Request For Waving of Fess

Name of Organisation

Postal Address

Contact Person

Phone Number

Area CodePhone Number

Email

example@example.com

Is your organisation registered for GST

Is your organisation Incorporated

Incorporation Number

Do you have Public LiabilityInsurance?

Name of Project Event

Type of Project Event

Project or Event Start Dates

Date

Project or Event End Dates

Date

Total Budget

Requested Funding

Project Description*

*(Project Description can include objectives, expected outcomes, proposed actions/purchases.

You are welcome to attach additional pages, or your project plan, should there be insufficient space.)

Will revenue be generated as a resultof the project / event?

Expected Revenue

Is this a fund raising project / event?

Beneficiaries

Add All Beneficiaries Names Here

Are you working with any other community groups or businesses in delivery of this project / event?

Group 1: Group Name, Contact Person and Phone

TS Shire, Raman S Virdi, 0412 345 678

Group 2: Group Name, Contact Person and Phone

Have you applied for other external funding?

Funding Body 1: Fund Name, Status and Amount

Lotterywest, Application Lodged, $200

Funding Body 2: Fund Name, Status and Amount

Type of fee charge that you are requesting be waived or reduced

eg: Hall Hire, Tables and Chairs, Projector etc

PROJECT /EVENT BENEFITS

Why is this project event important

Please describe how this project event will benefit members of your organisation

Does your project benefit the wider community Please CLEARLY explain how others will benefit from your project event

Does your project / event meet any of the Community Small Grant objective/s

If YES, please state which objective/s your project / event meets and how your project / event will achieve that objective/s

If NO please provide a comprehensive explanation as to why Council should consider your proposal

FINANCIAL DETAILS

BUDGET: Please provide a detailed budget for the project/event you are requesting support from the Council. All costs should be itemised in the space provided below. Please note that your income and expenditure should match. If the project/event is fundraising to be retained, please indicate as retained profit. Please refer to the Guidelines for in-kind support information.

Applicants Cash Contribution

If no contribution type 0

Total In-Kind Volunteer Labour @ $25/hr

If no contribution type 0

Total In-Kind Volunteer Labour @ $40/hr

If no contribution type 0

In-Kind Donated Materials

If no contribution type 0

Other

Fundraising - Retained Profit

Total Internal Funding

Shire of Three Springs Funding

Funding Organisation 1

If no contribution type 0

Funding Organisation 2

Participant Fees (if applicable)

If no fee income type 0

Other

Total External Funding

Total Income

Item 1

Must have atleast one expenditure item with cost

Item 1 Cost

Item 2

Item 2 Cost

Item 3

Item 3 Cost

Item 4

Item 4 Cost

Item 5

Item 5 Cost

Item 6

Item 6 Cost

Item 7

Item 7 Cost

Total Expenditure

Diffrence (Must be equal to $0)

= Total Expenditure - Total Income

Amount of council funding requested

DECLARATION: I hereby declare that the information supplied on behalf of the named organisation is correct. I consent to the Shire of Three Springs collecting the personal contact details provided in this application. We acknowledge your right to have access to our personal information, in accordance with the Privacy Act 2000. I also declare that I have read the Shire of Three Springs Community Small Grants Guidelines and agree to comply with the provisions included.

Signature

Type Full Name to Give Your Consent

Date

Position

REQUEST FOR WAIVING OF FEES

INCOME

INTERNAL FUNDING

EXTERNAL FUNDING

EXPENDITURE