Financial Assistance Program Request Form

Part 1: Application Information

Name of Group/Organisation *

Please indicate the category of the group/organisation who is making the request. *

Please indicate the category of financial assistance you are requesting.

Fee Rebate ($2000 and over)
Donation (Max of $250)
Grants (Max of $5000)
Rate Reduction (Up to Max of 25% refund)

Please specify the amount you are requesting from Council. *

$

Postal Address *

Contact Person *

First

Last

Position in Organisation *

Daytime Phone *

Must be an Australian phone number.

Email *

Website

Is your Group/Organisation incorporated? *

Yes
No

Does your Group/Organisation have an ABN? *

Yes
No

If yes, please provide ABN in the following box.

ABN #

Has your Group/Organisation previously received funding from Wentworth Shire Council? *

Yes
No

If yes, please let us know which financial year funding was received in the following box.

If you have previously received funding from Council, in which financial year was the funding received?

Part 2: Bank Account Details (Council's preferred method of payment is EFTPOS.)

Funds will only be made to organisations not individuals. Please provide bank account details for direct deposit if funding is approved.

Name of Bank Account *

BSB *

Account Number *

Part 3: Grant Request

Please describe the event/project or activity you are asking Council to support. *

Location *

Date

Start Time

End Time

If this relates to an event or hire from Council, have you lodged a Venue Lodgement / Hire Booking Form?

Yes
No

If you answered no, please make sure you fill out a Venue Lodgement / Hire Booking Form.

What is the estimated number of attendees?

How will this event/activity benefit the Wentworth Shire Council Community? *

How will you promote and market your project/purchase to the community? *

Have you sought and been granted funding for this project from other sources? *

Yes
No

If yes, please provide the following details in the spaces below.

Funding Body

Amount Granted

$

Please provide a Summary Budget that includes Cash Contribution by your group and organisation, In-Kind contribution by your organisation (volunteer hours x $25ph), Other In-Kind *

Please provide details.

Please provide any written quotes where applicable.

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Important: Alignment with the Community Strategic Plan (Please refer to Table 3 in Financial Assistance Program Application Guidelines)

As part of the general criteria for evaluating requests for financial assistance, groups and organisations must identify how the request links to the strategies and objectives in the Community Strategic Plan.

Which of the Community Strategic Plan objective(s) best fits the outcomes of the Event/Activity that this application is being lodged? *

Please indicate objective number(s).

Applications for Grants under this program must be accompanied by your organisation's Audited Financial Statements (your application will not be considered without this statement). *

Yes
No

Please attach a copy of your organisation's Audited Financial Statements.

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This is mandatory if you are requesting more than $2,000 in financial assistance.

Please attach any additional files to support your application

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Confirmation of Information *

I have read Council's Financial Assistance Policy.
I have attached the organisation's audited Financial Statements
I have completed all questions on this Application Form and provided all relevant supporting documentation.

Part 3: Declaration

I have read the guidelines relating to the Grant Request and certify to the best of my knowledge the information provided in this submission is true and correct and that the application has been submitted with the full knowledge and agreement of the Group/Organisation applying.

Name *

First

Last

Signature *

Date *

Privacy and Personal Information Protection Notice

We are collecting this information to process your request. We may not be able to do so without it. Supplying this information is voluntary and it will not be used for any other purpose without seeking your consent. We will store your personal information on our systems or in our offices, where it will be used by our staff and contractors. Other people can request access to it under the Government Information (Public Access) Act 2009. You can ask us to suppress your personal information from a public register and we will consider your request in line with the Privacy and Personal Information Protection Act 1998. Our Privacy Management Plan sets out how you can access or correct your personal information. Please visit www.wentworth.nsw.gov.au for a copy of the plan.

Part 1: Application Information

Part 2: Bank Account Details (Council's preferred method of payment is EFTPOS.)

Part 3: Grant Request

Important: Alignment with the Community Strategic Plan (Please refer to Table 3 in Financial Assistance Program Application Guidelines)

Part 3: Declaration

Privacy and Personal Information Protection Notice

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