Rural Halls and Domains Scheme
Application Form
This application form is for community organisations that provide public domain or
hall facilities, in rural areas of the Gore District, with capital projects and significant
works. Running costs are not eligible.
Please complete all sections of this form to ensure your application is considered.
Applications close on 31 July 2020. Late applications will not be considered.
A. ORGANISATION DETAILS
Name of Organisation
Purpose of Organisation
Postal Address
Contact Person
Contact Phone Number
Email address
Is your organisation a legally constituted society or trust?
Is your organisation GST registered?
GST Number: ___/___/___
Yes
No
Yes
No
B. THE PROJECT
Details of the project you are seeking funds for.
Please identify the beneficiaries of your service or project.
Please supply evidence of the need for your service (can be attached).
Please provide a breakdown of the budget for your project.
NB: If you are registered for GST, please do not include GST in these costs
EXPENDITURE
(List of project costs)
$
INCOME
(Financing of project)
$
Total cost of our project is:
Total (A)
Our contribution is:
Total (B)
This application for funding assistance is for:
TOTAL APPLICATION FOR FUNDING $
(Total A minus Total B = Total C) Total (C)
State the purpose for which your organisation’s surplus funds are being held.
C. OTHER INFORMATION
Do you have any formal or cooperative arrangements with other community
organisations? Please specify organisation and relationship.
Is your organisation willing to contribute information on problems, trends,
fundraising and other matters to like organisations and participate in a coordinated
approach to District issues?
Please explain how your organisation contributes to the goals and objectives of the
Council. Please refer to the Council’s Long Term Plan and Annual Plan.
Is there any other information your organisation considers relevant.
D. DECLARATION
I hereby declare the information supplied here on behalf of my organisation is
correct.
Signature
Name
Position
Contact No
Date
Note to Applicants
Applications MUST be accompanied by the organisations latest set of annual
accounts.
Please also provide a bank deposit slip for your organisation, in the event your
application is successful.
Activities or projects the Council considers should be funded by central government
or other agencies may not be funded.
Applicants need to demonstrate sustainability in their funding and resources base.
Application forms need to be returned by 31 July 2020 to:
Gillian Small
Gore District Council
PO Box 8
Gore 9740
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