2015 AGED CARE APPROVALS ROUND

PART A - RESIDENTIAL AGED CARE PLACES

Organisation name:(if approved provider, insert approved provider name)

Form InstructionsAll applicants applying for residential aged care places and/or a capital grant must complete this form.

If you are applying for residential aged care places only you must complete:

Part A – Residential Aged Care Places application form once for your organisation

Part B – Residential Aged Care Places application form for each service for which you are seeking residential aged care places

If you are applying for residential aged care places and a capital grant you must complete:

Part A – Residential Aged Care Places application form once for your organisation

Part B – Residential Aged Care Places application form for each service for which you are seeking residential aged care places

Part C – Capital Grant application form for each service

If you are applying for a capital grant only you must complete: Part A – Residential Aged Care Places application form once

for your organisation Part C – Capital Grant application form for each service

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 1 of 11

Detailed information about completing this application form is included in the 2015 ACAR Essential Guide.

Submit your electronic application to the Department of Social Services at acar@dss.gov.au on or before 11:59pm (AEST) 25 September 2015.

Details on how you can submit your electronic application can be found at Chapter 1 of the 2015 ACAR Essential Guide.

PART A – SECTION 1: APPLICANT DETAILS

1.1 Applicant:

ABN

1.2 Applicant postal address*:

Street name and number OR

PO Box number

Suburb/Town

State/Territory Select a state Postcode

*These details will be used as the official address for all enquiries the Department may have relating to this application.

1.3 Contact details:

Primary Contact Alternative ContactName of contact person

Position in organisation

Telephone number

Mobile number

Best hours to call

Email address**

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 2 of 11

Approved Provider ID (NAPS ID) (if applicable)

**A receipt of application will be sent to the primary email address provided.

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 3 of 11

Please specify the number of applications for residential aged care places your organisation will submit in each Aged Care Planning Region.

(Please note that you are required to complete a separate Part B for each service for which you are applying for places. Refer to Chapter 3 of the 2015 ACAR Essential Guide).

New South Wales

Region Number of applications

Region Number of applications

Central Coast New England Central West Northern Sydney Far North Coast Orana Far West Hunter Riverina/Murray Illawarra South East Sydney Inner West South West Sydney Mid North Coast Southern Highlands Nepean Western Sydney

Victoria

Region Number of applications

Region Number of applications

Barwon South Western Loddon-Mallee Eastern Metro Northern Metro Gippsland Southern Metro Grampians Western Metro Hume

Queensland

Region Number of applications

Region Number of applications

Brisbane North Mackay Brisbane South North West Cabool Northern Central West South Coast Darling Downs South West Far North Sunshine Coast Fitzroy West Moreton Logan River Valley Wide Bay

Western Australia

Region Number of applications

Region Number of applications

Goldfields Metropolitan South East Great Southern Metropolitan South West Indian Ocean Territories Mid West Kimberley Pilbara Metropolitan East South West Metropolitan North Wheatbelt

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 4 of 11

South Australia

Region Number of applications

Region Number of applications

Eyre Peninsula Metropolitan West Flinders and Far North Mid North Hills, Mallee and Southern Riverland Metropolitan East South East Metropolitan North Yorke, Lower North and Barossa Metropolitan South

Tasmania

Region Number of applications

Region Number of applications

North Western Southern Northern

Northern Territory

Region Number of applications

Region Number of applications

Alice Springs East Arnhem Barkly Katherine Darwin

Australian Capital Territory

Region Number of applications

Australian Capital Territory

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 5 of 11

PART A – SECTION 2: CAPACITY OF THE APPLICANT TO DELIVER RESIDENTIAL AGED CARE SERVICES

2.1 Provide a detailed description of your organisation’s board and/or senior management’s relevant expertise and experience in aged care, or other services.

Word limit 750

2.2 Provide a detailed description of how your organisation’s board and/or senior management will:

A. Monitor the performance of your aged care services, or other services.B. Oversee continuous quality improvement across your aged care services,

or other services.C. Manage risk (e.g. mitigation strategies).

Word limit 1,500

2.3 Provide examples of how your organisation will ensure the rights of care recipients are protected.

Word limit 750

2.4 Describe your organisation’s approach to ensure appropriate care is delivered to people with special needs and/or dementia.

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 6 of 11

Word limit 750

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 7 of 11

PART A – SECTION 3: FINANCIAL INFORMATION – APPROVED PROVIDER/APPLICANT ORGANISATION LEVEL

3.1 Statement of Organisational Financial Position and Projections – Assets.The projections should reflect the whole of the organisation’s financial position and not just for the services applied for.

A B C DActual positionAs at 30 June

2015*

Forecast situation immediately

BEFORE places are operational

As at

Forecast situation immediately AFTER

places are operational**

As at

Forecast situation at the financial year end when

max occupancy is achieved

As at

In columns B, C and D please insert the date in the following format dd/mm/yyyy

CURRENT ASSETS

Cash and bank accounts (not including Term Deposits)

Investments / Term deposits

Receivables - residents

Receivables - other debtors

Receivables – Loans to parent/related organisation

Other (please provide further details in the table “Other assets” below)

Total current assets

NON-CURRENT ASSETS

Land and buildings

Plant and equipment

Investments

Intangibles

Receivables - residents

Receivables - other debtors

Receivables – Loans to parent/related organisation

Other (please provide further details in the table “Other assets” below)

Total non-current assets

TOTAL ASSETS

* If your organisation’s financial year ends on a date other than 30 June, please provide your actual/forecast in accordance with your financial year end. That is, please do not adjust your actual/forecast financial position to 30 June.** For applicants with multiple applications for places, this would represent the financial year end closest to when the majority (at least 50 per cent) of the organisation’s new places are expected to become operational.

