Premier s Community Initiatives Fund Round 11. Application Form

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1 Premier s Community Initiatives Fund Round 11 Application Form Grant Programs Unit Telephone: (08) Website:

2 Before proceeding with your application please complete this checklist to ensure eligibility for the Premier s Community Initiatives Fund. 1. About your organisation: Yes No Is it incorporated under the Associations Incorporation Act 1985? IF YES, please provide a copy of the certificate Is it a Council subsidiary formed under Sections 42 or 43 of the Local Government Act 1999? IF YES, attach a copy of the Committee Constitution/Terms of Reference Is it incorporated under the Aboriginal Councils and Associations Act 1976? IF YES, please attach a copy of the Certificate Is it a company limited by guarantee formed under Corporations Law, or some other comparable legal status, such as incorporation by Act of Parliament? IF YES, please attach a copy of the Company Constitution Is it being auspiced by one of the above? If you have answered NO to all of the above questions in section 1, you are not eligible for funding from the Premier s Community Initiatives Fund and should not proceed with the application. 2. About your organisation: Yes No Is it a Government or semi-government organisation such as hospitals, libraries and private educational institutions (primary, secondary and independent schools, tertiary institutions)? Does it hold or is it affiliated with an organisation that holds a gaming machines licence Does it have unacquitted grants outstanding with the Grant Programs Unit? (If yes this must be acquitted before lodging this application form.) Does the project for which you seek funding commence prior to March 2013? Have you received a PCIF grant in either of the past two rounds? Please see the table below for further clarification If you have answered YES to any of the above questions in section 2, you are not eligible for funding from the Premier s Community Initiatives Fund and should not proceed with the application. Last Round Successful in Opening/Closing Dates Date of Grant Agreement Next Round Eligible to Apply Round 10 August/October 2011 March 2012 Round 13 Round 9 October/December 2010 April 2011 Round 12 2

3 Premier s Community Initiatives Fund APPLICATION FORM Round 11 Closes: Friday 19 October 2012 One-off project grants up to $10,000 Please read the application guidelines and frequently asked questions before completing this form, and complete the checklist to ensure you are eligible for the fund. 1. APPLICANT DETAILS 1.1 Applicant/Auspicing Organisation: Please note that all correspondence from the Department of the Premier and Cabinet will be sent to this organisation, addressed to the person listed in 1.3 Name of Applicant Organisation (as registered on the Certificate of Incorporation): Location address: Postal address (if different from above): ABN GST registered? (please circle) YES / NO 1.2 Organisation Contact Person: eg CEO or Director, who has authority to act on behalf of, and can answer questions about the organisation. Mr / Mrs / Ms: First name: Position: Surname: Phone: Mobile: 1.3 Project Contact Person: Mr / Mrs / Ms: First name: Position: Surname: Phone: Mobile: Please note if you are applying for funds on behalf of an unincorporated organisation, YOUR organisation will be responsible for the funds and reporting to the Department of the Premier and Cabinet, as per the Grant Agreement. 1.4 Auspiced Organisation: Use only if not incorporated and different from the Applicant Organisation Name of Unincorporated Organisation: Location address: Postal address: ABN GST registered? (please circle) YES / NO 2. ORGANISATION DETAILS 2.1 What are the aims of your organisation? What were you set up to do? Please also attach a copy of your constitution 3

4 2.2 What are your organisation s current activities? List any activities/services provided in the last 12 months 2.3 How many full-time equivalent staff members does your organisation have? Number of Paid Staff: Number of Volunteer Staff: 2.4 If your organisation is currently receiving funding from other State, Federal or Local Government sources, please provide details and amounts. Funding Body Year Project Amount 2.5 If your organisation has applied for, but not yet received, funding from any State, Federal or Local Government body please provide details and amounts. Funding Body Year Project Amount 3. PROJECT DETAILS 3.1 Project Name 3.2 Project Description and Outcomes Describe the type of project, what activities will be involved, how it will be implemented, what will be the benefits / outcomes of this project 3.3 Similar Projects List any similar projects/services operating in your area, run by other organisations, and how your project differs. 4

5 3.4 When will your project be implemented? Include approximate start and finish dates. Please note: successful projects will be funded in approximately March 2013 and project funds must be spent within 12 months from receipt of the funding. Start date: End date: 3.5 Where will your project be implemented? Building Name and Location Address 3.6 Who owns this building (referred to in 3.5)? If your organisation is leasing the building, state the owner s name and the date that the lease will expire. 4. TARGET GROUP DETAILS 4.1 Which target groups (members) of the South Australian community will benefit from your project? Refer to the Frequently Asked Questions in the Application Guidelines for an explanation of target groups. Tick all that apply Aboriginal and Torres Strait Islanders Ageing populations Homeless Mental Health New and emerging populations (eg Culturally and Linguistically Diverse) People with disabilities Other (please specify) Populations suffering significant economic or social disadvantage Regional populations Social Justice Substance Abuse Unemployed Young Offenders 4.2 Which strategic priorities does your project address? Refer to the Frequently Asked Questions in the Application Guidelines for an explanation of the strategic priorities. Tick all that apply Every chance for every child An affordable place to live Safe community, healthy neighbourhoods 4.3 How is the target group disadvantaged and how does your project address the needs of the target group, specifically relating to the strategic priorities above? Provide detailed information such as: why the target group needs your project, the gaps in service for the target group, the level of social disadvantage of the target group or any other emerging issues. 5

