Community War Memorial Program Application Form

Transcription

1 The Community War Memorial Program (CWMP) is a 5-year program that will sunset on March 31, Please Note: Veterans Affairs Canada will require that all inscriptions on new cenotaphs/monuments or major additions constructed with the assistance of Community War Memorial Program funding be in both official languages of Canada. Application Checklist (Please print) Please complete and include this checklist with your application. Your application package must include the following: The original application form completed and signed by an authorized individual from your organization (e.g., Chairperson, Mayor, Executive Director, etc.). Drawings and specifications of the proposed new cenotaph/monument or major addition. A photograph of the proposed site where the new cenotaph/monument will be built or, in the case of a major addition, a photo of the existing site. An original, signed document to identify ownership of the new or expanded cenotaph/monument. An original, signed document to identify roles and responsibilities relating to the ongoing maintenance of the new or expanded cenotaph/monument. Original contractors' quotes/estimates for all project work to be completed. Other - please specify: Instructions Please fill out all relevant sections of the application form, sign and date it. If you do not have enough space to complete a question, please attach a separate sheet to the application form. Ensure the budget section (Part D) of this form is complete and that all expected project costs have been provided. Keep a copy of the application and all relevant documents for your records. It is recommended that you send your completed application at least three months prior to the start date of your project to allow time for processing and notification of funding. Mail your application to: Veterans Affairs Canada Community War Memorial Program PO Box 7700 Charlottetown PE C1A 8M9 Community War Memorial Program Application Form Instructions for completing the Community War Memorial Program Application Form or Courier your application to: Veterans Affairs Canada Community War Memorial Program 191 University Avenue, Room 304 Charlottetown PE C1A 4L2 VETERANS AFFAIRS CANADA WILL NOT PAY FOR ANY EXPENSES THAT WERE INCURRED PRIOR TO THE RECEIPT OF YOUR APPLICATION. If you need assistance with your application, please call Veterans Affairs Canada toll free at (English) or (French). Ce formulaire est disponible en français.

2 Name of organization: Community War Memorial Program Application Part A - Applicant Organization - Contact Information (Please print) Protected when completed. Organization's status: Registered charitable organization no.: Name of contact person: Government Non-profit Business identity or GST no.: Title: Preferred language of communication: English Daytime telephone no.: Alternate telephone no.: French Facsimile no.: Mailing address: City: Province/territory: Postal code: address: Organization's Web site (if applicable): Brief description of organization's mandate/objectives: Does your organization employ, or have as a board member, a current or former public servant/public office holder who has left the federal government in the last 12 months (and who is under the Conflict of Interest and Post-employment Guidelines), involved in this project? Yes No If yes, please explain the role of that person or persons in this project. Ce formulaire est disponible en français. Page 1 of 7

3 If your project is for the construction of a new cenotaph/monument go to Part B. Proposed name for the new cenotaph/monument: Protected when completed. If your project is for a major addition* to an existing cenotaph/monument go to Part C. *For the purposes of this program, a major addition is an addition that has a capital cost greater than $25,000 and that is constructed directly or complementary (e.g., walls and columns) to an existing cenotaph/monument. Part B - Project Information - for the construction of a new cenotaph/monument (Please print) Ownership of the new cenotaph/monument: (Please attach required document to identify ownership, as outlined in the Program Guidelines.) NOTE: The Government of Canada will not, under any circumstance, assume any responsibilities related to the ownership of cenotaphs/monuments or major additions constructed through the Community War Memorial Program. Will the new cenotaph/monument be constructed on Crown land? Yes (This includes land owned by any federal government department, agency or organization.) How is the community supportive of the proposed cenotaph/monument, and will community groups support the ongoing maintenance once the cenotaph/monument has been erected? (Please attach required maintenance document to identify roles and responsibilities relating to the ongoing maintenance of the new cenotaph/monument, as outlined in the Program Guidelines.) No Description and location of proposed site, e.g., in a park, on a street corner, etc.: (Please attach required photographs of the proposed site, as outlined in the Program Guidelines.) Page 2 of 7

4 Description of the project and its objectives: Protected when completed. Part B - Project Information - for the construction of a new cenotaph/monument (Please print) - continued Who will the new cenotaph/monument commemorate? Local citizens who served and/or who lost their lives in: (check all that apply) First World War Second World War Korean War Other (e.g., Peacekeepers, Afghanistan mission, etc.) Will individual names be inscribed on the monument? If yes, approximately how many? Yes No Describe the importance of the cenotaph/monument to the community: Overall dimensions for the new cenotaph/monument: (Please attach required original drawings and specifications, as outlined in the Program Guidelines.) Anticipated time frame for the delivery of the project: *Please note that ANY project work completed PRIOR to the submission of an application is not eligible for funding. Estimated project start date: Estimated project completion date: yyyy-mm-dd yyyy-mm-dd Page 3 of 7

