COMMUNITY SMALL GRANT APPLICATION
Name of Organisation:
*
Postal Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person Name:
*
Email
*
example@example.com
Mobile
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is your organisation registered for GST?
*
Yes
No
Australian Business Number
Is your organisation Incorporated?
*
Yes
No
Incorporation No.
Do you have Public Liability Insurance?
*
Yes
No
PROJECT / EVENT SUMMARY
Type of Project / Event:
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Name of Project / Event:
*
Project or Event Date/s:
*
-
Month
-
Day
Year
Date
Total Budget:
*
Requested Funding From the Shire:
*
Add all the dates here (is multiple)
Project Description (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 result of the project / event?
*
Yes
No
Expected Revenue:
Is this a fund raising project / event?
*
Yes
No
Name of all the Beneficiaries:
Are you working with any other community groups or businesses in delivery of this project / event?
*
Yes
No
name the community groups or businesses that you are working with in delivery of this project / event?
Rows
Group / Business
Contact Name
Phone
Group 1
Group 2
Group 3
Group 4
Have you applied for other external funding?
*
Yes
No
Name the External Funding Details
Rows
Name of Organisation
Status
Amount
Funding Body 1
Funding Body 2
Funding Body 3
Funding Body 4
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 Grant objective/s?
*
Yes
No
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 for from 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.
Income
*
Rows
Item Type/Name
Amount ($)
Applicants Cash Contribution
In-Kind Volunteer Labour @ $25.00 per hour
In-Kind Volunteer Labour @ $40.00 per hour
In-Kind Donated Materials
Fundraising - Retained Profit
Other
Shire of Three Springs Funding
External Funding Body 1
External Funding Body 2
External Funding Body 3
Total Income
*
EXPENDITURE
*
Rows
Item Type/Name
Amount ($)
1
2
3
4
5
6
7
8
9
10
Total Expenditure
*
Balance
*
Bank Details
Please add your organisation's bank details here
Account Name
*
Bank Name
*
BSB
*
Account Number
*
Document Upload
Please upload the following documents
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Declaration
I hereby declare that the information supplied on behalf of the named organisation is correct. I consent to the Shire of ThreeSprings collecting the personal contact details provided in this application. We acknowledge your right to have access to ourpersonal 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 theprovisions included.
Signature
*
Type your full name here to sign
Date
*
-
Day
-
Month
Year
Date
Your Position
(Must be an executive committee member)
Submit
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