Community Development Fund
Community Partnership Fund Application
Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email enquiries@waitomo.govt.nz, Website www.waitomo.govt.nz
1. About your Organisation
Full Name
Postal Address
Phone
Mobile
Fax
Contact Numbers
Physical Location
Email
GST Number
Legal Status
Trust
Incorporated Society
Formally Constituted Society
Informal Group or Committee
Other (Please Describe)
Years of Operation
Purpose - What is the organisations main purpose and objectives?
Organisational Categories
Please identify which of the following areas your organisation supports. Tick as many, or as few, as appropriate.
Culture and Recreation
Health
Education and Research
Social Services and Emergency
Relief
Environmental and Animal
Protection
Development and Housing
Civic and Advocacy Groups
Philanthropic Organisation,
Aid and Relief
International Organisations,
Aid and Relief
Religious Congregations
and Associations
Not elsewhere classied
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Name
Position
Phone(day)
Email
Referee Details
Which of the following Community Categories will benet from the project or initiative?
(Tick as many, or as few, as appropriate)
Urban
Rural
All of District
2. About your Project or Initiative
Name
Position
Phone(day)
Email
Describe your Project
For example; Will this grant fund capital expendiure? (i.e. purchase of equipment). Will this grant fund the development
of existing facilities or services?
Length of Project - How long will your project or initiative continue for?
Community Benet - How will the community benet from your project or initiative?
Project Focus - Is your project or initiative focused within the Waitomo District?
Yes
No
Contact Persons
Two contact names are required. These must be the same people who make the declaration on behalf of your organisation
on page 6 of the application.
Name
Position
Phone(day)
Email
Name
Position
Phone(day)
Email
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3. Community Outcomes and Funding Priorities
The basis of this Community Development Fund is to ensure recipients are undertaking projects that
make a positive contribution to achieving the Council’s Strategic Community Outcomes. Below is a list
of Community Outcomes that contribute to the Community Development Group. Please identify which
outcomes your project or activity will contribute to. Tick as many or as few as appropriate.
CO1 Cultural Heritage
A place where people are enriched by the multicultural values of all its people and, in particular,
Maori heritage and culture are an inherent and valued part of decision making that affects
community life.
CO2 Recreation and Social Amenities
A place where all age groups have the opportunity to enjoy social, cultural and sporting
activities within our District.
CO3 Youth
1. A place where young people have access to education, training and work opportunities.
2. A place where young people feel valued and have opportunities for input into the District.
CO4 Vibrant and Prosperous District
1. A place that attracts more people who want to live, work and play, and raise a family.
2. A place where wealth and employment are created through local businesses and
development of tourism opportunities.
4. Funding for this Project or Initiative
If you are GST registered please do not include GST in these costs.
Please round all gures to the nearest dollar.
Please list separate costs (attached written estimates for verication) and not just a total gure.
Expenditure
Cost of the project
Income
How do you plan to fund the project
$
$
A Total Cost of
Project/Service
B Funds for
Project/Service
$
Total amount applied
for(A - B)
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5. Funding from other Parties for this Project or Initiative
Have you applied to, do you intend to apply to, or will you receive funding from any other group for
the project or initiative?
No
Yes
If Yes, please detail below:
Name of Group $
6. Previous Council funding for this Project or any other Service
Have you received nancial assistance from Waitomo District Council during the last three years for any
purpose? (i.e. rates relief, reduced rental, Triennial Grant / Discretionary Grants)
No
Yes
If Yes, please detail below:
What was the purpose of funding? $
7. Previous Funding for any other Projects or Initiative
Have you received nancial assistance from any other body or organisation during the last three years
for any purpose?
If Yes, please detail below:
What was the purpose of funding? $
No
Yes
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8. Financial Accounts
Please supply a copy of your organisations last Annual Financial Report, or, in the absence of the
Financial Report, a statement of income and expenditure for the past 12 months. If neither of these
documents is available, please explain why below and attach a copy of your organisations latest bank
statement/s.
9. Volunteer Support
What level of volunteer support will this project or service receive from your organisation?
Number of volunteer workers involved?
Describe the work volunteers will undertake
Resources supplied by volunteers
Please add any further information you may wish to provide. This could include details of voluntary
input towards the project or service and how you think the project will benet our community, or what
the impact would be on the community if the project is not provided. Letters of support from other
organisations within the community would assist with dening the level of community benet.
10. Further Information
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11. Declaration and Consent
In making this funding application I/we declare that:
1. I/We are authorised to do so and to the best of my/our knowledge the information contained herein
is true and correct.
2. I/We have read the Community Development Funding Policy and understand and meet the criteria
for applying to the Community Partnership Fund.
3. Any funding received will be used for the project/initiative for which is was approved.
4. If the application is successful, on completion of our project/initiative, I/we agree to provide an
Accountability Report to the Waitomo District Council.
5. I/We also consent to the Waitomo District Council collecting, retaining and using the contact details
of our organisation that have been listed in this application.
6. I/We agree to repay Waitomo District Council all funding that is not used for the purposes outlined
in this application.
Name
Signature
Position
Date
Name
Signature
Position
Date
Please read and complete the following before submitting your application. Incomplete or late
applications will not be accepted.
Please send completed applications to:
Waitomo District Council
PO Box 404
Te Kuiti 3941
Ph: 07 878 0800
Fax: 07 878 7771
Have you:
12. Checklist
Completed ALL sections of the application?
Checked ALL gures within the application?
Attached a copy of your Financial Report/Accounts?
Attached a detailed Business Plan?
Attached Referee Details - Letters of Support?
Attached a Bank Deposit Slip (If a donation is approved, payment will be direct
credited into your nominated account)
Applicant Use
Ofce
Use
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