Gambling Community Benefit Fund

Application Form
Effective October 2005

Stop. Before you start • Applicants are required to read the Funding Application
Package carefully before completing this application form. • Minister approved organisations are required to read the appropriate fact sheet. requested documentation with the application form.

2. Sponsor details – unincorporated organisations only
The sponsor is an incorporated organisation that will accept legal and financial responsibility for the grant. If the application is successful, the grant approval package will be sent to the sponsor. Refer to the section headed Sponsor details – unincorporated organisations on page 7 for further information. Name of organisation
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• Answer each question fully and submit copies of • Faxed copies of completed application forms will not be
accepted.

ABN

• Make a careful appraisal of the difference between a standard project and a complex project (see page 3). If you think you have a complex project contact the Secretariat before completing the application form. • Incomplete applications will not be considered and will
be returned to the applicant.

GST registered Income tax exempt Postal address

yes yes

no no

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1. Organisation details
The organisation is the body applying for the grant and undertaking the proposed project. The exact name of the organisation, as indicated on the Certificate of Incorporation, should be recorded here. If not incorporated, the organisation will need a sponsor (provide details of sponsor in Section 2). Name of organisation
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Street address
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Email address ....................................................................................................................

3. Accountable officer
The accountable officer is the President, Chairperson or School Principal. Mr Full name
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ABN

Mrs

Ms

Other .....................................................................

GST registered Income tax exempt

yes yes

no no

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Position in organisation ............................................................................................. Telephone (business hours) ................................................................................... Email address ...................................................................................................................

Postal address ..................................................................................................................
....................................................................................................................................................... (Address of playing field, meeting room or where equipment/project will be based. Do not provide if organisation is a women’s refuge.)

Street address

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4. Eligibility status of incorporated organisation
Confirm the organisation is eligible to apply for a grant by ticking the relevant box below. Incorporated under Associations Incorporation Act 1981 Incorporated with not-for-profit objectives under the Corporations Act 2001 (Cwth) Incorporated under Cooperative Act 1997 Incorporated under Aboriginal Councils and Associations Act 1976 (Cwth) Incorporated under Community Services (Torres Strait) Act 1984 An organisation with not-for-profit objectives incorporated by an Act of Parliament and/or approved by the Minister

Email address
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Contact person (for enquiries about the funding submission) Mr Mrs Ms Other .....................................................................

Full name ...............................................................................................................................
.......................................................................................................................................................

Telephone (business hours) .................................................................................... Position in organisation.............................................................................................. Email address .....................................................................................................................

5. Supporting documentation
A copy of the following documentation must be attached to the application form. Tick the relevant box to indicate what documents are attached.

Letters of support
Letters of support strengthen your application. They demonstrate that your organisation has support for the project from the wider community and emphasise the benefits the project will create. The following must be attached to your application: Letters of support (usually a minimum of three) from organisations and individuals who will benefit from and/or support your project e.g. Members of Parliament, councillors and other community groups.

Minor capital works projects
When applying for funding for minor capital works (including upgrades to leased premises) you must check if Council or State Government approval is required. Does your minor capital works project require Council or State Government approval? (tick one box only.) Yes No

Quotes
Provide competitive quotes representing the best price available to your organisation for the services/supplies required.

If yes, you are required to attach: copies of all relevant Council or State Government approvals All minor capital works projects must also include: copies of your organisation’s lease agreement a letter of support or agreement from the accountable officer of the lessor approving the proposed upgrades to their premises. All approvals must be obtained before you submit a funding application. Copies must be provided with your application form. An in-principle agreement will not be accepted. If you are successful in obtaining a grant, these approvals will help you meet budget and timeframe deadlines.

6. Primary service provided by organisation
For statistical purposes, please indicate the primary service provided by your organisation by ticking the relevant box below. (tick one box only). Access and mobility for people with a disability Accident/emergency/public safety Accommodation and support Animal care Child abuse prevention

Proof of ownership
Proof of ownership of the land on which the project is based (or on which the building involved is situated) needs to be provided. Documentation to support ownership includes a recent rates notice or audited financial report where the property is listed.

Child care Community development Community/neighbourhood centres Counselling Cultural activities including theatre, arts, music

Financial and legal documents
Copies of the following financial and legal documents must be attached to each application: Your organisation’s (or sponsor’s) Certificate of Incorporation, unless incorporated under Corporations Act 2001 (Cwth). A list of current committee/board members and position held. Financial information authorised by your accountable officer including: organisations established more than 12 months must provide the latest signed, full audited financial report organisations established less than 12 months with no audited financial report must provide a balance sheet and income and expenditure statement and the last two bank statements unincorporated organisations must provide a balance sheet and income and expenditure statement, the organisation’s last two bank statements and a copy of their sponsor’s signed, full audited financial report. Where an organisation is not eligible for an ABN, a Statement by a Supplier form as evidence of its status. Minister approved organisations must also refer to the fact sheet specific to their organisation type.

