Fillable Community Development Fund (Waitomo District Council New Zealand)

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Community Development Fund (Waitomo District Council New Zealand)

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Country of origin: NEW-ZEALAND
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Community Development Fund
Triennial Grants Fund Application
Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email info@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
A395937 : P1 of 6
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. Basis of Application
Name
Position
Phone(day)
Email
Describe your Funding Needs
Please identify what the funding will be used for in the 2018-2021 triennium. Will this grant fund operational costs for a
service? e.g. rates, power, phone, minor items, or will this grant fund the development of existing facilities or services?
Community Benet
How do you expect the Community to benet from your organisations services over the 2018-2021 triennium?
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
A395937 : P2 of 6
3. Community Outcomes and Funding Priorities
The basis of this Community Development Fund Triennial Grant is to ensure recipients are undertaking
projects and services that make a positive contribution to achieving the Council’s Strategic Community
Outcomes over the 2018-2021 triennium. Below is a list of Community Outcomes that contribute to the
Community Development Group. Please identify which outcomes your organisation will contribute to over
this period. (Tick as many or as few as appropriate)
Vibrant Communities
• A place where the multicultural values of all its people and, in particular, Maori heritage and culture is
recognised and valued.
• A place where all age groups have the opportunity to enjoy social, cultural and sporting activities within
our District.
• A place where young people have access to education, training, and work opportunities.
• A place where young people feel valued and have opportunities for input into the decisions for the District.
4. Funding for your Services
• Please include annual funding - the level of funding requested annually over the 2018-2021 period.
• 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)
Thriving Business
• A place that attracts more people who want to live, work and play, and raise a family.
Eective Leadership
• A place where the development of partnerships for the delivery of programmes and services is encouraged
and pursued.
A395937 : P3 of 6
5. Funding from other Parties
Have you applied to, or do you intend to apply for funding from any other source for the services identied
in this application?
No
Yes
If Yes, please detail below:
Name of Group $
6. Previous Council Funding
Have you received nancial assistance from Waitomo District Council during the last three years for any
purpose? (i.e. rates relief, reduced rental, previous annual grants/discretionary grants)
No
Yes
If Yes, please detail below:
What was the purpose of funding? $
7. 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 most recent
bank statement.
A395937 : P4 of 6
8. Volunteer Support
What level of volunteer support does your organisation currently receive?
Number of volunteer workers involved?
Describe the work volunteers undertake
Please identify any resources supplied by volunteers
Please add any further information you may wish to provide including letters of support, strategies and
business plans.
9. Further Information
A395937 : P5 of 6
10. 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. Any funding received will be used for the purpose for which it was approved.
3. If the application is successful, I/we agree to provide an accountability report to the Waitomo District
Council annually for the 2018-2021 triennium period.
4. 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.
5. I/we agree to repay Waitomo District Council all funding that is not used for the purposes outlined in
this application.
Name
Signature
Date
Name
Signature
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
info@waitomo.govt.nz
Have you:
11. Checklist
Completed ALL sections of the application?
Checked all gures within the application?
Attached a copy of your Financial Report/Accounts?
Attached Referee Details?
Attached a Bank Deposit Slip (If a donation is approved, payment will be direct credited into your
nominated account)
Applicant Use
Oce
Use
Attached additional information - any applicable letters of support, strategies or
business plans?
A395937 : P6 of 6
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Community Development Fund (Waitomo District Council New Zealand)

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Completed 11 February 2021

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