Grant Application Form Guidance for completing your application form: All sections are mandatory and must be completed in full Please ensure that you have read the full grant criteria to ensure that your group is eligible to apply to the fund. Applicants must provide detail of their Midcounties Co-operative membership card (please see section 5.1 for additional information). Funding is currently ring fenced to specific key locales of The Midcounties Co-operative trading area which are detailed below; please be aware that groups based outside of these areas will not currently be eligible to apply. The base of your group should be no more than five miles away from the nearest Midcounties trading site. Staffordshire Shropshire West Midlands (Walsall, Wolverhampton, Sandwell and Dudley) Worcestershire Gloucestershire Oxfordshire Buckinghamshire Northamptonshire Swindon We also provide funding for specific post codes in the following areas: Warwick CV5, CV8, CV10, CV36 Birmingham B43, B62, B72, B90, B94, B97 Groups applying to the fund must have been established for at least a period of one year at the time of application, be fully constituted and be able to supply full financial accounts to support the request if asked to do so. The group must also have their own bank account which has been held for a period of at least one year. Once your application is complete please return by either email or post (detail of the address can be found at the end of this form) Please ensure that if you are returning your form by post that the correct postage is applied as Midcounties cannot be responsible for applications not received due to insufficient postage. Should you require any additional guidance please contact the community team on 01902 492235 Good luck with your submission! Page 1
Section 1.0 All about you and your group 1.1 Name of your organisation: 1.2 Address of your Organisation: Address Ln1 Address Ln2 Address Ln3 Address Ln4 Town/City Post Code County Telephone Email Website Title Main Contact Person (these are the details that will used for correspondence purposes) Forename Surname Role Daytime Tel: Evening Tel: Mobile No: Fax No: Email: Alternative Address (if different from Organisation address above). TO ENSURE THAT YOU RECEIVE ANY CORRESPONDENCE QUICKLY IT IS PREFERABLE THAT YOU SUPPLY A HOME ADDRESS (UNLESS THE ADDRESS OF YOUR GROUP IS MANNED DAILY TO RECEIVE POST) Address Ln1 Address Ln2 Address Ln3 Address Ln4 Town/City Post Code County Page 2 of 13
1.3 Organisation Start Date: Month (e.g. 01) Year (e.g. 2000) 1.4 What type of organisation are you? (select as many as appropriate) A registered charity? (If yes please supply number): Company Limited by Guarantee? (If yes please supply number): Unincorporated club or association? Community Interest Company? Other? (If yes please supply): 1.5 Are you part of a larger regional/ national organisation? If yes then please state the name of this organisation Yes No 1.6 Staffing and volunteers: How many of each of the following are involved in the organisation? (insert numbers) Paid Full Time Staff / Workers Management Committee Paid Part Time Staff / Workers Volunteers (excl. Management Committee) 1.7 Describe briefly the aims and main activities of your organisation: Page 3 of 13
1.8 How many service users (the people you support) attend the group each week? (1 number only please) 1.9 How is your group funded? (Please tick all that apply) Member Subs How much and frequency? per session/week/month/annum Grants Donations Other Please give brief detail below of what this stream of funding is: Previous Midcounties Co-operative Funding Has your group been in receipt of a grant from any of the funds listed below (in the last 12 months). Please note that the total funding available from successful applications to any of The Midcounties Co-operative s funding programmes is limited to a collective maximum total of 2,000 per group. Please tick all that apply: The Midcounties Co-operative Carrier Bag Fund Please state the amount awarded and the date received The Midcounties Community Donation Support Fund (awards of up to 250) Please state the amount awarded and the date received Section 2.0 - About your grant application 2.1 Average yearly income for your group (over the past three years): per annum *Please ensure that as part of your supporting information you provide a copy of your latest bank statement for all accounts held (from within the last three months) Page 4 of 13
2.2 Does you group have any restricted funds, if yes please state the amount : 2.3 Please tell us what the restricted funds are to be used for and the dates by which this money needs to be utilised: 2.4 The funding you are applying for, Is this for: A new project To continue existing work 2.5 Does your project have Start or Finish dates, if not what period will the grant cover? Project / Funding start date Day Month Year Project / Funding finish date Day Month Year 2.6 Which town will the activity take place in? Page 5 of 13
2.7 What would you like to do with your grant? To help our judging panel in their decision making Please describe your project or activity and what difference this will make to your work Section 3.0 - Who will benefit 3.1 Approximately how many beneficiaries will there be for this particular project? (1 number only please) 3.2 Primary Beneficiaries Who will the primary beneficiaries for this project be? (Enter into the box below a single option from the list overleaf) Page 6 of 13
