Organisation overview Name of organisation Website Email Postal address Street address Suburb Postcode Contact person for application: (Please nominate a single point of contact for your application) Title First name Last name Position Mobile Email Phone Is your organisation incorporated? (choose one only) Yes No Name of sponsor organisation (if applicable): Does your organisation have an ABN? (choose one only) Yes No ABN number (if applicable) Is your organisation registered for GST? (choose one only) Yes No Does your organisation operate on a not for profit basis? (choose one only) Yes No Page 1 of 10
What is the purpose of your organisation? (in 100 words or 500 characters) List the main sources of funding for your organisation (in 25 words or 125 characters) Project details Title of project Project start date Project end date Grant amount requested: (Only grants of up to 10,000 are available) Total project cost: (The West Kimberley Community Grants Scheme will only support up to 50 per cent of the total project cost). Describe the activity or program you are requesting funding for and explain how it will work (in 300 words or 2,000 characters) Page 2 of 10
How have you identified the community need for this project? (in 200 words or 1,300 characters) What is the main aim or purpose of your project? (in 200 words or 1,300 characters) Key milestones Outline key activities and milestones for your project Activity / milestone / step Completion date Page 3 of 10
Community Participation How will the West Kimberley Community Grants Scheme contribution be acknowledged? (in 25 words or 125 characters) Examples include people attending an event, participating in an activity or accessing information such as on a website or publication. How many people will participate in or benefit from the project, and how? (in 25 words or 125 characters) This could include people attending an event, participating in an activity or accessing information such as on a website or publication. Please select which, if any, of the following sectors of the community your organisation and the project people engage with: (select all that apply) People with disabilities Culturally and linguistically diverse communities People of diverse social and economic backgrounds Aboriginal and Torres Strait Islander communities Outline how your organisation and project engages with the sectors of the community selected, if any (in 150 words or 1,000 characters) Page 4 of 10
Budget Outline your project budget. Examples of budget items include costs for venue and equipment hire, printing, collateral and phone and internet charges. Core organisational operating expenses including permanent staff costs are not eligible for funding. The West Kimberley Community Grants Scheme will only support up to 50 per cent of the total project cost. Please attach a separate budget page if you need more space. Project income Use this section to list your funding sources and indicate if this funding is confirmed or pending. Funding source Amount () Confirmed or Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Confirm Pending Total project income Page 5 of 10
Project expenditure Use this section to provide a breakdown of your project expenditure and the source of funding for each item. Please ensure you indicate how you intend to use West Kimberley Community Grants Scheme funding. Project item Amount Funding source Total project expenditure Page 6 of 10
In-kind contribution Use this section to indicate in-kind contributions. Volunteer time can be calculated using 25 per hour as a standard rate for admin/project support tasks. Organisation Description of contribution In-kind () Total in-kind contribution Quotes If you are applying for capital works or maintenance on a community facility, you must submit at least one quote. To give your application the best chance at being successful, it is recommended that you include quotes for significant single expenditure items over 1000. Page 7 of 10
Outcomes Please select which of the community outcomes your project supports. Projects must support at least one of the community funding outcomes listed below. Environmental sustainability: Relates to people having an appreciation of the preciousness of water and value of nature. Health and wellbeing: Relates to people s physical and mental health and wellbeing. Relates to increasing opportunities for physical activity. Community connection and participation: Relates to people s connections to their community. Community often relates to geographic locations but can also relate to family networks, support networks, people with common or shared beliefs, values, friendships, interests and activities. Relates to increasing opportunities for physical activity. Education: Relates to people having the opportunity for lifelong learning and gaining the knowledge and skills required to participate in education, employment and their community. Social inclusion: Relates to people feeling they belong and having the opportunity to freely express and celebrate who they are, regardless of culture or identity. Relates to people having an understanding of other people, their culture and identity. Please indicate how the selected outcomes relate to your project in the space provided (in 150 words or 1,000 characters) Page 8 of 10
Evaluation What measures or data will you provide after the project has been completed to demonstrate that the project has been successful and has achieved the outcomes previously indicated? This could include attendance, media exposure and behaviour change (in 150 words or 1,000 characters) Checklist Sighted and approved by an authorised person within your organisation; Included a copy of Certificate of Incorporation (if sponsored by another organisation, please include a letter of confirmation to administer the funding and a copy of their Certificate of Incorporation); Included a financial statement for the most recently completed financial year (an audited financial statement may be requested; Retained a copy of this application for your records; Provided quotes for any purchases over 1,000; Letters of support, particularly from significant partners outlining, how they will support your project. Privacy Statement The information requested on this form is being collected by Water Corporation and Lions Club Broome for the purpose of assisting with the assessment of applications for Community grants. The personal information provided will be disclosed to assessment panel members for the purpose of assessing your application. It will not be disclosed to any other external party without your consent, unless required or authorised by law. By submitting an application you consent to Water Corporation and Lions Club Broome publishing the successful applicant s name, project name and description and amount funded on our website. This information may also be used for promoting the West Kimberley Community Scheme more generally. Page 9 of 10
Acquittal form Declaration I hereby apply for funding for a Community Grant and acknowledge that if successful in this application we agree to comply with the Terms and Conditions and to submit necessary acquittal documentation when the project has been completed. I also acknowledge that all details supplied in this application form and in the attached documents are true and correct and that the application has been submitted with the full knowledge and support of the management of the applicant organisation and / or auspice organisation. Name of authorised person Signature Position Date Insert digital signature, or print and sign Submitting your application form To Lodge your application, click the Lodge Application button below, this will open a new email addressed to wkgrants@watercorporation.com.au and automatically attach this form to it. Then attach the additional items required to your email before sending. If printing this form please mail to: PO Box 132, Broome WA 6725 More information For more information about the West Kimberley Community Grants Scheme please review the West Kimberley Community Grants Scheme Guidelines or contact Water Corporation on (08) 9186 8266 or via email: wkgrants@watercorporation.com.au. Page 10 of 10