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COMMUNITY GRANTS PROGRAM APPLICATION FORM 2009/2010 Organisation must operate or provides services within Fraser Coast Local Government Area Complete this form if you are seeking one-off support for a community project or event 1. NAME OF ORGANISATION(S) .......................................................................................................... .......................................................................................................... 2. ADDRESS FOR CORRESPONDENCE .......................................................................................................... .......................................................................................................... 3. CONTACT PERSON / RESPONSIBLE OFFICER NAME:  HOME

.............................................................................................. .................

 WORK

MOBILE……………………………………………

.................

FAX ....................

EMAIL……………………………………..

4. THIS APPLICATION IS MADE ON BEHALF OF: Single Organisation

Two or more Organisations

Other (please specify) ........................................................................... 5. IS THE ORGANISATION CURRENTLY INCORPORATED? Yes

No

Pending

(If the organisation is not incorporated or seeking incorporation, you will need a letter of sponsorship from an incorporated organisation which is prepared to accept financial accountability for a grant.)


6. DOES THE ORGANISATION HAVE AN A.B.N? Yes

No

7. IS THE ORGANISATION REGISTERED FOR G.S.T? Yes

No

Note: If your organisation does not have an ABN and your grant application is successful, you will need to supply a completed form Statement by a Supplier’ when you claim your grant. This form can be obtained from www.ato.gov.au 8. ELIGIBILITY No

Yes

If yes how much? And for what purpose?

Organisation currently receives recurrent support from Council Organisation received funding from Council in the previous financial year Organisation has received funding from Council this current financial year Have previous grants from Council have been fully acquitted (see Policy for further information) 9. MEMBERSHIP DETAILS (a) Please indicate the number of current members. .................. (b) Please indicate the number of non-members who will participate in or benefit from the project …………………………………….. 10. PROJECT DETAILS Please provide a brief description of the project or event and attach any documents explaining it in further detail. .......................................................................................................... .......................................................................................................... .......................................................................................................... .......................................................................................................... ..........................................................................................................

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11. SELECTION CRITERIA a. Describe how you identified the community need for the project or event. ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... ....................................................................................................

b. What are the subsequent benefits for the community? ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... .....................................................................................................

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c.

Describe briefly what input your organisation will provide towards the project or event (specify funds, labour, or other in-kind support). ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... .....................................................................................................

d. Describe the involvement of the wider community in the planning and ongoing involvement in this project or event. ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... .....................................................................................................

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e. What are the expected outcomes of the planned project or event? ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... .....................................................................................................

f. Will the project or event involve working with other organisations and if so, how? ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... g. Have you sought funds for this project or event from any other sources? E.g. Gaming Community Benefit Fund, Jupiter’s Casino Community Benefit Fund, Volunteer Small equipment grants etc. If yes, who? How much? ..................................................................................................... ..................................................................................................... ..................................................................................................... ..................................................................................................... .....................................................................................................

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12. BUDGET Please list items for which the grant is sought and the cost of each item in priority order.

EXPENDITURE – total cost of the project Expenditure - cash

Total cost of each item

How much funding are you seeking to cover each item?

$

$

Salaries, fees & allowances Production, program & direct costs Promotion & marketing costs Administration costs Materials & equipment costs Installation costs Other Total costs

PROJECT/EVENT INCOME – Cash Source/description Amount Grant income Organisation’s contribution Sponsorship, fundraising & donations Other income Total income

$

In-Kind Assistance Description

Tasks undertaken

Amount & cost 25 hrs @$20 p/h

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eg

Total $

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AMOUNT Community Grant sought by your organisation Funds in hand for project Additional funds to be raised In kind & donations Other TOTAL INCOME

13. DOCUMENTATION (To be attached) (a) (b) (c) (d)

copy of the organisation’s objectives (as per Constitution); copy of the latest audited financial statement; any other information in support of your application; and incorporation documentation or sponsor’s Certificate of Incorporation

14. CERTIFICATION This Application is to be signed by two executive officers of the incorporated organisation accepting legal and financial responsibility for the project. I certify that: 

The information provided in this application is true and correct;



All conditions of the grant will be complied with, should a grant be approved;



This application is consistent with the aims and objectives of the incorporated body as set out in its Constitution; and



There will be appropriate insurance cover for the project.

NAME:

.................................

NAME:

.....................................

SIGNATURE:............................

SIGNATURE:.....................................

POSITION: ..............................

POSITION: .....................................

DATE:

DATE:

.................................

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Please return your application by 29 JANUARY 2010 to: Fraser Coast Regional Council Community Grants Program P O Box 1943 HERVEY BAY QLD 4655 For information or enquiries, please contact Council’s Grants Officer on  4190 5880.

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http://www.frasercoast.qld.gov.au/community/documents/Application_Form_Community_Grants_Program