cannot be considered unless all the following is included
Relevant Governing Documents
Copy of Full Audited Accounts / Financial Statements / Management Accounts for 3 most recent years, if applicable
Data Protection Act Form
Copy of current Bank Statements (3 months minimum) for all accounts held
Evidence of Matching Funding
Project Specific Information
Please enclose the following items as appropriate
Planning Permission & ConditionsHeritage Consents and Approvals
Notice of Exemption from PlanningOther Statutory Approvals
Business/Development PlanDrawings/Plans/Specifications
Voluntary Labour ScheduleCertified Valuation of land/property donated
*Evidence of Title*Evidence of Leasehold
Relevant Governing DocumentsVAT Exemption Letter from Revenue
Schedule of MembersCurrent Insurances
Equality of Opportunities PolicyFair Usage Policy/Inclusion Strategy
Appropriate No. of Quotations/Tenders based on Project Costs
Letters of Support
* Evidence of title or leasehold must be obtained in respect of capital projects involving land, e.g. sites of building construction or renovation, fixtures, traffic ways, etc. Any lease provided must –
- be signed by lessor and the promoter;
- be appropriately witnessed;
- be accompanied with a map identifying the land; and
- stipulate the term of the lease (must be for a period of at least 10 years from the date of the final payment to the promoter or for a term not less than the term of the contract, whichever is the longer).
Where the promoter cannot obtain a lease, legal documentation confirming the promoter’s authority to carry out the relevant activities (for at least a 10-year period post payment of grant aid), will suffice. This documentation must be witnessed by a solicitor and signed by a person or body recognised as the person or body in charge of the property. This document cannot be used as contribution-in-kind. Any agreement for a period of less than 10 years will not be eligible for funding.
Please enclose any other relevant documentation that supports your application for grant assistance