Community Grant Application Form Requests for one-off contributions between $1,000 and $10,000. Please ensure that you have read the KCGM Community Investment Guidelines and are formally recognised and/or registered with the appropriate government bodies before applying for a Community Grant. This form must be lodged electronically to [email protected]. Applications will not be accepted in hardcopy. If you need assistance completing this application, please contact the KCGM Community Relations Assistant on 9093 3488.

Contact Details Name Position Organisation Telephone Mobile Email Affiliations

Please list any other organisations, boards or committees you are affiliated with and your involvement with them:

Declaration I, the undersigned, certify that I have authority on behalf of the organisation, group or club to submit this application and that the information contained herein or in the attachments is, to the best of my knowledge, true and correct. I acknowledge that by applying for and accepting KCGM support I agree to abide by the Recipient Responsibilities outlined in the KCGM Community Investment Programme Guidelines. I agree that on approval of my application, the information provided in my application and all communication regarding my application will form the terms and conditions of support and will stand as a formal agreement between KCGM and the Recipient organisation. I also confirm that at the time of signing, to the best of my knowledge I am unaware of any conflict of interest that would prevent my organisation from proceeding with the project or any funding agreement my organisation or I may enter into with KCGM. I undertake that if at any time I have an actual, apparent or potential conflict of interest, then I will a) disclose that interest promptly to KCGM, and b) take action necessary to avoid the conflict as directed by KCGM. Applicant name:

Witness name:

Signature:

Signature:

Date:

Date:

Applicant Details Legal name of proposing organisation Registered business or trading name if other than legal name Registered business address Street address Suburb / Town / City State Postcode Postal address - If different from registered business address Street address Suburb / Town / City State Postcode Organisation contact numbers Telephone Mobile Email Is the organisation registered with an Australian Company Number (ACN), Australian Business Number (ABN), or Australian Registered Business Number (ARBN)?  YES ACN ______-______-______

ABN _____-______-______-_____

ARBN ______-______-______

 NO (Organisation must complete and provide a Statement by Supplier, available on the ATO website at www.ato.gov.au, with this application.) Is the organisation registered for GST?  YES  NO Please select method of payment:  Directly to applicant organisation by transfer to a bank account  Directly to applicant organisation by cheque rd

 To a 3 party supplier by transfer to a bank account rd

 To a 3 party supplier by cheque

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Project Details Project name

Date/s or term of project

What are the main aims of the project?

What major activities will be undertaken?

Which areas of the community does the project target?

Please indicate the category under which support is sought:  Health  Education and Training  Community Life  Arts and Culture  Environment

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How does the project meet the criteria outlined for this category?

How was the need for this project identified?

Who is involved in the project? Please include all project partners and their involvement.

What other sponsorships and funding sources have been applied for? Please specify applied for and confirmed amounts.

How will the project be managed and resourced? a) Number of staff b) Organisational structure

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How will the success of this project be measured?

How will this project be promoted to the community?

How will KCGM support be acknowledged?  Media releases and outlets  KCGM logo placement on printed materials  KCGM logo placement on signage  Verbal acknowledgment of KCGM support  Written acknowledgement (publications and letters)  Other (please specify)

Submitting an application It is essential that all sections of this application are completed, including the attached budget outline. Please submit the completed application form with any relevant supporting documentation to: [email protected]. Note: Organisations must complete a Project Evaluation within 60 days of the completion of the project. Failure to do so will result in withdrawal of KCGM support and a request for return of funds.

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Project Budget Please specify the type of support and specific amount or items requested from KCGM  Cash:  In kind: What will KCGM's support be predominately used for? Please note, budget outline must be completed. GST Inclusive

PROJECT INCOME

Non-GST

KCGM Community Grant Applicant contribution Cash In-kind (please specify) Other grants or sponsorships (please specify)

Donations

Fees / Ticket sales Other income – specify TOTAL INCOME TOTAL PROJECT EXPENDITURE Accommodation and meals Advertising and publicity Administration (telephone, postage, stationery) Artist / Presenters Fees Hire fees

Venue Equipment

Purchases

Equipment Materials

Insurance Travel, freight & transport Wages Other (please specify) TOTAL EXPENDITURE TOTAL BUDGET SURPLUS/DEFICIT

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