Council Grants Program Application Form

Section 1 - Eligibility Check

Please read pages 2 and 3 of the Guidelines for ineligible applications AND ineligible projects/costs. If you cannot check all of the boxes below please contact Council.

The application aligns with a theme or goal in Council's Corporate Plan or a Strategy
The application addresses an identified need in the community
The application benefits the Douglas Shire community / is in the public interest
The project demonstrates evidence of community support
The applicant has an active Australian Business Number (ABN)
The applicant is an Australian citizen or permanent resident who has permanently resided in the Shire for at least the preceding 12 months, or N/A
The applicant is a group or organisation, that primarily provides services in the Douglas Shire; or primarily provides services outside the Shire but the project is of community benefit to the Shire (provide evidence of community benefit), or N/A
The applicant has successfully acquitted all previous Council grants, or N/A
The applicant is free of overdue outstanding fees or debts with Council
The applicant is compliant with annual requirements of Office of Fair Trading, Australian Charities and Not-for-Profits Commission or Australian Securities and Investment Commission (whichever is applicable) or N/A

Application Type*

In-Kind Assistance (Non-financial)
Sponsorship
Micro Grant
Major Grant

Project Category*

Arts and Cultural
Community Development
Community Events
Place-Making
Economic / Industry Development
Environment and Sustainability
Sport and Recreation

Section 2 - Applicant Information

Applicant Type*

Applicant Name*

ABN	GST Registered? Y/N	Incorporation / Charity Number (if applicable)

Website/Social Media Page

Street Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your postal address the same as above?*

Postal Address

Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact person regarding application*

Name	Phone Number

Email

A copy of this application will be automatically sent to the email address provided.

Have you received Council Grant(s) before?*

Which financial year(s)?*

Organisation's Legal status (e.g. Incorporated / Company)*

Authorised Person*

Authorised on behalf of the organisation to sign application, contract and acquittal.

Full Name	Position in organisation (President, CEO or Director)

Groups / Auspice arrangement*

Contact person for project	Phone Number

Section 3 - Project Information

Project Title (Max. 10 words)*

What do you want to do?*

Why do you need to do this project?*

What community support do you have?*

How will the project benefit the community/be in the public interest? (community, economic, social or environmental outcomes)*

Amount/value requested (GST Exc)	Proposed start date:	Proposed completion date:	Proposed location of project:

Please indicate if your proposed activity directly and specifically targets one or more of the following groups as attendees or participants*

Which theme/s from Council's Corporate Plan does this project align with?*

Celebrating Our Communities
Fostering Economic Growth
Leading Environmental Stewardship
Inclusive Engagement, Planning and Partnerships
Robust Governance and Efficient Service Delivery

Please specify if there are other Council Plans/Strategies that your project aligns with

How many people do you expect to attend or participate in the project?*

Local	Regional	State	Interstate	Internationally

Section 4 - Project Partnerships - Non-Financial (In-kind) Component

What in-kind support are you requesting from Council?

Use of Council park/hall/foreshore (event/venue hire or other Council forms will be required for some in-kind requests)
Use of Council plant and equipment (subject to availability)

What in-kind support will be contributed by others (if applicable)?

Section 5 - Project Budget - Financial (Cash) and Non-financial (In-kind) Components

If you are not GST registered, amounts should include GST as this is part of the cost of the project. Amounts should be exclusive of GST if you are registered for GST.

Projected Income

Volunteer labour (IK)

Volunteer labour ($25 per hour non skilled / relevant rates for professional services)

Sponsorship (IK)

Sponsorship - cash

Own cash

Sales - tickets, enrolment, workshop fees

Other grants (Fed/State/Philanthropic)

Council grant sought in application

Total

Expenditure

In-kind labour

In-kind goods/services

Advertising/Promotion/Marketing

Other

Please specify

Other

Please specify

Other

Please specify

Other

Please specify

Total

Please ensure the total projected income and total expenses are equal. Contact Council for support if required.

Section 6 - Certification

The statements in this application are true and correct to the best of my knowledge, information and belief.
I certify that I have the appropriate delegation, as authorised by the applicant, to prepare and submit this application on behalf of the applicant.
I agree to provide Douglas Shire Council with any additional information required to assess this application.
I understand that Douglas Shire Council does not accept any liability or responsibility for the proposal in the application.
I understand that if Douglas Shire Council approves the application, I will be required to accept the terms and conditions of the Council Grants Program.
I consent to the media being given information if this application is approved and understand media may contact me.
I consent to the project being published on Council’s website, in promotional material or by way of civic and/or legislative requirements if this application is approved.
I agree to ensure all necessary approvals, permits, insurances, licences and qualifications are obtained prior to the project, program or event taking place and abide by all relevant health, safety, and professional and industry standards.
I will obtain a certificate of currency for public liability insurance and any other appropriate insurances, for an appropriate amount (in total and per event) based on level of risk current to cover the proposed project.

Full Name President / CEO / Director Date

Are you under the age of 18?*

If you are under the age of 18, your legal guardian must also sign this application

Guardian Full Name Date

Section 7 - Support Material

Please attach documentation to demonstrate need, demand, support or benefit of project.

Quotes - attach one quote for items over $500 to less than $5,000 (GST Exc), two quotes for items $5,000 to less than $15,000 (GST Exc) and three written quotes $15,000 to less than $200,000 (GST Exc)
Letters of support
Meeting minutes
Survey results
Photos
Project plan
Property owner approval
Other documentation

Other - please list

File

Drop files here or

Max. file size: 128 MB.

Douglas Shire Council – Information Privacy Statement Your personal information has been collected for the purpose of assessing your Application for Approval. The collection of your information is authorised under the Local Government Act 2009. You are providing personal information which will be used for the purpose of delivering services and carrying out Council business. Your personal information is handled in accordance with the Information Privacy Act 2009 and will be accessed by persons who have been authorised to do so. Your information will not be given to any other person or agency unless you have given Council permission or the disclosure is required by law.

Council Grants Program Application Form

Application - Council Grants Program

Section 1 - Eligibility Check

Section 2 - Applicant Information

Section 3 - Project Information

Section 4 - Project Partnerships - Non-Financial (In-kind) Component

Section 5 - Project Budget - Financial (Cash) and Non-financial (In-kind) Components

Projected Income

Expenditure

Section 6 - Certification

Section 7 - Support Material

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