Please tick any other beneficiary groups who will benefit from your grant: Children & Young People Adults Older People NEET* Long term unemployed People with general health issues People with learning difficulties People with physical disabilities People with mental health difficulties People with weight/obesity issues Families Carers Local residents People in Rural Areas People in Urban Areas Disadvantaged / Low Alcohol / Drug income Addiction Lone parents BME groups ** Migrant workers Men Homeless people Refugees / Asylum Seekers Other: (please specify) Ex Offenders and Women Prisoners Lesbian, Gay, Bi-sexual & Transgender groups * Not in Education, Employment or training ** Black and Minority Ethnic 3.3 Primary Ethnic Group Please indicate the primary ethnic group who will mainly benefit from your grant: (Enter into the box below a single option from the list overleaf) Please tick any other ethnic groups who will benefit from your grant: White British Irish Eastern European Gypsies & Travellers Other White Mixed Asian and Asian Black or Black Chinese or British British other group Black Caribbean and White Indian Caribbean Chinese Black African and White Pakistani African Any Other Asian and White Bangladeshi Other Black Other Dual Ethnicity Other Asian Page 7 of 13
3.4 Primary issues Choose from the list below the primary theme to be addressed by this grant application: Please tick any other applicable themes for your grant: Arts and Culture Health and Wellbeing Social Inclusion Community Support and Development Housing Counselling / Advice / Mentoring IT / Technology Crime Poverty and Disadvantage Disability and Access Racial and Cultural issues Integration Education and Training Religion Employment and Labour Rural Issues Environment / Recycling/Renewable energies Social Services and Activities Sport and Recreation Supporting family life Transport Issues Volunteering Social Enterprises Others (please specify): 3.5 Primary Age Group Choose from the list below the primary age group that will benefit from your grant: Please tick any other applicable age groups for your grant: Early years (0 to 4) Young People (13-18) Adults (26-65) Children (5-12) Young Adults (19-25) Seniors (65+) Section 4 - Project Budget Please note that the upper limit for funding is 2,000; if your project requires funding in excess of this limit then your group must have raised 75% of the overall costs prior to application 4.1 What is the total cost of this project (include all costs relating to the overall project) 4.2 How much money are you applying to us for? (Note 2,000 is the upper limit for funding) 4.3 How much money has already been raised towards this project? Page 8 of 13
4.4 If this funding is towards event costs what is the date of the event? Month (e.g. 01) Year (e.g. 2000) Where will the event take place? 4.5 Budget breakdown summary (incl VAT) Please only supply a breakdown of costs for the items you wish to be funded by a grant of up to 2,000 (continue on a separate sheet if required) Description of item Total cost Section 5.0 Other Information 5.1 Membership: To apply for funding the *applicant (individual submitting the form) must be a member of The Midcounties Co-operative and membership should have been in place for at least three months prior to application. *The applicant must have proven personal involvement with the group applying for funding i.e. be a Member of the Group/Group s Management Committee, is a service user, paid member of staff or a volunteer. Please be aware that only membership of The Midcounties Co-operative qualifies you to make an application to our fund, other Societies such as Co-operative Group, Midlands Co-operative, Heart of England Co-operative etc are not part of The Midcounties Co-operative business but operate their own funding programmes. Your Midcounties membership card will look like the picture below and will clearly state The Midcounties Co-operative on the card: Page 9 of 13
The wording here shows the name of the Society that you are a member of; to apply to our fund this must say The Midcounties Co-operative As part of the supporting documentation we will require you to provide a photocopy of your card and return this with your application form see section 5.7. 5.2 Bank Details: If your application is successful our preferred method of payment is via BACS transfer directly to the account held in your group s name (please note that we are unable to make payments to individuals). We do not request account information until it has been confirmed whether or not your group has been successful in gaining an award. Please note that processing time for awards may take up to 28 days from the point of our panel meeting. 5.3 Could you please tell us how you found out about this grant programme? (please tick where appropriate) Through your local store The Midcounties Co-operative website *CF website Press/TV/Radio /Social Media Local CVS Event / meeting Word of mouth Other, please specify *Local Community Foundation website 5.4 Volunteering Opportunities: Please tick if you feel that your group has volunteering opportunities for Midcounties Cooperative staff In a few words describe what this could be and when you would require the support i.e. daytime / evening / number of hours etc: Page 10 of 13
Is there any direct involvement with your group by a current employee of The Midcounties Co-operative? Yes No If yes what is their name, which branch to they work at and how do they support your work? Has your group worked with The Midcounties Co-operative in any other capacity? e.g. through colleague volunteering Yes No If yes please give details below 5.5 Do you or members of your group shop with The Midcounties Co-operative? Yes/No What is the nearest Midcounties trading outlet to the location of your group? (this could be Food, Healthcare, Funeralcare, Travel or Childcare). 5.6 Declaration and Signatories: It is essential that you understand and agree to sign up to the following statements. If you leave the organisation or can no longer fulfil your responsibilities, or someone else takes over responsibility for the grant on behalf of the organisation, you must inform us immediately. We certify that the information contained in this application is correct and that we are authorised by the organisation to accept these conditions on their behalf; We confirm that the group is fully constituted and can provide if asked to do so a copy of this constitution or set of governing rules. We confirm that if asked to do so we will provide detail of the group s most recent financial accounts. We confirm that the group has in place all relevant policies i.e. Child Protection/Vulnerable Adults appropriate to the project for which funding has been requested, and we can if asked to do so provide this detail. Page 11 of 13
