Standard Application Form for Funding - dss.gov.au · Web viewPage 17 of 17. Application Form. Version 1.1 Jan 2013

Program 7.5 – Stronger Futures in the Northern Territory

Food security – strengthening remote stores measure

APPLICATION FORM

For Store Owners and Operators in the Northern Territory

Page 1 of 17Application FormVersion 1.1 Jan 2013

APPLICATION FORM Program 7.5 – Stronger Futures in the Northern Territory

Food Security – strengthening remote stores

Information for applicants

Closing Date Applications from licensed store owners 1or stores that will be licensed can be submitted for the 2012-2013 financial year from 1 July 2012 up to and including 31 May 2013.

How to lodge Completed application forms can be submitted electronically to [email protected] or posted to:

DirectorCommunity Stores SectionFaHCSIA Northern Territory State OfficeGPO Box 9820DARWIN NT 0801

You may also hand deliver your completed application marked for the attention of the Director, Community Stores Section, to the reception desk at:

FaHCSIA Northern Territory State OfficeLevel 5Jacana House 39-41 Woods Street Darwin NT 0800

Note: The Department will not issue Application Forms or accept completed applications by fax.

Applications are unlikely to be accepted after 31 May 2013 for the 2012-13 financial year.

Preparing your application

When preparing your application you should:

read the information in this application form and the program guidelines;

address the Selection Criteria in Part 5;

provide detailed answers to each question in the application form;

complete the Declaration at Part 6 and have it signed by someone who is authorised to sign and submit the application on behalf of the organisation;

complete the Application Checklist at Part 7 and forward the required supporting documentation;

forward the required supporting documents to the Community Stores 1 Store Owner/Entities is the legal owner of a store, roadhouse, takeaway or mobile food van.


mailto:[email protected]

Section; and

provide copies of documents, unless asked for as originals, as accompanying documents will not usually be returned to applicants.

Please note: Completion of the application form and the related assessment process cannot be interpreted to create any binding obligations between the Department and an applicant until a Funding Agreement (if any) is signed, dated and exchanged by the relevant contracting parties.

The Community Stores Section does not provide funding to cover retrospective costs incurred before a payment has been approved and it does not cover costs incurred in the preparation of this application or related documentation.

National Relay Service (NRS)

If you are deaf or have a hearing or speech impairment, you can use the NRS to contact any of the Department's listed phone numbers. To access a 1800 FaHCSIA number NRS users should phone 1800 555 677 or visit the NRS Website at http://www.relayservice.com.au/

Program Guidelines

If you are completing this application form you should only proceed if you have read the program guidelines attached to this form. Assessment of applications will be based on the information provided in the program guidelines.

Information Use Please note that FaHCSIA may use successful applicants’ informationother than personal information that has been provided in the applicants’ application, to assist FaHCSIA to:

(a) comply with the Australian Government’s requirement to publish the names of all funding recipients on the FaHCSIA website;

(b) inform staff negotiating and establishing funding agreements of risks and issues which need to be addressed in the agreement for that program;

(c) inform future assessments for applications in the same program; or

(d) inform assessments for applications for other programs.

You can only apply if you agree to the department using the information (not personal information) you have provided in your application for the purposes listed at (a), (b), (c) and (d) above.

I agree


Part 1 Eligibility1a Organisation type and financial status

Is your organisation non-government or government?

Non-government

State/Territory government

Local government

Is your organisation not for profit?

Not for profit

For profit

1b Organisation entity type2

Please put an X in all applicable boxes.

Incorporated association incorporated under Australian State/Territory legislation

Incorporated cooperative incorporated under Australian State/Territory legislation

Aboriginal corporation incorporated under the Corporations (Aboriginal and Torres Strait Islander) Act 2006)

Organisation established through specific Commonwealth or State/Territory legislation

Company incorporated under Corporations Act 2001 (Commonwealth of Australia)

Partnerships

Trustee on behalf of a trust

An Australian Local government body

An Australian State/Territory government

An individual or – jointly and separately – individuals. (Only where there is no suitable alternative and agreement has been obtained by the Minister for Indigenous Affairs.)

If you have not ticked any box from the list above, your organisation is not able to apply for funding. You should refer to the program guidelines.

2 Only Australian legal entities are eligible to receive funding for the provision of services in Australia.Page 4 of 17

Application FormVersion 1.1 Jan 2013

Part 2 Applicant details 2 What is the legal name of your organisation?This is the name that appears on all official documents and legal papers. It may be different to your trading name.

All further responses within this form must relate to this entity.This is the legal entity that FaHCSIA will enter into Funding Agreements with.

3 What is the trading name of your organisation?This is the name your organisation trades or provides services under.

4 What is the store name?

5 What is the community name the store is located at?

6 Does your organisation have an Australian Business Number (ABN)?

Yes

No

If yes, what is the ABN of your organisation?

If your organisation has an ABN branch number, please provide it here.

