Majors Minors Etc AF

7/29/2019 Majors Minors Etc AF

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

Please indicate the category for this application (tick one)

Major Facilities Better Pools

Minor Facilities Seasonal Pool Renewal

Soccer Facilities

Section 1 Contact Information Fields marked (*) are mandatory

Part A: Applicant Organisation Details

* Name of Council: * Main Street Address: * Town / Suburb: * Postcode: * State: Postal Address (if different from above): Town / Suburb: Postcode: State:

Authorised person (This is the person who is authorised by the organisation to make the application on their behalf)

* Title: * First name: * Last name: Position: Telephone: Mobile: Fax: Email: Councils Australian Business Number (ABN):

Part B: Activity Representative Contact Details

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

Part C: Club/Community Representative Contact DetailsPlease provide contact details for the main beneficiary of the Activity.

Title: First name: Last name: Organisation Name: Telephone: Mobile: Fax: Email:

Part D: DPCD ContactWho in the Department have you discussed your Activity with?

DPCD Officer:

Community Facility Funding Program 2013-2014 Page 1 of 6


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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 thefacility/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 andwhat 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 landuse or community access agreement.

Who is the land manager? (e.g. Council, Department of Sustainability and Environment, Department of Education and EarlyChildhood 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.



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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 Name the LGAs:

A whole Region/s will benefit Name the region/s:

Benefits will be Statewide

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)

Diversity People who are Indigenous (Aboriginal and/ orTorres Strait Islander)

Young People (15-24)People from culturally and linguistically diversebackgrounds

Adults (25-54) People who are refugeesSeniors (54 +) People with disabilities

Gender Men Volunteers Committee/ decision making

Women Other

Industry Groups

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 youanswer 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%)



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Section 5 Activity Budget

Please provide details of the income and expenditure for your activity, excluding GST. Note that the total income should equaltotal expenditure.

You are required to submit your budget using the categories provided. If you cannot provide enough details in this sectionplease provide a summary here and the details on a separate sheet(s) using the same categories.

Income Expenditure

*Amount requested from CFFP $ Contingencies Escalations and Allowances $

Other State Government Funding $ In-Kind Labour $

Local Government Funding $ Professional Fees $

Federal Government Funding $ Project Construction $

Funds from your Organisations $ Project Coordination $

Funds from Community Organisations $ Site Preparation $

Funds from Business Contributions $

Funds from Philanthropic Contributions $In-kind support from your Organisations $

In-kind support from other sources $

Other (please specify) $ Other (please specify) $

*Total income $ *Total expenditure $

NB * In-kind support is only applicable to applications submitted under the Minors Facilities, Soccer Facilities and SeasonalPool 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.



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I am forwarding required supporting documentation via:

Email (zipped file) to [email protected]

CD/USB to Department of Planning and Community Development, Community Investment Services, GPO Box2392, Melbourne VIC 3001

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

* Signature: * Date: * Print name: * Position: (Note: This should be an Authorised Person, who is the person authorised by the organisation to make the application on theirbehalf, 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 endorsementof 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 bankstatements)

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 benefitfrom 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 PlanningTool has been completed to determine if a Cultural Heritage Management Plan is required for the project. The Aboriginal

Heritage Planning Tool can be accessed atwww.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 UseProposal (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 bankstatements)

mailto:[email protected]://www.dpcd.vic.gov.au/indigenous/heritage-toolshttp://www.dpcd.vic.gov.au/indigenous/heritage-toolsmailto:[email protected]://www.dpcd.vic.gov.au/indigenous/heritage-tools


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Quotes, internal cost estimates

Quantity Survey, tender price or independent qualified expert report for Soccer Facilities and Seasonal Pools projectsonly 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 benefitfrom 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 PlanningTool has been completed to determine if a Cultural Heritage Management Plan is required for the project. The AboriginalHeritage Planning Tool can be accessed atwww.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 (pleasedo 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

http://www.dpcd.vic.gov.au/indigenous/heritage-toolshttp://www.dpcd.vic.gov.au/indigenous/heritage-toolshttp://www.dpcd.vic.gov.au/indigenous/heritage-tools

Documents

Majors Minors Etc AF