standard application form for funding · web viewpart 4 financial viability and governance 16....

APPLICATION FORM FOR FUNDING UNDER THE

FINANCIAL MANAGEMENT PROGRAMCOMMONWEALTH FINANCIAL COUNSELLING (CFC)

FINANCIAL COUNSELLING TO SUPPORT PEOPLE AFFECTED BY PROBLEM GAMBLING INITIATIVE

Information for applicants

Closing Date Applications must be received by 2:00pm AEDT Tuesday 12 February 2013.

How to lodge Application forms can be completed and submitted in hardcopy and/or by email and must be lodged by the closing date listed above. Applications postmarked after the closing date may not be included in the assessment process.

Paper based applications must be lodged at:

Financial Counselling to Support People Affected by Problem GamblingFaHCSIA/12/RFT745 Department of Families, Housing, Community Services and Indigenous Affairs, Module B Reception, Tuggeranong Office Park, Athlon Drive Tuggeranong ACT 2900

Electronic applications must be sent to: [email protected]

by the closing date and time specified above.

Electronic applications must include a scanned signed copy of Part 6.

mailto:[email protected]

Questions and Answers

Should you have any questions about this application form, please consult the Financial Management Program Guidelines (Part A through to Part C), found at http://www.fahcsia.gov.au/our-responsibilities/communities-and-vulnerable-people/programs-services/commonwealth-financial-counselling-cfc#gambling

If you cannot find the information you require please email [email protected]

Questions and answers will be posted at the website above. Questions will not be taken or responded to after Tuesday 5 February 2013, or at any time during the assessment phase.

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. Assessment of applications will be based on the information provided in the program guidelines.

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

(a) comply with the Australian Government 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

(d) inform assessments for applications for other programs or

(e) promote access to the program.

Please indicate whether 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) (d) and (e) above.

I agree

I do not agree

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http://www.relayservice.com.au/

http://www.fahcsia.gov.au/our-responsibilities/communities-and-vulnerable-people/programs-services/commonwealth-financial-counselling-cfc%23gambling



Part 1 EligibilityTo be eligible for funding through this selection process applicants are to be existing organisations funded under:

the Australian Government’s Financial Management Program to provide Commonwealth Financial Counselling services and/or

state/territory governments to provide general financial counselling services or problem gambling financial counselling services to individuals and/or

therapeutic counselling services working with problem gamblers that are funded by either the Commonwealth or state/territory governments and

a member of, or to be eligible for membership of, a relevant financial counselling association.

General financial counselling refers to face to face and/or telephone financial counselling services. This excludes rural financial counselling.

1a. Organisation type and financial status

Is your organisation (or lead agency) non-government?

Non-government

State/Territory, Local government

Is your organisation (or lead agency) not-for-profit?

Not for profit

For profit

Is your organisation funded by the Australian Government’s Financial Management Program and/or a state/territory government to provide general financial counselling services, problem gambling financial counselling services or therapeutic problem gambling counselling services to individuals?

Please tick √ all applicable boxes.

Yes the organisation is funded by the Australian Government’s Financial Management Program to provide Commonwealth Financial Counselling

No the organisation is not funded by the Australian Government’s Financial Management Program to provide Commonwealth Financial Counselling

Yes the organisation is funded by state/territory government/s to provide general financial counselling services to individuals

No the organisation is not funded by state/territory government/s to provide general financial counselling services to individuals

Yes the organisation is funded by state/territory government/s to provide problem gambling financial counselling services to individuals

No the organisation is not funded by state/territory government/s to provide problem gambling finanical counselling services to individuals

Yes the organisation is funded by state/territory government/s to provide therapuetic counselling services to individuals affected by problem gambling

No the organisation is not funded by state/territory government/s to provide therapuetic counselling services to individuals affected by problem gambling

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If you have not ticked Yes to one of the previous boxes your organisation is not eligible to apply for funding. You should refer to the Financial Counselling to Support People Affected by Problem Gamblers (Financial Management) Program Guidelines Part C.

Does your organisation currently have a Funding Agreement with FaHCSIA for any other activities/service strategies under the Financial Management Program?

Yes

No

Does your organisation currently have a Funding Agreement with FaHCSIA for any activities/service strategies (other than the Financial Management Program?)

Yes

No

1b. Organisation entity type1

This eligibility list contains entity types with which FaHCSIA is able to enter into funding agreements.

Please tick √ all applicable boxes.

Incorporated association incorporated under Australian State/Territory legislation

Incorporated cooperative incorporated under Australian State/Territory legislation

Organisation established through specific Commonwealth or State/Territory legislation

Company incorporated under Corporations Act 2001 (Commonwealth of Australia)

Non–government legal entity

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

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Part 1b Service Coverage AreasService Coverage areasPlease clearly identify the service coverage area you are intending to service. A separate application must be submitted for each Service Coverage area being applied for.