7 Is your organisation registered for GST?(Questions on GST requirements should be addressed to the Australian Taxation Office.)

Yes

No


8 Does your organisation plan to sub-contract any or all of the service provision, if this application is successful?

Yes

No

If yes, successful applicants may be asked to provide details of those sub-contracting arrangements and the organisations involved.

9 What is your organisation’s physical address?Enter the contact person’s address if your organisation does not have its own registered address etc.

Physical address (not a PO box)

Building/floor

Street no. and name

Suburb/town

State Postcode

10 What is the postal address of your organisation?

Same as above

Postal AddressBuilding/floor

Street no. and name or PO box

Suburb/town

State Postcode


12 If you are successful for funding, provide details of your nominated bank account. (It may be necessary to provide verification of these details if funding is approved)

Account Name BSB Account Number Bank Name, Branch


11 Who are the authorised Contact Persons for this funding application?

Preferred contact Alternative contact

Title

First name

Surname

Position in organisation

Telephone number

Mobile number

Fax number

Business email address

Part 3 Financial viability and governance

13 Please indicate if your organisation has the following:

Please indicate where applicable

Your organisation’s most recent audited financial statements (with previous year for comparison)

an organisation chart

financial policy and procedures

delegations, (authorised financial delegates or decision makers)

business plan

current minutes of board meetings

As a part of our financial viability verification process you may be asked to provide copies of these documents.

Can you provide copies of these documents within 7 days of a request by us?

Yes

No If no, which documents would not be available?

If you have provided audited financial statements to the Department under the Community Stores licensing regime, (under The Stronger Futures in the Northern Territory Act 2012 (the Act) or previously the Northern Territory National Emergency Response Act 2007), please indicate whether you agree to FaHCSIA using this information in the assessment of this application?

Yes

No

14 Please indicate if any of the following apply to your organisation.

Any form of litigation or enquiry during the past three years, current or pending.

NOTE: If you have settled a claim on confidential terms, please indicate this in your response.Any significant financial matter which may impact on the organisation e.g. insolvency or voluntary administration.

Future commitments or contingent liabilities that might materially affect the organisation.


If you have marked any of the above (Q12) please provide a short explanation here (further information may be requested).

Recent funding applications

15 Has your organisation recently applied for any other FaHCSIA funding?

FaHCSIA program name

Amount of funding Period of funding Date of application

16 Has your organisation applied for funding from any other source to deliver the same services covered by this application?

Program or funding source name Contact officer Date of application


Part 4 Project Activity questionsProject Details

17 Project Title / name of project activity. (Description of the project and other information is to be provided at Part 5 – Responses to Selection Criteria)

18 Amount of funding being sought? Budget breakdown is at Q22

GST Exclusive - $ GST Inclusive - $

19 Is the amount of funding being sought the full cost of the project?

Yes

No

If no, please provide details of other agencies or organisations contributing funds to the project (including amounts/or in kind) that reflect the total cost of the project

20 Provide details about the Store’s ability to contribute funds to the project.Provide details of any funds or resources (including in-kind) to be contributed to this project.


21 Project QuotesAttach to your application any independent quotes and/or cost estimates you have obtained to assist you in determining your project budget. Note: a minimum of two quotes is required.

Two quotes are attached?

Yes

No

22 Are there any planning approvals (including Aboriginal Areas Protection Authority Assessment) in relation to this proposal?

Yes

No

If yes, please provide details.

23 Please provide details of any land tenure issues in relation to this project.

24 If this project involves the acquisition of an asset(s) over $10,000 (inclusive of GST) e.g. vehicle, forklift, combi oven) provide details about who will be responsible for the ongoing management, maintenance and repair of the asset(s).


25 Please provide a breakdown of the budget for the project. The amounts entered should be exclusive of GST and under the headings of Capital and Operational (as applicable).

BUDGET ITEMSInsert rows for line items as required

FINANCIAL YEAR2012-2013

GST Exclusive

INCOMEFaHCSIA FUNDING REQUESTED

Capital Amount 3

Operational Amount4

Other project income (list source/s)

TOTAL PROJECT INCOMEEXPENDITURECapital (list items)

Total CapitalOperational Costs (list items)

Total OperationalTOTAL EXPENDITURE

3 Capital Amount is defined as: purchase of land; purchase of existing buildings; construction of new buildings; significant renovation of existing infrastructure; construction of other infrastructure (e.g. roads).4 Operational Amount is defined as: the funding required in implementing the project activity, e.g. the purchase of plant and equipment, labour and travel costs.


Part 5 Responses to Selection CriteriaIMPORTANT:

You need to provide information against each of the Selection Criteria below to help us to determine if your proposed project is value for money and to also determine its relative importance and priority against any competing applications for limited funds.

You must provide information for each of the following Selection Criteria.

You should ensure that sufficient information to assess the application is provided.

You can use up to 800 words to support your claim for each Selection Criterion.

