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1. Applicant OrganisationApplicant OrganisationThe Applicant Organisation is the organisation that is applying for grant funding and will deliver the project or activity.Name of Legal Entity:Common or Trading Name:Applicant Organisation AddressStreet Address:City/Suburb/Town:State and Postcode:Postal Address:City/Suburb/Town:State and Postcode:Organisation Email:Organisation Phone:Applicant Organisation Contact Officers (complete all that apply)

Project Contact President/Chair CEOName:Phone:Email:Legal Status of Applicant Organisation Incorporated Charitable Entity (Attach Certificate of Incorporation) Not Incorporated Charitable Entity (Complete Section 11. Sponsoring Organisation) Local Government Other Please specify:

Healthy Tasmania Community Innovations grants 2017 Application Form Application Form of 2

Applicant Organisation GST Registration StatusRegistered for GST Not Registered for GST

Applicant Organisation’s Australian Business NumberLeave blank if the Applicant Organisation does not have an ABN.ABN: _ _ _ _ _ _ _ _ _ _ _Applicant Organisation Bank DetailsIf the Applicant Organisation is being sponsored by an incorporated charitable organisation, leave blank and complete Section 11.Bank:Account Name:

BSB: Account Number:

2. Project OverviewAbout the Project

Project Title

Project Summary (max 25 words)Provide a brief useful working definition of your project or activity. It should be concise and clear. (e.g. To promote healthy eating in our community by using produce from our community garden for food boxes and community cooking classes.)Priority Area (tick all that apply) Healthy Eating Physical Activity Reduce SmokingProject Start and Finish DateProjects must be completed by 31 January 2020

Start: Finish:

Funding RequestUp to $25,000 (ex-GST) per organisation.Organisations registered for GST should add this component to the middle column.Organisations not registered for GST should leave N/A in the middle column.

Funding Request (ex-

GST)

GST(if

applicable)

Total Funding Request (incl.

GST)

Where will the project be delivered? (Town, city, region, community.)

Healthy Tasmania Community Innovations Grants 2018–19 Application Form of 10

3. Project DescriptionYour ProposalDetailed description to support your application (700 words or less):Please link your proposal to the Healthy Tasmania Community Innovations Grants Guidelines 2018–19.1. Overview – What is your project and who are you helping?

2. Rationale – Why is the project needed? Use available sources of information about the community need where possible. (see Useful Resources document)

3. Community Based – How does the project build on or expand existing community strengths, services and resources?

4. Innovation – How is the project new, or new to your community?

5. Reach – How is the project including diverse groups and increasing reach in the community? How many people from the target group will be impacted and how frequently they will be involved?

6. Access – How is access improved for those who are vulnerable to poor health?

7. Sustainability – How will the outcomes continue to benefit the target group or community after the project?


4. ActivitiesProject Work Plan – overview of the major activities and milestones for your projectList the main work activities planned and the dates each activity will be completed.

Activity and Milestone Completion Date (Month/Year)

5. OutcomesThe outcomes are the changes or results that are expected to be achieved when the project ends.

What is the project intended to achieve?

6. Monitoring and Reporting – Key Performance IndicatorsHow much will you do? How well will you do it? Is anyone better off?How Much? provide two to three measures or activitiesFor example, how many people are you expecting to reach with your project? (# of people using the service)

How Well? provide two to three measuresFor example, how well has the project achieved its aims; how far was the reach of the project in the community? (% of the target population)

Is Anyone Better Off? Provide one to two measuresFor example, how will you measure if your participants are better off as a result of the project? (e.g. surveys comparing participants’ knowledge at beginning and end of project, quotes, success stories from participants, partners and stakeholders). You may consider writing a case study (see our Writing a Case Study online resource.)


7. Partnership and CollaborationYour OrganisationPlease provide a brief description of your organisation and tell us why your organisation is the best to deliver the project.Name your collaborative partners and what they will provide (e.g. networks, skills, in-kind contributions.)Organisation Description:

Collaboration & Support – who are you partnering with and why?Collaborative Partner(s)

Collaboration – What will your partner provide?

8. Past Project DeliveryPrevious Delivery of the ProjectHas this project been delivered at any time in the past?

Yes (provide details below) No (go to Section 9)

When was it delivered and how was it funded?

What were the project outcomes?(maximum of 50 words)

How has the project continued beyond the funding period?

Why is the project being proposed again and how is it different to the previous project?


9. BudgetBudgetPlease provide a realistic project budget.If you do not have a project budget, the template below may be used as a guide. Add or remove rows as required.

Core business activities will not be funded. Eligible costs are new costs incurred in project delivery. Costs such as corporate costs,

overheads and salaries will not be funded unless they are new costs explicitly linked to project delivery.

