Application Form: Community Facility Funding Program 2013-2014 Local Government Application

Please indicate the category for this application (tick one) Major Facilities Minor Facilities Soccer Facilities Better Pools Seasonal Pool Renewal

Section 1 Contact Information

Part A: Applicant Organisation Details
* Name of Council: * Main Street Address: * Town / Suburb: Postcode: Mobile: * First name: * Postcode:

Fields marked (*) are mandatory

* State:

Postal Address (if different from above): Town / Suburb:

State:

Authorised person (This is the person who is authorised by the organisation to make the application on their behalf) * Title: Position: Telephone: Email: * Last name: Fax:

Councils Australian Business Number (ABN):

Part B: Activity Representative Contact Details

Title: First name: Mobile: Postcode: Fax: State: Last name: Postal address: Town / Suburb: Telephone: Email:

Part C: Club/Community Representative Contact Details

Please provide contact details for the main beneficiary of the Activity. Title: First name: Mobile: Fax: Last name:

Organisation Name: Telephone: Email:

Part D: DPCD Contact

Who in the Department have you discussed your Activity with? DPCD Officer:

Community Facility Funding Program 2013-2014

Page 1 of 6

Fields marked (*) are mandatory

Section 2 Activity Overview

* Activity name We will use this name on all correspondence. Please use 10 words or less and name the facility/reserve and activity type (for example, Smith Reserve Lighting Project).

What are you going to do?

Describe the activity in one to two sentences. Particularly describe what you have now and what you are going to achieve as a result of the activity.

Where will your activity happen? Please provide the address of where most of your planned activity will take place. Street Address, Suburb and Postcode: Local Government Area: This should be the one where most of the activity is happening. Local government area:

Who owns the land where the activity is to be located? If on private land, you must provide evidence of a legally binding land use or community access agreement.

Who is the land manager? (e.g. Council, Department of Sustainability and Environment, Department of Education and Early Childhood Development)

Describe your organisations tenure over the land. (e.g. own, lease, license)

Does the activity require any permits or approvals before it can commence? (For example, building or planning approval, DSE/Ministerial approval for Crown Land) if so, please advice on status of approval.

Community Facility Funding Program 2013-2014

Page 2 of 6

Fields marked (*) are mandatory

Section 3 Describing the Benefits

What places will this activity benefit? Pick one of the following: A specific Local government Area (LGA) or group of LGAs A whole Region/s will benefit Benefits will be Statewide Name the LGAs: Name the region/s:

Is the activity specifically directed at particular groups? Tick any that apply. If the Activity is not targeted to any groups, do not tick any boxes. Age (years) Children (0-14) Young People (15-24) Adults (25-54) Seniors (54 +) Gender Men Women Industry Groups Volunteers Diversity People who are Indigenous (Aboriginal and/ or Torres Strait Islander) People from culturally and linguistically diverse backgrounds People who are refugees People with disabilities Committee/ decision making Other

Section 4 Activity Details that address the Assessment Criteria

Please indicate how your activity addresses the following assessment criteria. Refer to the program guidelines to help you answer the questions. Note you will need to respond to each specific category criteria. Attach additional pages if required.

* What will the activity achieve? (50%)

* Why is this activity needed? (20%)

* How will you carry out the activity? (20%)

* Who will the involved in the activity? (10%)

Community Facility Funding Program 2013-2014

Page 3 of 6

Fields marked (*) are mandatory

Section 5 Activity Budget

Please provide details of the income and expenditure for your activity, excluding GST. Note that the total income should equal total expenditure. You are required to submit your budget using the categories provided. If you cannot provide enough details in this section please provide a summary here and the details on a separate sheet(s) using the same categories.

Income
* Amount requested from CFFP Other State Government Funding Local Government Funding Federal Government Funding Funds from your Organisations Funds from Community Organisations Funds from Business Contributions Funds from Philanthropic Contributions In-kind support from your Organisations In-kind support from other sources Other (please specify) $ $ $ $ $ $ $ $ $ $ $

Expenditure
Contingencies Escalations and Allowances $ In-Kind Labour Professional Fees Project Construction Project Coordination Site Preparation $ $

$ $ $

Other (please specify)

*Total income $

*Total expenditure $

NB * In-kind support is only applicable to applications submitted under the Minors Facilities, Soccer Facilities and Seasonal Pool categories. Consideration will be given to claiming in-kind expenses to a maximum of 25 per cent of the total activity cost. Council must underwrite any in-kind contribution.