ACT North Canberra South Canberra

NSW Canterbury-Bankstown Murrumbidgee-Murray South Eastern Fairfield-Liverpool Richmond-Tweed Mid-North Coast Inner Sydney Central Coast (Sydney) North Western Central Western Sydney Hunter Northern Blacktown Illawarra Central West Inner Western Sydney St George-Sutherland

NT Darwin Alice Springs Katherine

QLD Logan City Wide Bay-Burnett Mackay Ipswich City Northern – North West Far North Darling Downs – South

West Caboolture-Pine Rivers-Redcliffe

Sunshine Coast

Gold Coast

SA Eyre-Northern Adelaide Outer Adelaide Yorke and Lower North-Murray Lands-South East

TAS Mersey-Lyell Southern-Greater Hobart Northern

VIC Greater Dandenong City Hume City Western Melbourne Northern Middle

Melbourne Western District -

Barwon Gippsland-East Gippsland

Melton-Wyndham Inner Melbourne Moreland City

WA Perth Ngaanyatjarra Lands (This position will be selected

through a separate selection process due to its remote location)

Please include whether you are currently located in service coverage area, providing services in the service coverage area and the type of service you provide.

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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 application 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. 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 will be asked to provide details of those sub-contracting arrangements and the organisations involved as part of the funding agreement negotiation process.

5. 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 P.O box)Building/floor

Street no. and name

Suburb/town

State Postcode

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6. What is the postal address of your organisation?

Same as above

Postal AddressBuilding/floor

Street no. and name or P.O box

Suburb/town

State Postcode

7. What is the outlet name, where the service will be delivered? (If different, to Q2 or Q3.)

8. What is the outlet’s physical address?


Street no. and name

Suburb/town

State Postcode

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9. If more than one outlet is going to be used to deliver the service please list Enter the contact person’s address if your organisation does not have its own registered address, etc. If more space is required please attach details.


Street no. and name

Suburb/town

State Postcode


Street no. and name

Suburb/town

State Postcode

10. Who are the authorised Contact Persons for this application?

Preferred contact Alternative contact

Title

First name

Surname

Position in organisation

Telephone number

Mobile number

Fax number

Business email address

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Part 2a Consortia like arrangement detailsConsortia like arrangement Definitions

Lead agency – This is the legal entity, specified in Part 2, which if successful will be offered a funding agreement by FaHCSIA.

Consortia like arrangement – This is the combined group of entities that is applying for funding through this application form. FaHCSIA will only contract with individual providers. Applicants may determine that efficient or effective service delivery is best achieved through the use of a network of providers through a sub-contracting arrangement. This can be recorded in responses to the selection criteria. A successful provider who utilizes an authorised sub-contracting arrangement will be held liable for all obligations contained in the terms and conditions of the funding agreement. This includes monitoring, management, financial performance, service outcomes, and specifically insurance coverage. Note: that the consortia like arrangement does not sign any funding agreement with the department.

11. Consortia like arrangement details (Lead agency details must be completed in Part 2.)

Please list the legal names of all members of the consortia like arrangement and provide a brief description of each member’s role in the delivery of the services.

Organisation legal name ABN Role in consortia like arrangement1 Lead agency and contract signatory

2

3

4

5

Attach a signed statement by the proposed consortia like arrangement members showing:* their agreement to enter into a consortia like arrangement for the purposes of this funding,* the nature of the legal relationship that will occur between parties if the application is

successful, and* how the arrangements between the members will be managed and overseen by the Lead

Agency.

The Department will not accept changes to consortia like arrangements that, in the opinion of the Department, represent a material change to its application.Further evidence of the consortia like arrangements may be sought from successful applicants prior to the signing of the funding agreement.

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Part 3 Financial detailsFaHCSIA is unable to fund your organisation if you do not provide bank account details.

12. 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.

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

Yes

No

14. If you would like Recipient Created Tax Invoices (RCTIs) to be sent to an alternative email address to that of the preferred contact listed in Q10, please provide the new email address here.

If this is left blank RCTI’s will be sent to the preferred contact email address at Q10.

15. Please provide details of your organisation’s bank account for payment should your application be successful.

Record the account details of the organisation listed at Q3 only. FaHCSIA will not make payments to a third party.

BSB number

Account number

Account name

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Part 4 Financial viability and governance

16. Please attach the following information:

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

Are these statements fully compliant with Australian accounting standards?

Yes

No

If no, what is your rationale for preparation of financial statements which are not fully compliant with Australian accounting standards.

a current financial statement (income and expenditure, balance sheet, and statement of equity - this statement does not need to be audited).

an income and expense budget, for the financial year for which funding is sought. (Excluding the funding being applied for in this application).

17. Please indicate if your organisation has the following:

Please tick where applicable(√ )

an organisation chart

duty statements for all positions

financial policy and procedures (systems manual)

delegations, (authorised financial delegates or decision makers)

business plan

risk management plan

minutes of board meetings

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

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

Yes

No

18. Please tick (√) 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 ticked any of the above (Q18) please provide a short explanation here (further information may be requested).

Recent funding applications

19. Has your organisation recently applied for any other FaHCSIA funding?

FaHCSIA program name Amount of funding Period of funding Date of application

20. Has your organisation applied for funding from any other source to deliver the same services covered by this application? If yes please list details below.

Program or funding source name Contact officer Date of application

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Part 5 Responses to selection criteriaHow to fill in selection criteriaResponses to the selection criteria (1-5) should not be more than 700 words for each criterion.