Service Delivery (e.g. training, transport, communications, rooms, catering, wages for new posts)

Cost

Equipment (any equipment critical to the project, e.g. fridge, icebox, fitness trackers, mobile phone)

Cost

Infrastructure (e.g. anything that needs to be built or purchased, such as a raised garden bed, bike racks or community kitchen equipment) Cost

Promotion (e.g. flyers, media, advertising, invitations) Cost

Reporting (e.g. travel costs to networking forum) – see Guidelines for informal and formal reporting

Cost

Sub-contractors (project consultants, subject matter experts, health professionals)

Cost

TOTAL $


10. Alternative Funding SourcesDetails of other funding sources for the project (including pending grant applications and in-kind contributions)Funding Body Fundin

gProject Title & Purpose Current

Status

Application AuthorisationsApplicant Organisation Agreement YesIt is understood that the organisation, if successful in its Community Innovations Grants 2018–19 Application, will need to enter into a Short Form Funding Agreement with the Department of Health before any grant can be made.For the Community Innovations Grants process, I consent to the Department of Health contacting any relevant persons or organisations about the application.

Declaration and signature of two persons authorised to sign on behalf of the organisation.We declare that the information we have given on this form is complete and correct and that the group/organisation that we represent supports the project.

Authorised Officer 1 Authorised Officer 2

Signature(SIGN BY HAND)

Print NamePosition in OrganisationOrganisation NamePhone

Date


Submitting ApplicationsApplications close 5:00 pm, Friday 2 November 2018. Late applications will not be accepted. Questions? There is a FAQs section online at www.dhhs.tas.gov.au/innovationgrantsQuestions can also be directed to [email protected] with the subject line ‘Community Innovations Grants Questions’.

Email your application as an attachment in both Word and PDF format to [email protected] with the subject line ‘Community Innovations Grants’.

In your covering message, please state your organisation, project name, and address. Scan and email the signed signature page and any hard-copy supporting documents.

Only submit a hard copy application if you are unable to email your application, please post to:

2018–19 Healthy Tasmania Community Innovations GrantsPopulation Health ServicesDepartment of HealthGPO Box 125 Hobart TAS 7001

Keep a copy of your application for your records and ensure you have proof that the application was mailed or emailed before the closing date.

Application ChecklistDocument CompletedA completed Community Innovations Grant Application Form, including:

A signed Application Authorisations page

A Certificate of Incorporation (for your organisation or your Sponsoring Organisation)

For organisations applying under a sponsorship agreement:A completed Section 11. Sponsoring OrganisationAn Agreement to Sponsor letter (example letter provided in Attachment)

Supporting Documents, if applicable


mailto:[email protected]

mailto:[email protected]

11. Sponsoring Organisation (if applicable)Only complete this Section if your organisation is not incorporated and you have agreed to be sponsored by an incorporated charitable organisation.

Sponsoring OrganisationThe Sponsoring Organisation receives the Community Innovations Grant funds and accepts the legal and financial obligations involved in accepting the grant including the transfer of funds to the grantee. The Sponsoring Organisation must provide a Certificate of Incorporation and an Agreement to Sponsor letter.

Name of Legal Entity:Common or Trading Name:Sponsoring Organisation AddressStreet Address:City/Suburb/Town:State and Postcode:Postal Address:City/Suburb/Town:State and Postcode:Organisation Email:Organisation Phone:Sponsoring Organisation Contact Officers (complete all that apply)

Project Contact President/Chair CEOName:Phone:Email:Legal Status of Sponsoring OrganisationThe Sponsoring Organisation must be an incorporated not-for-profit organisation whose dominant purpose is charitable. It will be responsible for appropriate acquittal of the funds. Incorporated Charitable Entity (Attach Certificate of Incorporation) Other Please specify:

Sponsoring Organisation GST Registration StatusRegistered for GST Not Registered for GST

Sponsoring Organisation’s Australian Business NumberLeave blank if the Sponsoring Organisation does not have an ABN

ABN: _ _ _ _ _ _ _ _ _ _ _Sponsoring Organisation Bank DetailsBank:


Account Name:

BSB: Account Number:


ATTACHMENT: Example of an Agreement to Sponsor LetterFor applicant use only – do not submit with application

For the purpose of the Healthy Tasmania Community Innovations Grants, an eligible sponsoring organisation is defined as an organisation that is a not-for-profit ‘incorporated entity’ andits dominant purpose is charitable. The Sponsoring Organisation receives the Community Innovations Grant funds and will accept the legal and financial obligations involved in accepting thegrant including the transfer of funds to the grantee. The Sponsoring Organisation must provide a signed letter agreeing to the sponsorship (example below) and sign the Application Authorisations page.This letter must be provided on the Sponsoring Organisation’s official letterhead.

Date

Chair, Healthy Tasmania Community Innovations Grants Working GroupDepartment of HealthGPO Box 125 Hobart TAS 7001

Dear Sir/MadamOur organisation is an incorporated charitable organisation and is prepared to act as the sponsoring body for the [name of applicant organisation] should it be successful in obtaining funding from the 2018–19 Healthy Tasmania Community Innovations Grants, to undertake [name of proposed project].We are aware that the grant will be paid to our organisation and we accept the legal and financial obligations involved in accepting the grant.

Yours sincerely[Name][Position in organisation]
