DEPARTMENT OF CHILDREN & YOUTH AFFAIRS

NATIONAL LOTTERY GRANT SCHEME 2014

APPLICATION FORM

Please read this form and information leaflet carefully before submitting an application. All sections of the form must be completed in full. Incomplete applications will be returned and not processed unless re-submitted.

The closing date for receipt of fully completed applications is no later than 12:30pm on Friday, 6th June, 2014. No exceptions will be made to this closing date All applications must be clearly marked “National Lottery Grants”

Please send the signed completed form and supporting documentation to the following FREEPOST address:

National Lottery Grants,Freepost,Department of Children and Youth Affairs,43-49 Mespil Road,Dublin 4.

Document Checklist

Before you submit this application please ensure that you have fully completed it and included all the relevant supporting documentation. Failure to do so will result in your application being returned.

Checklist

Financial information e.g. Annual Financial Statements, Bank Statements, Annual Accounts

Tax Clearance Certificate / Authorisation if required

Charitable Status Number (CHY No.) or

Details of Tax Registration Number/ Tax Reference Number / Tax District

Certificate of Expenditure (if applicable)

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A. Organisation Details

Name of Organisation(Please ensure that you use the same name as you have used in previous applications)

Address

What are the aims and objectives of the organisation?

Briefly describe its activities

When was the organisation founded?

Please state your Tax Registration No:Tax Clearance Cert No:

Tax District:If your organisation has been granted Charitable Tax Exemption from the Revenue Commissioners please state the CHY:

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B. Contact Details

(For person to whom all correspondence will be sent)

First name

Surname

Address

Position held (within organisation)

Telephone

Mobile

Fax

Email

C. Previous National Lottery Funding

Has your organisation previously received National Lottery funding from the Department of Children and Youth Affairs or any other source?

If Yes, please specify;

Yes No

Year Amount Certificate of Expenditure Submitted

Yes No

Yes No

Yes No

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Note:New applications cannot be approved before certificates of expenditure for any previous National Lottery funding have been received and verified.

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1. D. Other Funding Applications

The Department of Children and Youth Affairs 2014 National Lottery Grant Scheme is targeting projects in areas which are not covered by other Programmes currently operated by DCYA, DCYA funded organisation or other government funded sources.

If your organisation has made, or intends to make an application to any other source (private or public) for a grant towards this project please provide details for each application:

Grant Scheme Application Submitted / Grant Amount Sought

DCYA Childcare Programmes for Capital Grant Funding Yes No €_______

Status / Outcome:

DCYA Youth Organisations and Services Capital and Current Grant Funding Yes No €_______

Status / Outcome:

Family Support Agency Grant Scheme Yes No €_______

Status / Outcome:

Department of Health National Lottery Scheme Yes No €_______

Status / Outcome:

Department of Transport, Tourism and Sports National Lottery Sports Capital Scheme Yes No €_______

Status / Outcome:

Other (please specify)_____________________________ Yes No €_______

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Status / Outcome:

E. Details of Proposed ProjectDescribe the project for which the grant is now sought. (Please explain precisely what you need the grant for and a breakdown of the associated costs)

Is this project

Once-off

Part of a continuing operation

When will/did the project commence for which funding is now sought?

When is it due to end?

State the estimated:

Total cost of the project

Cost in the current year

State the amount of the grant now sought:

If your organisation currently/previously received funds from public or private sources, please provide details:

Source of funding:

Amount sought:

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Please provide details of the amounts and sources of funds that are available to your organisation for this project e.g. cash on hand, donations, fund-raising.

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A copy of your organisation’s recent audited accounts, annual report and/or bank statement should be forwarded with this application.

F. Tax ClearanceOrganisations in possession of a Charitable Status (CHY) number do not need to complete Part F of this form.

A valid Tax Clearance Certificate and Tax Registration Number must be supplied with the application unless you have a CHY number. Applicants who are required to submit a Tax Clearance Certificate must produce an original or a certified copy of the Certificate before a grant can be paid. Alternatively, the Department can, with the permission of the applicant, carry out an online verification of tax clearance status using the website of the Revenue Commissioners. Please complete the following section if you wish the Department to carry out this online verification:

Tax Clearance Certificate No:

Tax Registration Number:

I/we authorise the Department of Children and Youth Affairs to carry out an online verification of tax clearance status using the website of the Revenue Commissioners.

Signed: Date:

Name:(in block capitals)

On behalf of (Organisation’s name)

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G. Construction Operations

This section must be completed in all cases, including registered charities, where a grant is to be used for Construction Operations exceeding €650 in value. Please see the information leaflet for a definition of “Construction Operations”. You may attach additional pages if necessary.

Please supply the following details in respect of each contractor / sub-contractor who will be employed on the grant-aided work:

Name Tax Reg No.

Address Tax District

Tax Clearance No.

Expiry Date

Name Tax Reg No.

Address Tax District

Tax Clearance No.

Expiry Date

Name Tax Reg No.

Address Tax District

Tax Clearance No.

Expiry Date

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Name Tax Reg No.

Address Tax District

Tax Clearance No.

Expiry Date

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H. Applicant’s Statement Applicant's statement I/we certify that I/we have read and understood the information leaflet and criteria of the Department of Children and Youth Affairs and agree to comply fully with them.

I/we certify that all information in this application and all information in any supporting documents is truthful and accurate.

First signatory

Signed: Date:

Name:(in block capitals)

On behalf of (Organisation’s name)

Second Signatory (if applicable)

Signed: Date:

Name:(in block capitals)

On behalf of (Organisation’s name)

IMPORTANT

Please ensure you sign your completed application form when returning it to the Department

The Department will only accept completed and signed original application forms

Please submit two copies of this application form (the original and one photocopy) along with one copy of the required supporting documentation

Please note applications will not be accepted by e-mail

CLOSING DATE FOR RECEIPT OF SIGNED/COMPLETED APPLICATIONS

NO LATER THAN 12:30PM ON FRIDAY 6th June, 2014

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Freedom of Information: The Department of Children and Youth Affairs wishes to advise applicants that, under the Freedom of Information Act the information supplied in the application form may be made available on request, subject to the Department’s obligations under law.

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I. Bank Details (for Organisation)Payment will only be made by electronic fund transfer (EFT) to your organisations bank account.

(BLOCK CAPITALS PLEASE)

Name of Bank:

Address of Bank:

Bank Account Name:

Bank Account Number:

Bank Sort Code:

Email: (for which Remittance will be forwarded)

I, ________________________________, authorise the Accountant, Department of

Children and Youth Affairs to make payment to _________________________________by

way of Electronic Funds Transfer (EFT), and in order to facilitate the transaction, I agree to

provide the Department with the information requested above.

Signed: _______________________________ Date: _______________

Position: _______________________________

(Must be senior member of organisation e.g. CEO, Chair, Treasurer, Secretary etc)

Data Protection:

The bank account details supplied will be held in accordance with Data Protection Act 1988, and the Data Protection Amendment Act, 2003. The Department will keep it only for one or more specified and lawful purposes, process it only in ways compatible with the purposes for

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which it was given to the Department initially, keep it safe and secure, and retain it no longer than is necessary for the specified purpose or purposes .

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