title goes here - dhhs.tas.gov.au web viewthe applicant organisation must be an incorporated...

Community Support LevyCharitable Organisations Grants

Program

2017-2018 Application Form

6 January 2018 – 2 February 2018

1. Applicant OrganisationApplicant OrganisationThe Applicant Organisation is the organisation that is applying for grant funding and will deliver the project or activity.

Name of Legal Entity: Common or Trading Name:

Applicant Organisation AddressAddress/PO Box: City/Suburb/Town: State: Postcode: Organisation Email: Organisation Phone: Organisation Chair: Name and Position

Applicant Organisation Contact OfficerName: Position/Role: Phone: Email: Legal Status of Applicant OrganisationThe Applicant Organisation must be an incorporated not-for-profit organisation whose dominant purpose is charitable. It will be responsible for the project and for appropriate acquittal of the funds. If an Applicant Organisation is not incorporated then it must seek sponsorship from an eligible incorporated charitable organisation.

(Attach Certificate of Incorporation)

(Complete Section 1a Sponsoring Organisation)

Please specify: Applicant Organisation GST Registration Status

Applicant Organisation’s Australian Business NumberLeave blank if the Applicant Organisation does not have an ABN.

ABN: Applicant Organisation Bank DetailsIf the Applicant Organisation is being sponsored by an incorporated charitable organisation, leave blank and complete Section 1a.

Community Support Levy Charitable Organisations Grants Program 2017-2018 Application Form Page 1 of 9

Incorporated Charitable EntityNot incorporated Charitable Entity

Other

Registered for GST Not Registered for GST

Bank: Account Name:

BSB: Account Number:

1a. Sponsoring Organisation (if applicable)Only complete this Section if your organisation is not incorporated and you have agreed to be sponsored by an incorporated charitable organisation.

Sponsoring OrganisationThe Sponsoring Organisation receives the Community Support Levy grant funds and accepts the legal and financial obligations involved in accepting the grant including the transfer of funds to the grantee. The Sponsoring Organisation must provide a Certificate of Incorporation and an Agreement to Sponsor letter.

Name of Legal Entity: Common or Trading Name:

Sponsoring Organisation AddressAddress/PO Box: City/Suburb/Town: State: Postcode: Organisation Email: Organisation Phone: Organisation Chair: Name and Position

Sponsoring Organisation Contact OfficerName: Position/Role: Phone: Email: Legal Status of Sponsoring OrganisationThe Sponsoring Organisation must be an incorporated not-for-profit organisation whose dominant purpose is charitable. It will be responsible for the project and for appropriate acquittal of the funds.

(Attach Certificate of Incorporation)

Please specify: Sponsoring Organisation GST Registration Status

Sponsoring Organisation’s Australian Business NumberLeave blank if the Sponsoring Organisation does not have an ABN


Incorporated Charitable Entity

Other

Registered for GST

Not Registered for GST

ABN: Sponsoring Organisation Bank DetailsBank: Account Name:

BSB: Account Number:

2. Project OverviewAbout The Project

Project Title

Funding RequestUp to $15 000 (ex-GST) per organisation.

Funding Request (ex-

GST)

GST(if

applicable)

Total Funding Request (incl

GST)

$ $ or N/A $ Organisations registered for GST should add this component to the middle column. e.g.$15 000 $1 500 $16 500

Organisations not registered for GST should leave N/A in the middle column. e.g. $15 000 n/a $15 000

Project Summary (max 25 words)Provide a brief useful working definition of your project or activity. It should be concise and descriptive.

Project Start Date and DurationProjects must be completed by 31 December 2019

Start date:

Duration:

Target Group(s)The target group represents the people in the community your project will support. Please see the Funding Focus section of the CSL Charitable Organisations Grants Program 2017-2018 Guidelines for more details.

Where will the project be delivered?The location refers to the site or region where your project or activity will be based. It does not refer to your office location. Tick any Local Government Areas (LGAs) that apply or tick State-wide for projects impacting all LGAs.



Break O-Day Flinders Launceston

Brighton George Town Meander Valley

Burnie Glamorgan-Spring Bay Northern Midlands

Central Coast Glenorchy Sorell

Central Highlands Hobart Southern Midlands

Circular Head Huon Valley Tasman

Clarence Kentish Waratah-Wynyard

Derwent Valley King Island West Coast

Devonport Kingborough West Tamar

Dorset Latrobe State-wide (all)

3. Project Description and ObjectivesYour ProposalDetailed description to support your application (500 words or less)Please link your proposal to the Funding Focus in the CSL Charitable Organisations Grants Program 2017-2018 Guidelines. Please address: Rationale – What is the community need for your project? Why is the project required? Outcomes – What benefit will be delivered for your target group or community? Activities – What will the project do? Scope – How many people from your target group benefit from your project and how will they be

involved? Community Links – How does the project connect with existing community services, networks and

resources? Evaluation – How will you measure whether the project is on time and on budget and if outcomes have

been achieved? Sustainability – How will the outcomes continue to benefit your target group after the project ends?


4. Normal Business How Does Your Project Differ From Normal Business?CSL Grants Funding is not recurrent. CSL Grants will not be provided to fund projects or activities that your organisation delivers as part of its normal business (e.g. programs or activities that are already being delivered, core services, maintenance). Please indicate how your proposed project or activity differs from your normal business.

5. Past Project DeliveryPrevious Delivery of the Project

Has a version of this project been delivered at any time in the past?

When was it delivered and how was it funded?

How is it different to the previous project and why is it being proposed for delivery again?


Yes (provide details below)

No

6. Organisational CapacityYour OrganisationPlease provide evidence to demonstrate that your organisation has the capacity to deliver the project and the project outcomes (e.g. delivery of previous projects/programs, staffing, experience, governance, quality and safety).

