Community Grants Scheme - 2022 Application Form

Name of organisation *

Postal address *

Street Address

Street Address Line 2

City Region

Post Code Country

Contact Person (who is readily available) *

First Name Last Name

Phone (Work)

Phone (Home)

Email *

example@example.com

GST Registration No (If applicable)

What type of social service do you provide to the community? *

Number of people in the past year that have accessed your organisation’s services/programme who live in the Kāpiti Coast District: *

Fewer than 5 people between 6 – 20 people between 21 – 40 people Between 41 – 60 people between 61 – 80 people over 80 people

Over the past year have the people that access your service/progamme: *

increased decreased no change

Which area(s) do you service: *

Paekākāriki Raumati South Raumati Paraparaumu Waikanae Te Horo Ōtaki

Age range(s) of people that use your service/programme: *

Preschool 0 - 5 School Age 5 – 12 Youth / young adults 13 – 24 Adults 25 - 64 Seniors 65+ Older Seniors 80+

Ethnicity range of people that use your service: *

All Asian Māori NZ European/Pākehā Pasifika

Grant Request (maximum $2000): *

Briefly describe the activity or project for which this application is being made *

Is this a new or ongoing activity/project: *

New Ongoing

Briefly describe the benefit of this activity/project to the community? *

• If you are registered for GST please do not include GST in these costs
• Round all figures to the nearest dollar
• Attach quotes and any other supporting documentation

Project Costs

List all the costs eligible for this project e.g.

training costs
equipment purchase or hire
administration
publicity / educational material
other?

Project Costs *

	Expense item	Cost ($)
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2
3
4
5
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7
8
9
10

Attach quotes and any other supporting documentation

Upload documents

(A) Total cost of the project is *

Income

How will your group contribute financially to the project? e.g.

current contracts
equipment purchase or hire grants (successful or proposed)
administration sponsorship
publicity / educational material Fundraising
cash savings
other?

Income *

	Income	Amount ($)
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2
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10

(B) Your contribution is *

To find out how much money you require for your project, subtract your contribution (B) from the total cost of the project (A). The answer is the amount of money you need in order for your project to go ahead.

Your organisation must provide a financial contribution

Please attach a current statement of income and expenditure *

Upload documents

Have you applied to any other organisation for funding for this project? *

Yes No

Please list the organisations(s), amount applied for, and when you expect to know the outcome. *

	Organisation	Amount	Status (successful/unknown/unsuccessful
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What will you do if you cannot raise all the money required? *

Have you received funds from any organisation in the last two years? *

Yes No

Please give details below: *

	Funding Organisation	Project	$ Received	Year
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DECLARATION *

We hereby declare that the information supplied here on behalf of our organisation is correct. We consent to Kāpiti Coast District Council collecting and retaining the personal contact details provided in this application and using these details for the purpose of assessment of this scheme. If the application is successful, we agree to use the monies for the purpose for which they are granted and account for them, or in the event that is not possible, such monies will be refunded to Council. We have obtained the consent of the other contact person to provide these details. This consent is given in accordance with the Privacy Act 1993.

Name *

First Name Last Name

Position in organisation *

Date

Please give the names of two people who we can contact during the day if we need more information. The first contact must be the person who filled out the form.

Under the Privacy Act (1993) consent from these people must be given before their details are recorded here.

Your name *

First Name Last Name

Your phone number (day)

Your phone number (evening)

Second Contact persons name *

First Name Last Name

Second Contact persons phone number (day)

Second Contact persons phone number (evening)

Community Grants Scheme - 2022 Application Form

Details of organisation

The Application

People who use your services

Activity/Project details & benefits

Financial Details $$

Signatories

Contact people