Community Benefit Fund

Major Community Grant Application Form

Applicants should read the Major Community Grant Application Guidelines carefully before completing this Application Form.

Applicant details

Organisation Name

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

Number of Members in the Organisation 

Postal Address

Postcode

Street Address

Postcode

Email Address

ABN

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

Position in Organisation

Telephone (business hours)

Email Address

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’ of the Grant Application Guidelines).

Name of Sponsor

Sponsor Details (cont)

Postal Address (If same as the organisation, write ‘as above’)

Postcode

ABN

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.

2. Project Title

3. 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

4. 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

5. Budget

Total amount requested for the project?

$

Total cost of the project?

$

What other grants have been approved or applied for to undertake this project? (government or non-government)?

No   q    Yes   q Please specify

Program

Amount

Does your organisation currently receive operational funding from Commonwealth, Territory or Local Government sources?

No   q    Yes   q Please specify

Program

Amount

6. Project Description

Attach a detailed statement of the project.  The statement must include the following information.

1. Detailed description of the project.

2. Timeline for the project.

3. How the project will benefit the target group?

4. List all personnel involved in the project.

5. Expected outcomes of the project and how the outcomes will be demonstrated.

6. Detailed budget including in-kind support and funding from other sources.  (please identify if GST is included or excluded from your budget calculations)

7. Identify any partnerships the project will create or strengthen.

8. Identify other projects the organisation has been responsible for in the past 2 years.

Each application will be considered in accordance with the following assessment criteria.

The project demonstrates:

· a strong community development focus.

· the capacity of the organisation to deliver the project.

· evidence of sound financial management.

· a clear plan and proposed outcomes.

· evidence of community support and involvement.

· An accurately costed and viable budget including support from other sources.

Completed applications should be posted, faxed or delivered to the Community Benefit Fund:

Community Benefit Secretariat

Posted: GPO Box 1722 DARWIN  NT  0801 Fax: 08 8935 7798

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

Full Name of Accountable Officer

Position in Organisation

Signature

Date

Sponsor - Accountable Officer

Full Name of Accountable Officer

Position in Organisation

Signature

Date