7. Other Funding SourcesDetails of other funding sources for the project (including pending grant applications)

Funding Body Funding

Project Title & Purpose Current Status


8. BudgetBudgetPlease provide a detailed and realistic project budget.If you do not have a project budget, the template below may be used as a guide. Add or remove rows as required.

Quotes or other evidence of costs should be provided for any actual project costs. Core business activities will not be funded. Eligible costs are new costs incurred in project delivery. Costs such as corporate costs and

salaries will not be funded unless they are new costs explicitly linked to project delivery.

Salaries and Wages (e.g. FTEs, salary costs, on-costs) Quotes Y/N Cost

Service Delivery (e.g. training, transport, communications, rooms, catering)

Quotes Y/N Cost

Equipment (any equipment critical to the project) Quotes

Y/N Cost Corporate (e.g. payroll, accounts payable, recruitment) Quotes

Y/N Cost Marketing (e.g. fliers, media, ads, invitations) Quotes

Y/N Cost Miscellaneous Quotes

Y/N Cost


TOTAL $


9. Project WorkplanProject WorkplanOverview of the major activities and milestones for your projectPlease provide an estimate of the expected dates for your key project activities.Activity Expected Completion

Date (Month/Year)


10. Application AuthorisationsApplicant Organisation

We acknowledge that submitting an application for funding electronically warrants that we are duly authorised to submit an application on behalf of the organisation that is seeking a grant from the Charitable Organisations Grants Program 2017-2018. Further, we acknowledge that the absence of a handwritten signature in the application for funding does not invalidate the electronic submission. We also undertake to sign and forward a hard copy of this signature page, along with supporting documentation, where the application was lodged electronically.Declaration and signature of two persons duly authorised to sign on behalf of the organisation.We declare that the information we have given on this form is complete and correct and that the group/organisation that we represent supports the project.

Authorised Officer 1 Authorised Officer 2

Signature(SIGN BY HAND)

Print name Position in organisation

Phone

Date

Sponsoring OrganisationDeclaration and signature of person duly authorised to sign on behalf of the Sponsoring Organisation (if applicable). Sponsoring Organisation

Signature(SIGN BY HAND)

Print name Position in organisation

Phone

Date


Sponsoring Organisations must also complete a ‘Letter of Agreement to Sponsor’ (example letter provided in Attachment 2).


ATTACHMENT 1: Application Instructions and Application ChecklistFor applicant use only – do not submit with application

Submitting ApplicationsApplications close 5.00pm Friday 2 February 2018. Late applications will not be accepted. Submit by email to: [email protected]

Please note, email applications are strongly recommended. Please send the application as an attachment. In a covering email, state your organisation and project names, and address as indicated on the first page of the Application Form. Scan and send the signature page and any supporting documents. It is recommended that you activate read receipt notification on your email if available.

If you need to submit a hard copy application, please post to:2017-2018 CSL Grants ProgramGambling Support ProgramDepartment of Health and Human ServicesGPO Box 125 Hobart TAS 7001

It is recommended that your keep a copy of your application for your own records and ensure that you have proof that the application was mailed or emailed before the closing date.For information about this grants round, including funding focus, organisation eligibility, funding preferences and Frequently Asked Questions, please see the Community Support Levy Charitable Organisations Grants Program 2017-2018 Guidelines.

Application Checklist (do not submit)

Document CompletedA completed CSL COGP 2017-2018 Application Form, including:

- A Budget for this project, including quotes for actual project costs

- A Work Plan for this project

- A signed Application Authorisations page

A Certificate of Incorporation (for your organisation or your Sponsoring Organisation)

For applicant use only – do not submit with applicationCommunity Support Levy Charitable Organisations Grants Program 2017-2018 Application FormAttachment 1

Application Form

Budget and Quotes

Work Plan

Signed

Cert. of Incorporation

http://www.dhhs.tas.gov.au/gambling/grants/recipients_of_charitable_organisations_grant_programs

http://www.dhhs.tas.gov.au/gambling/grants/recipients_of_charitable_organisations_grant_programs

mailto:[email protected]

ATTACHMENT 1: Application Instructions and Application ChecklistFor applicant use only – do not submit with application

For organisations applying under a sponsorship agreement:An Agreement to Sponsor letter (example letter provided in Attachment 2)


Sponsor Letter

ATTACHMENT 2: Example of an Agreement to Sponsor LetterFor applicant use only – do not submit with application

For the purpose of the Charitable Organisations Grants Program, an eligible sponsoring organisation is defined as an organisation that is a not-for-profit ‘incorporated entity’ and its dominant purpose is charitable. The Sponsoring Organisation receives the Community Support Levy funds and will accept the legal and financial obligations involved in accepting the grant including the transfer of funds to the grantee. The Sponsoring Organisation must provide a signed letter agreeing to the sponsorship (example below) and sign the Application Form authorisation page.

This letter must be provided on the Sponsoring Organisation’s official letterhead.

Date

Chair, Charitable Organisations Grants Program Advisory Groupc/- Gambling Support ProgramDepartment of Health and Human ServicesGPO Box 125Hobart TAS 7001

Dear Sir/Madam

Our organisation is an incorporated charitable organisation and is prepared to act as the sponsoring body for the [name of applicant organisation] should it be successful in obtaining funding from the 2017-2018 Community Support Levy Charitable Organisations Grants Program, to undertake [name of proposed project].We are aware that the grant will be paid to our organisation and we accept the legal and financial obligations involved in accepting the grant.

Yours sincerely


ATTACHMENT 2: Example of an Agreement to Sponsor LetterFor applicant use only – do not submit with application

[Name][Position in organisation]


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