Other assets: Please provide further details in relation to the assets that are classified as “Other” in the above table.Other current assets

Other non-current assets

Word limit 150

Liabilities

A B C DActual positionAs at 30 June

2015*

Forecast situation immediately

BEFORE places are operational

As at

Forecast situation immediately AFTER

places are operational**As at

Forecast situation at the financial year end when max occupancy

is achievedAs at

In columns B, C and D please insert the date in the following format dd/mm/yyyy

CURRENT LIABILITIESPayables Employee entitlements Accommodation bonds, refundable accommodation deposits and refundable accommodation contributions - payable within 12 months (estimate)

Accommodation bonds, refundable accommodation deposits and refundable accommodation contributions - payable after 12 months (estimate)

Bridging finance Bank finance (including: bank overdraft, bank loans etc).

Parent/related organisation loans Zero Real Interest Loan Other (please provide further details in the table “Other liabilities” below)

Total current liabilities

NON-CURRENT LIABILITIESEmployee entitlements Bridging finance Bank finance (including: bank overdraft, bank loans etc).

Parent/related organisation loans Zero Real Interest Loan Other (please provide further details in the table “Other liabilities” below)

Total non-current liabilities TOTAL LIABILITIES TOTAL ASSETS LESS TOTAL LIABILITIES (A) * If your organisation’s financial year ends on a date other than 30 June, please provide your actual/forecast in accordance with your financial year end. That is, please do not adjust your actual/forecast financial position to 30 June.** For applicants with multiple applications for places, this would represent the financial year end closest to when the majority (at least 50 per cent) of the organisation’s new places are expected to become operational.

Other liabilities:Please provide further details in relation to the liabilities that are classified as “Other” in the above table.Current liabilities

Non-current liabilities

Word limit 150

Reconciliation of movement in Net Assets to Operating Surplus (Deficit)

A B C

In columns A, B and C please insert the date in the following format dd/mm/yyyy

Actual positionAs at 30 June 2015*

Forecast situation immediately

BEFORE places are operational

As at

Forecast situation immediately AFTER

places are operational**

As at

Forecast situation at the financial year end when max occupancy

is achievedAs at

Opening NET ASSETS (i.e. previous year)

Current year’s operating surplus/Deficit***

Other changes to equity (For example: contributed capital received, dividend payments, etc)

Closing NET ASSETS (i.e. current year) * If your organisation’s financial year ends on a date other than 30 June, please provide your actual/forecast in accordance with your financial year end. That is, please do not adjust your actual/forecast financial position to 30 June.** For applicants with multiple applications for places, this would represent the financial year end closest to when the majority (at least 50 per cent) of the organisation’s new places are expected to become operational. *** Relates to the whole organisation’s operating surplus/deficit.

Other changes in equity:Please provide details in the table below.

Word limit 150

3.2 Required attachments.

Document Have you attached evidence?

NOTE: Only attach your organisation’s audited financial statements if you: are not an existing approved provider of aged care; and/or have not submitted your 2013-14 General Purpose Financial Report.

Audited 2013-14 financial statements, including any notes and/or auditor’s opinions(to confirm the starting position for your financial projections).

ENDORSEMENT OF APPLICATION

This application can be signed only by those persons who are legally empowered to give assurances and enter into contracts and commitments on behalf of the applicant.

In signing this endorsement, you are affirming that this proposal has the full consent and support of your organisation’s Board of Directors, or other equivalent relevant authority.

Giving false or misleading information is a serious offence.

There are offences established by the Aged Care Act 1997 and the Criminal Code Act 1995relating to providing false or misleading information.

Approvals based on false or misleading information may be revoked.

I am aware of my responsibilities as prescribed in the Aged Care Act 1997 and the Aged Care Principles, including that the provisional allocation period for making places operational is currently two years after the day on which the allocation is made, unless extended, in accordance with section 15-7 of the Aged Care Act 1997.

I am aware that any provisional allocation of residential aged care places made through this and subsequent ACAR processes will not be extended beyond six years from the date of allocation, without exceptional circumstances.

I have read the 2015 ACAR Essential Guide.

I declare that the information provided in this application and associated attachment(s) is true and complete.

I declare that the key personnel in the applicant organisation are, and will continue to be, suitable to provide aged care and are not disqualified individuals.

I consent to the Secretary of the Department of Social Services providing relevant information in respect of this application to other persons or organisations, in order to obtain their advice as necessary to assist in assessing this application or in assessing other applications submitted in the 2015 ACAR. These organisations may include, but are not limited to, the Australian Aged Care Quality Agency and state, territory or Australian Government Departments and/or other relevant sources, such as independent financial analysts.

I consent to the persons or organisations that are contacted in relation to our organisation’s 2015 ACAR application(s) releasing information to the Department of Social Services.

Full name

Signature

Position held

Date

Company seal and citation