PLEASE ENSURE THAT YOU HAVE READ THE NEIGHBOURHOOD FUND GUIDANCE NOTES SHADED IN GREY BEFORE COMPLETING THIS APPLICATION FORM

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2 PLEASE ENSURE THAT YOU HAVE READ THE NEIGHBOURHOOD FUND GUIDANCE NOTES SHADED IN GREY BEFORE COMPLETING THIS APPLICATION FORM ALL PROJECTS AWARDED FUNDING MUST BE DELIVERED BY 28 TH FEBRUARY What is the title of your project? Please give a title to the project or activity you are carrying out (This is not the name of your group) 2. Please tick which neighbourhood priority you are applying under Environmental improvements Sustainability Employment & training Bringing the community together Healthy living Young people & children Older people Community safety 3. Applicant details Name of your group / organisation Name of contact person State the name of your group. State the name of the person responsible for this funding application. Address of contact State the address to where all correspondence should be sent. Postcode Telephone Mobile Provide a full postcode. Provide the phone number the applicant can be contacted on. Provide the mobile phone number the applicant can be contacted on. Provide an the applicant can be contacted on. 4. Your organisation How would you describe your organisation (please tick one) Community Group Voluntary Group Social Enterprise Registered Charity Individual Other (give details below) Other: How long has the organisation existed?

3 5. How much money are you bidding for? 6. About your project Please tell us about your project detailing how it will benefit Adactus residents / neighbourhoods, the aims and objectives of the project and intended outcomes. You need to provide as much information as possible in this section. This is where you should describe the purpose of the project/activity you are undertaking, how it will be run and what you hope to achieve from running it. Give details how it will benefit Adactus residents / neighbourhoods. When will your project take place? If possible, we would like to attend some events delivered by groups using the neighbourhood fund.

4 Where will your project take place? Give details of where your project will take place. How many people do you think will benefit from your project? Please ensure that you detail how many people you anticipate will benefit from your project. How can you demonstrate a need / demand for your project? (e.g. consultation with local residents) What was it that made you decide to run this specific project? Give details of any consultation you have undertaken. 7. Project cost How much will your project cost? (please give an itemised breakdown below in order of priority. This may be used to decide in cases where a partial award is granted) Expenditure: Item / activity Cost Amount requested 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) Totals How have you worked out your costs? (include details of suppliers etc.) Please show how you have worked out your costs giving details of any quotes or prices obtained from suppliers.

5 Please give details of where remaining costs will be funded from (if applicable) Give details of where any remaining costs will come from including in kind contributions and match funding. Has this funding been secured? Yes / No (please delete as appropriate) You must include all the additional information required with your application form. Your application will not be considered without them. You can find this information in the guidance notes. All relevant documents must be provided for each application you submit. Information is contained in the guidance notes indicating what documents different kinds of projects will need. Please indicate below which documents apply and what you have provided. Child protection policy Safeguarding policy Public liability insurance Risk assessment(s) DBS (formerly CRB) details 8. Declaration I confirm that I have read and understand the Neighbourhood Fund guidance notes The information provided, is to the best of my knowledge, true and accurate If my application is successful, the grant awarded will only be used for the purposes stated in my application form I agree to keep a record of all financial transactions related to the grant award and will forward receipts/invoices to the association where required I agree to complete the grant evaluation form following the project and understand that failure to do this will affect any future applications. Name Position Signed Date For official use only: (date stamp when received)

6 Please return your form as below: By post: Area: Cheshire, Neston & Manchester Adactus Housing Association Neighbourhood Fund Application Baker House 542 Oldham Road Manchester M40 8B By Area: Chorley, Wigan, Leigh, Sefton & Lancashire Chorley Community Housing Neighbourhood Fund Application Ann James House St Thomas s Road Chorley PR7 1HR grantwest@chorleych.co.uk Other information Please provide us with any other information that may help your application. Use additional sheets if required.