Domestic violence prevention Drug abuse prevention Education and training Employment assistance Environmental protection Historical societies Home care services Information/referral/advisory Medical related support services Outreach services Recreation and sport Respite care Peak body Other ..................................................................................................................................
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7. Selection criteria
Stop. Before you start section 7
Answer each of the following selection criteria: - ensure you do not exceed the stipulated word count - attach the answers to your application.

Stop. Before you start section 7.6
• Make a careful appraisal of the difference between a standard project and a complex project (see page 3). • If you think you have a complex project you must contact the Secretariat for confirmation. • Once you have confirmation that you have a complex project you are required to answer the following project

plan questions. Remember to:

7.1 Overview of your organisation

(up to 150 words)

- not exceed the stipulated word count - attach the answers to your application as a printed copy - copy the project plan to a CD-Rom and attach it to your application.

Provide a brief overview of your organisation including: a) the date your organisation was established; b) how many members your organisation has; c) why your organisation was established; d) what your organisation does; and e) the geographical coverage of your organisation.

7.6 Additional criteria for complex projects
Title of Project
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7.2 Overview of your project

(up to 200 words)
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Provide a brief description of your project including: a) an outline of your project; b) project objectives; c) how you identified the need for the project; and d) how you believe the project will assist you to attract other resources (funds, volunteers, business sponsors etc). Task description Resources needed 7.6.1 Project timeline Outline the key tasks in the project as in the example below. You must include the project start and finish dates. Expected completion date e.g. 20th May ‘05

e.g. e.g. Position Recruit 2 volunteers descriptions

7.3 Community benefit

(up to 200 words)

Describe how your project will benefit the community including: a) the benefit for your members; and b) the benefit for the wider community.

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7.6.2 Project risks

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7.4 Partnerships

(up to 150 words)

Describe the partnerships your organisation has including: a) how your organisation includes the community; b) how your organisation works with other organisations; and c) how the current project enhances or demonstrates partnerships.

Identify possible risks which impact on the project and how you will manage these risks using the template shown below. It is important that an organisation is able to demonstrate its ability to identify and manage risks. Potential risk e.g. Cannot attract a staff member to manage the project Risk management strategy

7.5 Acknowledging the grant

(up to 30 words)

Tell us how you will publicly acknowledge the grant.

If you have a standard project, go to section 8.

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e.g. ensure training, e.g. high mentoring and supervision is available to staff internally to ensure that project objectives are achieved

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Likelihood

7.6.3 Performance measurement You will be required to report against your stated objectives at the completion of the project. To do this you will need to measure your performance against the objectives using the template shown below. Objective Measure e.g. Increase access to e.g. 20 women assisted community housing for women at risk of homelessness

9. Budget items
List the items for which funding is sought in priority order. A copy of the quote for each item must be attached and a breakdown of costs for projects must be outlined. Budget item $ Total cost $ Total cost less GST

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7.6.4 Sharing your project outcomes

(up to 100 words)

How do you intend to share the outcomes of your project, or the information you have gained by doing the project, with other community groups and organisations? 7.6.5 Project viability (up to 150 words)

You must demonstrate how your organisation can achieve the objectives of the project by explaining the resources and systems your organisation has in place to financially manage the project. a) If the project is a pilot, how will you fund future costs? b) How can your organisation demonstrate sound financial management of projects? For example, describe other projects your organisation has successfully completed. Audit cost (if applicable) Total project cost Less organisation’s contribution to project (if applicable) Less funds to be raised (if applicable) Total grant sought

$0.00

$0.00

8. Primary target group for project
For statistical purposes, please indicate the primary target group for your project by ticking the relevant box below. Tick one box only. Aboriginal and / or Torres Strait Islanders Australian South Sea Islanders Carers Children Community - General Families Isolated people Men Older people Members of ethnic communities People with disabilities Unemployed people Women Women and children in crisis situations Young people Other ......................................................................................................................................
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$0.00

$0.00

10. Other funding
Does your organisation currently receive funding from any Commonwealth, State or Local Government program? No Yes. Specify the funding body and program name and amount of funding provided. Recurrent funding Amount Yes Yes Yes no no no

Funding body and program

Have you made, or do you intend to make, an application for a grant from any other sources (government or non-government) for this project or activity? No Yes. Specify the funding body and program name and amount of funding provided. Amount Outcome date