Community Facility Funding Program 2013-2014

Page 4 of 6

I am forwarding required supporting documentation via: Email (zipped file) to grantapplications@dpcd.vic.gov.au CD/USB to Department of Planning and Community Development, Community Investment Services, GPO Box 2392, Melbourne VIC 3001

Declaration
I state that the information in this application and attachments is to the best of my knowledge true and correct. I will notify DPCD of any changes to this information and any circumstances that may affect this application. I acknowledge that DPCD may refer this application to external experts or other Government Departments for assessment, reporting, advice, comment or for discussions regarding alternative or collaborative grant funding opportunities. I understand that DPCD is subject to the Freedom of Information Act 1982 and that if a Freedom of Information request is made, DPCD will consult with the applicant before any decision is made to release the application or supporting documentation. I understand that this is an application only and may not necessarily result in funding approval.

* Signature: * Print name:

* Date: * Position:

(Note: This should be an Authorised Person, who is the person authorised by the organisation to make the application on their behalf, for example Chief Executive Officer, Director/General Manager.)

Supporting documents checklist

Please submit the following documents (where applicable) with your application:

Major Facilities and Better Pools (planning permit removed) A legally binding land use agreement for projects located on private land. For those projects located on school land, a completed Joint Use Agreement, or a completed Community Joint Use Proposal (Proposal) to enter into a Community Joint Use Agreement, plus a letter from DEECD that indicates endorsement of the project at both the regional office and central office level. A Project Management Framework Evidence of confirmation of funding sources (for example, local government report confirming contribution, club bank statements) Quantity Survey, tender price or independent qualified expert report Endorsed Schematic Plans Detailed Schedule of Use Letters of support from organisations that clearly indicates how the group/individual will either support the project or benefit from the scope of works (as described in the What section of the Assessment Criteria) Where applicable attach evidence (printable process list) that the Aboriginal heritage Act 2006, Aboriginal Heritage Planning Tool has been completed to determine if a Cultural Heritage Management Plan is required for the project. The Aboriginal Heritage Planning Tool can be accessed at www.dpcd.vic.gov.au/indigenous/heritage-tools (for Greenfield sites only) Relevant sections of local government reports / plans / strategies / community consultation to support the project (please do not attach entire documents) Environmentally Sustainable Design report(s) and budget Technical and / or Access Audits (where available) Completed Code of Conduct Form for Tenants from all clubs that are tenants of the facility Minor Facilities, Seasonal Pools and Soccer Facilities A legally binding land use agreement for projects located on private land. For those projects located on school land, a completed Joint Use Agreement, or a completed Community Joint Use Proposal (Proposal) to enter into a Community Joint Use Agreement, plus a letter from DEECD that indicates endorsement of the project at both the regional office and central office level. A Project Management Framework Evidence of confirmation of funding sources (for example, local government report confirming contribution, club bank statements)

Community Facility Funding Program 2013-2014

Page 5 of 6

Quotes, internal cost estimates Quantity Survey, tender price or independent qualified expert report for Soccer Facilities and Seasonal Pools projects only over $500,000 (excluding GST) Concept/ Schematic Plans Letters of support from organisations that clearly indicates how the group/individual will either support the project or benefit from the scope of works (as described in the What section of the Assessment Criteria) Where applicable attach evidence (printable process list) that the Aboriginal heritage Act 2006, Aboriginal Heritage Planning Tool has been completed to determine if a Cultural Heritage Management Plan is required for the project. The Aboriginal Heritage Planning Tool can be accessed at www.dpcd.vic.gov.au/indigenous/heritage-tools (for Greenfield sites only) Relevant sections of local government reports / plans / strategies / community consultation to support the project (please do not attach entire documents) Technical and / or Access Audits (where available) Completed Code of Conduct Form for Tenants from all clubs that are tenants of the facility

Community Facility Funding Program 2013-2014

Page 6 of 6