Any attachments should not include additional text, but can include diagrams, tables and graphs. Additional text may not be considered by FaHCSIA.

(Note: dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)

1. The scope of the project and how it will be implementedMatters to be addressed include:

The scope of the project, describing how it meets one or more of the eligible activities listed in the program guidelines, which include:

effective solutions to food security

governance mentoring and training

retail mentoring and training

emergency repairs and maintenance

minor infrastructure upgrades.

Key activities/tasks that will need to be completed in the project and estimated timeframes.

How the project will be viable and sustainable and not require ongoing Stronger Futures financial assistance.

Community employment or training outcomes (if applicable).

[Adjust area size to suit the required word limit]


2. The need for the project. Matters to be addressed include:

The need for the project and how the project links to or supports the store business plan and meets the priorities of the Stronger Futures food security measure.

Benefits of the project, for example, improve food security for an Aboriginal community, improve the management and operation of the store, improve the store’s ability to meet licensing requirements or environmental health and hygiene regulations.

Consequences of the project not proceeding.


3. The ability of the funding recipient to implement and manage the project activity(ies) to achieve quality outcomes.Matters to be addressed include:

Your experience and skills in managing this type of project (including details of previously funded projects).

Mechanisms and procedures that would be followed to provide performance and financial reports, including any outside bodies that would be used (e.g. accounting companies).

How progress will be monitored to achieve the desired outcomes of this project.

Strategies that will be put in place to minimise the risk of project failure.



4. The experience and qualifications of staff or contractors/consultant who are responsible for delivering the project.Matters to be addressed include:

Experience and qualifications of personnel responsible for managing the project and key personnel to be engaged in its delivery.

Experience and qualifications of any consultants, project managers or other specialists/experts to be engaged in delivering the project.

Experience, expertise or qualifications of staff working with specific target groups, including their skills in delivering services to those groups (e.g. members of Indigenous corporations).

Arrangements that will be put in place with any consultants/contractors to ensure a quality outcome (e.g. a contract, payment upon satisfactory completion of work, MOU


5. The Value for money represented by the project, including an indicative budget.Matters to be addressed include:

The value for money offered by the project plan, including reasons why it should be preferred over other plans or quotes. Reasons could relate to timeliness, quality and cost.

The level of contribution by way of funding or resources (if any) that the store owner (or funding recipient) will make to achieving successful project delivery.



Part 6 Declaration Please

complete the declaration

NOTE: Applications being submitted by post or email MUST be signed.

I declare that: the information, including financial information, contained in this form is true

and accurate; I have read the program guidelines; I have read, understood and accept the terms and conditions of funding and

my organisation will be able to fully comply with those conditions; I understand that incomplete applications may not be considered; if and where any personal details of a third party are included, the third party

has been made aware of, and given their permission for, those details to appear in this application;

I am not aware of any perceived or actual conflict of interest that will arise by submitting this application. (For more information please see page 5 of Part B of the program guidelines. Describe below any conflicts of interest that have been identified; and

This funding application has the support of the organisation’s store board/governing committee and has been approved at a duly constituted meeting, and I am authorised to lodge the application on behalf of the organisation.

Please describe any conflict of interest that may occur from submitting this application:

Signature Date

Name (please PRINT) Position in organisation

IMPORTANT:

Funding agreementSuccessful applicants must agree to and sign a funding agreement with the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). Funding of projects requiring funds of less than $25,000 may be agreed via a ‘letter of offer’. All other projects will require agreement via the FaHCSIA standard Funding Agreement. The terms and conditions of the standard funding agreement can be found at: http://www.fahcsia.gov.au/grants-funding/general-information-on-funding/terms-and-conditions-standard-funding-agreement


http://www.fahcsia.gov.au/grants-funding/general-information-on-funding/terms-and-conditions-standard-funding-agreement

http://www.fahcsia.gov.au/grants-funding/general-information-on-funding/terms-and-conditions-standard-funding-agreement

http://staffnet/ourbusiness/service_delivery/Documents/letter_offer_v5-1.DOC

http://staffnet/ourbusiness/service_delivery/Documents/letter_offer_v5-1.DOC

Part 7 Application checklist

To ensure that your application is complete, use the following checklist.

Part 1 Eligibility: Have you responded to all relevant areas?

Part 2 Organisation details: Completed

Part 3 Financial Viability: Have you completed all questions?

Documents indicated at question 11 can be supplied, if required

Short explanation to question 12 has been attached, if required

Independent quotes have been attached – minimum 2 quotes (question 20)

Part 4 Project Activity specific question: All questions answered?

Part 5 Responses to selection criteria: Have you addressed selection criteria 1 to 4, in this application, in line with the program guidelines?

Part 6 Declaration: Have you read, signed and completed the declaration?

Part 7 Application checklist (this part): Have you completed the application checklist?

Please note: applications that are incomplete and do not have all information attached may not be considered.