Funding body and program

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11. Declaration
Declaration of acceptance of the Gambling Community Benefit Fund grant terms and conditions.
If a funding submission is approved, your organisation (or sponsor, if applicable) agrees to the following terms and conditions: 1. The grant will be used for the purpose for which it was given and will be spent within 6 months in accordance with the grant approval package. If there is to be any delay in spending the grant, a written request for extension of time will be made. Any such request will be made within six months of the date of notification of grant approval. 2. The acquittal documentation will be returned to the Secretariat within eight months of the date of notification of grant approval (see section headed Acquittal on page 9). 3. Unspent funds of $300 or more will be returned to the Secretariat within eight months of the date of notification of grant approval. Cheques should be made payable to Treasury Department. 4. The project, or any component of the project forming part of the application, will not commence before formal notification of grant approval. If, for any reason, the project is to commence before notification, the organisation will contact the Secretariat before commencement of the project. 5. It is the responsibility of the organisation/sponsor to ensure adequate insurance cover for the project. 6. The organisation will acknowledge the contribution of the Gambling Community Benefit Fund. 7. All relevant records of the grant will be kept for a period of seven years, and will be made available for audit at any time. 8. The organisation agrees to the Secretariat collecting information in its funding submission to assist in the assessment of its application. 9. If an ABN has not been provided, I declare that the organisation: a. is not eligible for an ABN because it does not meet the definition of ‘enterprise’ for tax purposes; or b. has Income Tax Exempt status; or c. has had its application for ABN rejected by the Australian Taxation Office. 10. For a GST registered entity, to comply with GST requirements, the organisation authorises the Treasury Department to issue a Recipient Created Tax Invoice (RCTI) in respect of this grant. The organisation will not issue tax invoices in respect of this grant. 11. For grant acquittal purposes, all required tax invoices, receipts and audit statements will be submitted as evidence of expenditure of the grant in accordance with the terms of the grant. Mr Mrs Ms Other ..................................................................... 12. All documentation supporting quotations and payments to be made will be on commercial terms and consistent with quotes obtained from other contractors/suppliers. Quotes will represent the best price available to the organisation for those services/supplies. Any contract entered into with a supplier/contractor will be on commercial terms to ensure no conflict of interest issues arise between the organisation, its members and suppliers. 13. All successful applications will be listed in the GCBF’s Quarterly Regional Report. The Report is publicly available on the GCBF website following the Minister’s approval of each round of grants. 14. Any special conditions that are attached to the grant will be met. I have read and agree to the terms and conditions set out in the funding application package and certify that all information provided in the funding submission is correct. I give permission for Secretariat staff to contact the relevant person from the organisation and/or those persons or organisations that have provided letters of support for further information. The organisation also agrees to the Secretariat giving some or all of the information contained in its funding submission, if successful, to the organisation’s local Member of Parliament. Signed for and on behalf of the organisation or sponsor. Only the Chairperson, President or School Principal (or another officer, formally delegated such authority*), and the Secretary/Treasurer of the organisation which is to receive the grant should sign. * Where this agreement is signed by a delegated officer, current documentation authorising such a delegation of authority, signed by the Chairperson or President, must be attached to this document. Mr Mrs Ms Other .....................................................................

Full name of President/Chairperson/School Principal (circle one)
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Signature .................................................................................................................................. Date.............................................

Full name of Secretary/Treasurer (circle one)
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Signature .................................................................................................................................. Date............................................. NB: Minister approved organisation types must refer to their fact sheet to ensure the correct signatures are provided.

Checklist
If your funding submission is incomplete or does not contain all the information required, it will be returned to you for completion. If the application is not returned so that it is received by the Secretariat by the closing date, it will go into the next funding round. Before submitting your application, please use the following checklist to assist you to ensure your application is complete.

Section 1 Have you provided your organisation’s details? Have you indicated if your organisation is registered for GST? Have you provided your ABN or Statement by a Supplier form as evidence of your ITE status?

Section 8 Have you indicated your primary target group?

Section 9 Have you completed the budget items list? Have you included a copy of the selected quote/s for all items in your budget and ensured all quotes show the GST amounts separately for each item requested?

Section 2 If your group is not incorporated, have you provided details of your sponsor?

Section 10 Have you advised other sources of funding your organisation may receive?

Section 3 Have you provided the name of your accountable officer?

Section 11 Have the accountable officer and office bearer signed the application form? Records Have you kept a copy of your funding submission for your organisation’s internal records?

Section 4 Have you confirmed that your organisation is eligible to apply?

Section 5 Have you provided all relevant supporting documentation? Relevant documents may include: • leases • letters of support • evidence of building approvals. Please ensure: both signatures in the declaration are original. Photocopies of signatures are not accepted. Faxed copies of application forms are not accepted. the application is stapled or clipped. All folders are discarded before applications are considered by the Committee. your application is submitted on time. The GCBF strongly encourages you to send your application by regular post. Due to changes in mail security arrangements, you must notify the GCBF in advance of the expected arrival of any courier deliveries. All mail postmarked on or before the funding round closing dates will be accepted.

Section 6 Have you indicated your primary service type?

Section 7 Have you addressed the selection criteria?