5 Protectedwhencompleted. Part C - Project Information - for the construction of a MAJOR ADDITION to an existing cenotaph/mounument (Please print) Name of existing cenotaph/monument to which the major addition will be added: Ownership of the existing cenotaph/monument and major addition: (Please attach required document to identify ownership, as outlined in the Program Guidelines.) NOTE: The Government of Canada will not, under any circumstance, assume any responsibilities related to the ownership of cenotaphs/monuments or major additions constructed through the Community War Memorial Program. Will the new cenotaph/monument be constructed on Crown land? Yes No (This includes land owned by any federal government department, agency or organization.) How is the community supportive of the proposed major additon, and will community groups support the ongoing maintenance once the major addition has been erected? (Please attach required maintenance document to identify roles and responsibilities relating to the ongoing maintenance of the new cenotaph/monument's major addition, as outlined in the Program Guidelines.) Description and location of present site, e.g., in a park, on a street corner, etc. (Please attach required photographs of the existing cenotaph/monument and site, as outlined in the Program Guidelines): Page 4 of 7

6 Protected when completed. Part C - Project Information - for the construction of a MAJOR ADDITION to an existing cenotaph/mounument (Please print) (continued) Description of the project and its objectives: Who will the new major addition commemorate? Local citizens who served and/or who lost their lives in: (Check all that apply) First World War Second World War Korean War Other (e.g., Peacekeepers, Afghanistan mission, etc.): Will individual names be inscribed on the major addition? If yes, approximately how many? Describe the importance of the major addition to the community: Yes No Overall dimensions of the proposed major addition: (Please attach required original drawings and specifications of the proposed major addition.) Anticipated time frame for the delivery of the project: *Please note that ANY project work completed PRIOR to the submission of an application is not eligible for funding. Estimated project start date: Estimated project completion date: yyyy-mm-dd yyyy-mm-dd Page 5 of 7

7 Protected when completed. Part D - Project Budget - to be completed for ALL projects I PLANNED PROJECT COST What is the total cost of your project? Itemize and list costs; include contractors' quotes. Include all anticipated expenditures related to the project. What are the capital costs? Only capital costs, such as building materials, equipment rentals, landscaping required for accessibility, labour costs related to new construction, labour costs related to landscaping for accessibility, are reimbursable. (If more space is required, submit the information on a separate document). What are the in-kind costs? In-kind costs may be submitted for any goods and/or services donated to the project. At the time of application, applicants must provide signed estimates, provided and signed by the donor, that indicate the value of the good or service (at fair market value). Once the project is completed, invoices signed by the donor will be required prior to any reimbursement being made. II ANTICIPATED REVENUE Indicate in the table below all planned source(s) of revenue for this project. Please note: Organizations may request up to 50% of the total project cost, up to a maximum contribution of $50,000 per project, from Veterans Affairs Canada. Stacking of Contributions: Total government assistance (federal, provincial, or municipal) may total 100% of total project costs for CWMP projects; however, only one federal department may contribute funding. Salaries/wages Consultant/assessment fees Architectural/design fees Administrative costs (e.g., printing, photocopying, etc.) Other (please specify) Total (i) PROJECT COSTS Cash $ In-Kind $ ANTICIPATED REVENUE Cash $ In-Kind $ Provincial government Territorial government Municipal government Private sector Donations Fund-raising Applicant's own funding Other (please specify) PROJECT CAPITAL COSTS Equipment rentals Building materials Landscaping for accessibility Labour related to new construction Labour related to landscaping for accessibility Total (ii) (I) Total Project Cost (i + ii) (II) Total Anticipated Revenue (III) Funding Requested from VAC Page 6 of 7

8 Protected when completed. The information provided on this application form is collected for the purpose of administering the Community War Memorial Program. Provision of the information is on a voluntary basis. Information on this form that is deemed personal is protected from unauthorized disclosure by the Privacy Act. The Privacy Act provides you with a right to access your own personal information which is under the control of the Department. The Privacy Act also affords you the right to challenge the accuracy and completeness of your personal information and have it amended as appropriate. For further information on the above, you can contact the Access to Information and Privacy Coordinator's Office, Veterans Affairs Canada, PO Box 7700, Charlottetown, PE, C1A 8M9. Please quote record number VAC MVA 735 of the Government of Canada's Info Source publication. I AFFIRM THAT the information in this application is accurate and complete and that the project proposal, including plans and budgets, is fairly presented. I agree that once funding is provided, any change to the project proposal will require prior approval of the Department. I agree to publicly acknowledge funding and assistance by the Department, in accordance with the terms of the funding agreement. I also agree to submit a final report, and where required, financial accounting for evaluation of the activity funded by the Department. I understand that the information provided in this application that is not deemed personal may be accessible under the Access to Information Act. Applicant Authority Name of person authorized by by-laws or constitution of the organization to sign financial agreements: (Please print) Title: (please print) Signature: Date: (yyyy-mm-dd) Page 7 of 7