2024 Organisation Accountability Form

GENERAL DETAILS:
THE PETER MALONE COMMUNITY GRANTS SCHEME ORGANISATION ACCOUNTABILITY FORM 2024
1. FULL NAME OF ORGANISATION:*
2a. NAME CONTACT PERSON FOR THIS ACCOUNTABILITY FORM:

First NameLast Name
2b. POSITION (e.g. Chairperson, Treasurer):
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 organisation's name need to be attached. For wages, please provide copies of IR348/349s - IR Employer Monthly Schedules - and bank statement proving salary payments:

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

Total Income: (note you do not need to fill in this field it will automatically complete from what is entered above)
This field auto calculates
6b. Receipts or proof of purchase in the organisation's name need to be attached. For wages, please provide copies of IR348/349s - IR Employer Monthly Schedules - and bank statement proving salary payments 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.
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9. DECLARATION (to be signed by two members of your organisation):

We 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 here on behalf of our organisation is correct. We 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 this application, we declare that all of the information given herein is complete and true to the best of our 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 ORGANISATION ACCOUNTABILITY FORM 2024