Online Form - Community Support Grants

Name of Organisation*

Name of Contact Person*

Phone number*

Email*

Town*

Postal Address*

Is your organisation incorporated?*

YesNo

Incorporation Number

ABN

Registered for GST*

YesNo

Bank details for grant payment

Bank account name*

BSB*

Account Number*

Has your organisation received Council funding in the past 3 years?*

YesNo

Details

Has your organisation received a small assistance donation this financial year?

YesNo

Amount received

Details of project

Name of project*

Have you read the Updated Council Policy Community Grants, Donations and Funding? https://www.ashburton.wa.gov.au/documents/369/community-donations-grants-and-funding*

YesNo

Project description*

Community benefits*

Date of estimated start of project*

Date of estimated project completion*

Estimated total project cost*

Project income

Amount CASH being requested from the Shire of Ashburton*

Amount IN-KIND being requested from Shire of Ashburton*

Description of IN-KIND support from Shire of Ashburton

Other grant applications*

Contributions from other groups/businesses*

Any other income or contributions? Please specify.*

Other invested parties

Date of previous project

Project expenses

Expenses : Please list project expenses (amount excluding GST)*

Expenses: quotations

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Insurance details

Public Liability Insurance Company*

Public Liability Insurance Policy Number*

Public Liability Insurance Expiry Date*

Other file uploads

Max File Size: 10.00 MB
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Declaration

Provide details on how the event will be promoted to the community and how you intend to acknowledge the Shire of Ashburton. You will need to demonstrate how the Shire will be acknowledged for their contribution as part of the grant acquittal.*

I have read and understood the Funding Guidelines in Section 1 of this application and declare that;*

The funds requested would be used only for the purpose described. If the funds are not used, or the total funding amount is not used on the described project, they will be returned immediately to the Shire of Ashburton
The information given on this form is complete and correct
I have listed all relevant income and expenditure
We have reviewed the Shire of Ashburton Disability and Inclusion Plan before submitting this application
I/We authorise the Shire of Ashburton to reproduce the images taken for promotional purpose including web, newspaper, social media and other forms of communication materials if required.

Name of Authorised Representative*

Position*