Applications for each service coverage area will be assessed individually. If applying for more than one service coverage area you will need to complete a separate application for each coverage area to be considered eligible for funding.

Selection Criterion 1: Service delivery model

Describe your proposed service, and how this will be made operational to achieve Commonwealth Financial Counselling outcomes for people affected by problem gambling who are in personal financial difficulty. Your response should include:

a) The location from which the service would be delivered; and any proposed outreach service;

b) the process for identifying and prioritising target groups and key referral mechanisms ;c) information about your service provision to vulnerable and disadvantaged people,

including Indigenous communities, people who have low literacy skills and/or where English is not their first language;

d) difficulties that could be encountered in implementing the service and solution strategies to overcome any problems;

e) client feedback and complaints handling policy;f) any proposed subcontracting arrangements; andg) any limitations to physical and telephone accessibility of the service delivery outlets.

(These 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.)

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Selection Criterion 2: Qualifications for and recruitment of service delivery staff

Demonstrated expertise and qualifications of staff to achieve quality outcomes in delivering Commonwealth Financial Counselling services for people affected by problem gambling and a demonstrated ability to fill the advertised position expeditiously. Your response should include:

a) Information about how you ensure that your financial counsellors undertake appropriate training in order to have adequate skills and knowledge to satisfactorily provide financial counselling services;

b) an outlining strategy for filling the advertised position within a short period of time specifically highlighting whether an existing staff member could fill the position or if not what recruiting methods will you undertake to fill the role?


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Selection Criterion 3: Management capability

Demonstrated ability of your organisation to manage financial counselling services to a high standard and to achieve quality outcomes for people affected by problem gambling who are in personal financial difficulty. Your response should include:

a) Your organisational structures to support the management of problem gambling financial counsellors;

b) your organisations support and supervisory arrangements for problem gambling financial counsellors;

c) your organisations workforce planning, training and development of problem gambling financial counsellors; and

d) your organisations quality assurance mechanisms.


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Selection Criterion 4: Stakeholder Engagement

Demonstrated ability to develop and maintain positive and effective relationships and partnerships to assist and support delivery of financial counselling services to people affected by problem gambling, including:

a) The ability to establish and maintain effective ongoing relationships with gaming venues, for example through established networks;

b) strategies to identify and engage problem gamblers and their families in order to deliver counselling services;

c) demonstrating how your organisation will work collaboratively within local community service networks, how it will link clients with complementary support services and how your organisation will work collaboratively with gaming venues;

d) establishing and maintaining effective relationships with relevant support services and how your organisation will link up to relevant referral services to develop a holistic approach to problem gambling; and

e) integration with existing FMP services.


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Selection Criterion 5: CALD/Indigenous Engagement

Describe your service delivery model in relation to how it offers culturally appropriate, accessible services including:

a) A demonstrated understanding of issues, specifically problem gambling issues for CALD and Indigenous persons in your community;

b) strategies to promote access to services by CALD and Indigenous clients;c) policies and processes to develop and implement culturally appropriate services to

Indigenous and CALD communities; andd) your organisations experience and demonstrated ability to work with Indigenous

and/or CALD clients.


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Part 6 Declaration

Please complete the declaration

NOTE: Applications being submitted by post 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, I agree to receiving recipient created tax invoices (RCTIs) for this funding

should this application be successful, consortium members (if applicable) will be those specified in the application:

from the time the application is received by the Department, and through assessment and any funding agreement negotiations,

if a consortium is used and there is any change to its composition, I will notify the Department prior to signing any funding agreement,

consortium members (if applicable) have given permission for their organisation’s information to be made available to the Department,

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).

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

If any financial information requested at Q16 has not been submitted please list any missing documents here.

Signature Date Click here to enter a date.

Name (please PRINT) Position in organisation

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).

A copy of the FaHCSIA Terms and Conditions – Standard Funding Agreement – for agreements entered into from 11 May 2011 is available on the Department’s website: http://www.fahcsia.gov.au/our-responsibilities/housing-support/grants-funding-new/terms-and-conditions-standard-funding-agreement .

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http://www.fahcsia.gov.au/our-responsibilities/housing-support/grants-funding-new/terms-and-conditions-standard-funding-agreement

http://www.fahcsia.gov.au/our-responsibilities/housing-support/grants-funding-new/terms-and-conditions-standard-funding-agreement

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 1b Service Coverage Area: Is the Service Coverage Area indicated?

Part 2 Applicant details: Completed?

Part 2a Consortia like arrangement details: (If applicable) Consortia members and roles listed? Signed statement by consortia members attached?

Part 3 Financial Details: All questions completed?

Part 4 Financial Viability and governance: Have you provided the documents requested at Q16, and completed all questions?

Short explanation to question 18 has been attached if required

Part 5 Responses to selection criteria: Have you addressed each of the section criteria?

Service delivery model

Qualification of service delivery staff

Management capability

Stakeholder engagement

CALD/Indigenous Engagement

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

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

Note: applications that are incomplete may not be considered.

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standard application form for funding · web viewpart 4 financial viability and governance 16....

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