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Community Benefit Fund
Community Organisation Grant Application Form
Community Benefit Fund
Community Organisation Grant Application Form
Applicants should read the Grant
Application Guidelines carefully before completing this Grant Application Form.
Applicant details
Organisation Name
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Organisation/Group Type
Please tick the relevant box below:
Incorporated...................................................... q
q Associations Act (NT)
q ORIC (Office of the Registrar of Indigenous Corporations)
q Other State/Territory (list) ...................................................
Unincorporated ................................................. q
(if unincorporated a sponsor is required refer to Section 3.)
Company Ltd.................................................... q
Other (list)........................................................ q
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Number of Members in the Organisation
Postal Address
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Postcode |
Street Address
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Postcode |
Email Address
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ABN |
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If no ABN, please supply a copy of the Statement by a Supplier form.
GST Registered Yes q No q
Contact Person (for enquiries regarding application)
Mr q Mrs q Ms q Miss q Other _________
(please specify)
Full Name
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Position in Organisation
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Telephone (business hours)
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Email Address
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Regional Location
Please indicate the region in the Territory where your organisation conducts its main activities.
Darwin ............................................................. q
Darwin Regional................................................ q
East Arnhem ................................................... q
Katherine ......................................................... q
Tennant Creek ................................................. q
Alice Springs ................................................... q
NT Wide .......................................................... q
Sponsor Details (if applicable)
The ‘sponsor’ is a not-for-profit body that will accept legal and financial responsibility for the grant. (Please refer to ‘Sponsor Details’ on page 9 of the Grant Application Guidelines).
Name of Sponsor
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Sponsor Details (cont)
Postal Address (If same as the organisation, write ‘as above’)
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Postcode |
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ABN |
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Please tick one: GST Registered Yes q No q
1. Activities of the Applicant Organisation
Please describe briefly the activities and services provided by your organisation.
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2. Purpose of the Grant
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3. Regional location that will benefit from the grant
Darwin ............................................................. q
Darwin Regional................................................ q
East Arnhem ................................................... q
Katherine ......................................................... q
Tennant Creek ................................................. q
Alice Springs ................................................... q
NT Wide .......................................................... q
4. Budget Details
(Please attach budget if space is insufficient).
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Budget Item |
$ Total Cost |
$ Total Cost |
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$ Total Cost |
$ Total Cost |
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Total Project Cost |
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Less: Organisation’s contribution to project (where applicable) |
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Less: Funds to be raised (where applicable) |
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Total Project Sought |
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5. Will the project proceed with less money?
No q Yes q
6. Other Funding
Does your organisation currently receive funding from Commonwealth, Territory or Local Government sources?
No q Yes q Please specify
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Program |
Amount |
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Have you made, or do you intend to make, an application for a grant for this project or activity from any other source (government or non-government)?
No q Yes q Please specify
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Program |
Amount |
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Date Outcome Expected ........................................
7. Target Community Group for Project
Please indicate the target group for your project by ticking one of the boxes below.
Indigenous people ............................................ q
Carers ............................................................. q
Children ........................................................... q
Community - general ........................................ q
Families .......................................................... q
Isolated people ................................................. q
Men ................................................................ q
Older people .................................................... q
Members of ethnic communities ........................ q
People with disabilities ..................................... q
Unemployed people .......................................... q
Women ........................................................... q
Families in crisis situations ............................... q
Young people ................................................... q
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Before submitting your application, please use this checklist to ensure your application is accurately completed.
Incomplete applications will be returned to you for completion and if not returned before closing date, will not be considered.
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Section 1 |
Have you provided your organisation’s details? |
q |
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Have you provided your ABN and GST information requirements? |
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Section 2 |
Have you indicated the region where the funding will be used? |
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Section 3 |
If your group is not incorporated, have you provided details of your sponsor? |
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Section 4 |
Have you provided the name of your Accountable Officer and they have signed the application form? |
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Section 5 |
Have you confirmed that your organisation is eligible to apply as an incorporated/sponsored body or applied for exemption status? |
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Section 7 |
Have you described the purpose of the grant clearly? |
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Section 8 |
Have you provided full details of your budget items? |
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Section 9 |
Have you advised us of other sources of funding your organisation may receive? |
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Section 10 |
Have you indicated the target group for your project? |
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Records |
Have you kept a copy of your funding application for your organisation’s internal records?
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Completed applications
should be posted, faxed or delivered to: Community Benefit Fund: Community Benefit
Secretariat Posted: GPO Box 1722 DARWIN NT 0801 Delivered: Level 3, Old Admiralty Towers 68 The Esplanade DARWIN NT 0800 Phone: 08 8935 7447 Fax: 08
8935 7798 Tollfree: 1300 650
153 Email: cbf.doj@nt.gov.au Internet: www.justice.nt.gov.au
Signatures
Applicant Accountable Officer
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Full Name of Accountable Officer |
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Position in Organisation |
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Signature |
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Date |
Sponsor - Accountable Officer
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Full Name of Accountable Officer |
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Position in Organisation |
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Signature |
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Date |