2023 Individual Accountability Form

THE PETER MALONE COMMUNITY GRANTS SCHEME INDIVIDUAL ACCOUNTABILITY FORM 2023
GENERAL DETAILS:
1. FULL NAME OF GRANT RECIPIENT:*

First NameLast Name
2a. NAME OF PARENT OR GUARDIAN IF RECIPIENT IS UNDER 18 YEARS:

First NameLast Name
2b. RELATIONSHIP OF APPLICANT TO GRANT RECIPIENT:
3. CONTACT DETAILS:
Work Phone:
Home Phone:
Mobile Phone:*
Email:*
example@example.com
FUNDING DETAILS:
4a. AMOUNT GRANTED:
Place $ amount above
4b. AMOUNT SPENT (if different to amount granted):
Place $ amount above
5. PURPOSE FOR WHICH THE GRANT WAS FUNDED:

6a. PLEASE COMPLETE THE FOLLOWING BREAKDOWN OF GRANT EXPENDITURE: Receipts or proof of purchase in the recipient’s (or guardian’s) name need to be attached:

	ITEM	$ AMOUNT
1.
2.
3.
4.
5.
6.
7.
8.
9.

Total Expenditure (note you do not need to fill in this field it will automatically complete from what is entered above)
This field auto calculates
6b. Copy of receipts or proof of purchase in the recipient's or guardian's name to be uploaded below:

Please ensure you check your files before uploading as there is no preview feature on this form.
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7. WHAT WERE THE KEY OUTCOMES:
8. HOW WAS THE SUPPORT OF NETWORK TASMAN CHARITABLE TRUST ACKNOWLEDGED (PLEASE ATTACH EVIDENCE):
Upload evidence below:

Please ensure you check your files before uploading as there is no preview feature on this form.
Cancelof
9. DECLARATION (to be signed by recipient or guardian if recipient is under 18 yrs):

I hereby declare that the grant from Network Tasman Charitable Trust has been applied to the above project in accordance with the conditions set out by the Trust and that all information supplied is correct. I acknowledge that we are personally liable for any loss to Network Tasman Charitable Trust arising from any false information supplied in support of this application or the accountability.
E-Signature:

In submitting my application, I declare that all of the information given herein is complete and true to the best of my knowledge and belief.
Name:

First NameLast Name
POSITION:
DATE:

DayMonthYear
Date
Name:

First NameLast Name
POSITION:
DATE:

DayMonthYear
Date
Please verify that you are human*
Should be Empty:

THE PETER MALONE COMMUNITY GRANTS SCHEME INDIVIDUAL ACCOUNTABILITY FORM 2023