6 4.4 Indicate the number of people who will benefit from this project: Within the organisation Within the community 5. PROJECT COSTS. The following information is about the costs related to the project, including existing and proposed funding 5.1 Project Expenditure: i) List each item requiring funding from Premier s Community Initiatives Fund in order of priority and include quotes for items of $500 or greater total must not exceed $10k (excluding GST) Priority Item/Activity Amount (inc GST) 1 $ $ 2 $ $ 3 $ $ 4 $ $ 5 $ $ 6 $ $ 7 $ $ 8 $ $ 9 $ $ 10 $ $ 11 $ $ 12 $ $ 13 $ $ 14 $ $ 15 $ $ 16 $ $ 17 $ $ 18 $ $ 19 $ $ 20 $ $ 21 $ $ 22 $ $ 23 $ $ 24 $ $ 25 $ $ (A)Total cost of items $ $ Amount (exc GST) 6

7 5.2 Other costs associated with the project (including provision of equipment, hire of facilities. If in-kind please stipulate.) (B)Total $ 5.3 Total costs associated with the project (A + B) TOTAL $ 5.4 Project Income: Contributions from your organisation $ Contributions from other sources (please list, including any other sources of funding) $ $ $ $ TOTAL $ 5.5 How much are you seeking from the Premier s Community Initiatives Fund? $ (GST exclusive) 5.6 If this project has received or is receiving funding from other State, Federal or Local Government sources please provide details and amounts. Funding Body Year Project Amount 5.8 If your organisation has applied for, but not yet received, funding for this project from any State, Federal or Local Government body please provide details and amounts. Funding Body Year Project Amount 7

8 6. DOCUMENTATION CHECKLIST. Before submitting your application please check that you have: Had the application signed by the Chairperson (or equivalent) AND the Treasurer (or equivalent) at Section 7 Answered all the questions in the Application Form and included; A letter from your Financial Institution, as proof of security for the grant. (This must be addressed to the Department of the Premier and Cabinet advising that your organisation holds an account in its own name and that TWO (2) or more signatories are required to sign co-jointly to operate the account. Please note an account statement is not sufficient). Your organisation s most recent audited/certified financial statement covering the 2011/2012 financial year. A copy of your: Certificate of Incorporation. (If you are registered under the Associations Incorporation Act 1985 or the Aboriginal Councils and Associations Act 1976) A copy of your: Committee Constitution/Terms of Reference (if you are a Council Subsidiary); or Company Constitution (if you are a Company Limited by Guarantee) See Question 2.1 for further information. Copies of quotes for all items over $500 listed in the itemised budget at Question 5.1 PLEASE NOTE: If you have not ticked all 7 boxes above, you have not completed and attached the required information. Without the required information your application will be deemed as incomplete and therefore ineligible for funding. I confirm that I have read the guidelines and checklists and completed this application in accordance with them. (To be completed by the applicant) Signature Name Position Date / /2012 8

9 7. DECLARATION 7.1 Declaration by applicant organisation Please have two authorised signatories from your organisation complete the information below i.e., President/Chairperson of Management Committee and Treasurer/Secretary. We declare that: the Application Form has been accurately completed in accordance with the Application Guidelines for the Premier s Community Initiatives Fund and all essential documentation is attached; we have been duly authorised by the applicant organisation to prepare and submit this application for funding to be used as outlined in the application; we agree that the Department of the Premier and Cabinet may disclose information contained in this application to other government agencies, local government, reviewers and staff assisting with the administration or promotion of State Government Grants Schemes; we understand that information we supply as part of this application becomes public if approved and the Department of the Premier and Cabinet may use information about the Program on their website or as an example to other applicants; the applicant organisation does not hold, nor is affiliated with an organisation that holds, a Gaming Machine Licence issued under the Gaming Machines Act 1992; we will keep a copy of this application for our own records; we are aware that if successful, we must enter into an Agreement with the Government of South Australia in order to receive funding, and we are required to fulfil obligations associated with that Agreement; the information supplied is true and accurate to the best of our knowledge; and also acknowledge that this one-off project does not involve ongoing Government funding. We accept that this application will be deemed ineligible if any information is missing or questions are not answered. We understand that the application cannot be accepted if either of the required original signatures below are missing. 1) Name Signature Position President or Chairperson 2) Name Position Treasurer or Secretary Date Signature Date 9

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