Masterton District Council Community Development Grant 2016/2017 Application Form BACKGROUND One of the roles of the council is to work with local organisations to provide local public services that meet the current and future needs of communities in a cost-effective way. The Community Development Grants are available to non-profit organisations that provide a public service to the Masterton community and contribute to an Active, Involved and Caring Community. Your organisation should be able to contribute a significant portion of the cost of the project, and be able to account for its funds. All grants are expected to be used within the year and organisations must complete an Organisation Receipt Form and return this by the 30th June 2017. Groups that received a grant last year must have completed this form before a new application will be considered. For more information about these grants please refer to the attached document. If you have any questions about this application please contact Andrea Jackson, Manager Community Facilities & Activities, by telephoning 06 370 6300 or emailing [email protected] APPLICATION CLOSING DATE Applications close at 4.30pm on Friday, 29th July 2016. 2016.

If you have any questions about the Community Development Grant, contact Andrea Jackson, Manager Community Facilities & Activities: Phone: (06) 370 6300 Email: [email protected]

Completed applications can be posted to: The Manager Community Facilities & Activities Masterton District Council P O Box 444 MASTERTON 5840 Or email to [email protected]

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COMMUNITY DEVELOPMENT GRANT – APPLICATION FORM (This page must be completed in full. Please do not bind your application)

A. GENERAL DETAILS Name of Organisation: Postal Address: Telephone: (business hours)

B. CONTACT DETAILS Name of person whom we can contact if further information is required and to acknowledge this application. Name: Phone: (day)

(evening)

Position in organisation: Email:

C. ORGANISATION DETAILS 1. Is your organisation a legally-constituted society or trust? Yes / No Is your organisation registered for GST? Yes / No GST Number _______________ / _______________ / ___________________

Bank Account Name and Number: This is where funds will be direct credited if your application is successful. Please include a bank deposit slip if you have not received a grant from council in previous years or if your bank account has changed.

Bank Account Name

Bank Account Number

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2.

3.

Numbers involved in the organisation Staff:

Volunteer

Paid

Members:

Individuals

and/or Families

Number of people who receive your services each year: Individuals

and/or Families

4.

What is the purpose of your organisation? (Include the public service that your organisation provides.)

5.

How will your project contribute to the Community Outcomes, especially an Active, Involved and Caring Community? A summary of the outcomes is provided with the application form and a full copy can be obtained from the 2015-2025 Long-Term Plan available on the Council’s website or by request.

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D. PROJECT INFORMATION 1. Project Description Please provide a description of your project. You should include what you are going to do; why it is important; who the project will benefit (including number); when it will happen; whether you are working with other organisations.

(Please attach additional pages if necessary) Total cost cost of project:

$

How much are you applying for: $

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2. Financial Details (a)

What will the grant be spent on and what is the organisation’s contribution? e.g. capital improvements, furniture, equipment, training and skill development, travel, wages (give role, such as social worker, secretary, coach etc), other.

PROJECT COSTS (List all the costs associated with this project)

Total cost of project is:

(b)

Amount

$

INCOME (How group wil willl contribute)

Amount

Organisation contribution:

$

What funding have you applied for and/or received for this project in your current financial year from other organisations/councils Funding Organisation Amount Amount Result date Requested Received /

/

/

/

/

/

/

/

/

/

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(c)

What funding has has your organisation previously received from Community Development Grants over the past three years? Year Received

(d)

Amount Received

What assets does your organisation hold in total as at 30 June 2016? (include all bank accounts and investments) $___________________

E. FINANCIAL INFORMATION Please attach your latest annual accounts and latest monthly financial statement

F. DECLARATION AND CONSENT UNDER UNDER PRIVACY ACT 1993 This must be signed by two people, one of whom is listed as the contact on the first page of this application form. 1.

We hereby declare that the information supplied here on behalf of our organisation is correct.

2.

We consent to the Masterton District Council collecting the personal contact details provided above, retaining and using these details for the purpose of administering its grants. We undertake that we have obtained the consent of the other contact person to provide these details. We acknowledge our right to have access to this information. This consent is given in accordance with the Privacy Act 1993.

Organisation Contact Name: Name: (from page 2 of the Application Form) Signature: Date:

Name: Signature: Date Telephone: Position in Organisation: Email:

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