The money received from this grant will only be used for activities or purchases undertaken after the date that this grant is received by our group (i.e. it will not fund any retrospective costs); We will only spend the grant for the purposes outlined in this initial application unless we have received written confirmation, from The Midcounties Co-operative Community Fund, that we can make a variation of spend; In the event of fraud or deliberate fault The Midcounties Co-operative Community Fund will reclaim the grant; The grant is made on a one-off basis and does not carry any commitment to future funding; We accept that The Midcounties Co-operative Community Fund will, under no circumstances, be liable for any damage, injury or loss of any kind whatsoever to any property or persons occurring as a result of activities undertaken with this grant; We will ensure that all necessary permits and licenses (including CRB checks) have been obtained for any event or project funded by the grant and that the event or project complies with all relevant regulations; We acknowledge we cannot sell or dispose of any equipment or other assets funded or partfunded by The Midcounties Co-operative Community Fund without first receiving written permission. If any equipment or assets are sold within their working life without such undertaking, The Midcounties Co-operative Community Fund can ask for a percentage of the original grant to be re-paid; We confirm that the grant will not be used for the provision of services to asylum seekers when those services are inconsistent with immigration laws or Home Office policy. We understand this includes, but is not limited to: the promotion of work based training to asylum seekers; the provision of employment to asylum seekers unless they are otherwise permitted to take employment; and the provision of services or activities, to asylum seekers, which are intended to assist with the integration of refugees; We realise we must keep all financial records and accounts including receipts for items bought with the grant for at least 2 years. These must be made available to The Midcounties Cooperative Community Fund if requested; We agree to complete an End of Grant form on completion of our activity/project which is to be returned to the Midcounties Co-operative by the date specified and understand that failure to do this will render our group ineligible for future grants; When requested to complete the End of Grant Form and supply the invoices and receipts for ALL expenditure, the information which we supply will only relate to expenditure incurred after the date that the grant was received. All invoices and receipts will be dated for the funding period that the grant was awarded for; We give permission for The Midcounties Co-operative to record the information in this form electronically and to contact our organisation by phone, mail or email with regards to this application. We give permission for the information set out in the application form to be held by The Midcounties Co-operative and used for purposes of marketing, administration and other related activities. Page 12 of 13
This form should be signed (in black/blue ink) to confirm acceptance of the terms and conditions of the grant as they are set out within this declaration and within the Grant Guidelines. Name: (please print) *Signature: *black/blue ink Date: 5.7 Supporting Documentation Checklist: Please ensure that each section of this form has been completed in full and return with all of the requested supporting documentation to the email or postal address stated at the end of this form and by the deadline date. NB: failure to do this will result in your application being inadmissible. Fully completed application form sections 1.0 to 5.7 A photocopy of your Midcounties Co-operative Membership card (membership should have been held for at least 3 months prior to application) please see guidance details in section 5.1 A copy of your latest bank statement for all accounts held by your organisation (from within the last 3 months) The Grants Panel will only consider fully completed applications received by no later than 5pm on: Friday 16 th February 2018 FOR SUBMISSION TO THE APRIL 2018 GRANTS PANEL OR Friday 21 st September 2018 FOR SUBMISSION TO THE NOVEMBER 2018 GRANTS PANEL Return of your application The quickest way to submit your application to us is by email; we will accept scanned copies of all of the documentation (no requirement for originals to be sent) you can do this by emailing communityfund@midcounties.coop (please quote your organisation name within your email subject line). Alternatively you may post the application to the address below however please be aware that we are unable to accept responsibility for failed deliveries of signed for post or items which have had incorrect postage applied. The Co-operative Community Fund Admin Team, The Midcounties Co-operative, 2 Stonefield Walk, Bilston, West Midlands, WV14 0FA Telephone enquiries: 01902 492235 Page 13 of 13