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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 AddressAddress/PO Box:City/Suburb/Town:State and Postcode:Organisation Email:Organisation Phone:Organisation Chair: Name: Position:

Applicant Organisation Contact OfficerTitle:Name:Position/Role:Phone:Email:Legal Status of Applicant OrganisationThe Applicant Organisation must be an incorporated not-for-profit organisation whose dominant purpose is charitable. It will be responsible for the project and for appropriate acquittal of the funds. If an Applicant Organisation is not incorporated then it must seek sponsorship from an eligible incorporated charitable organisation.

Incorporated Charitable Entity (Attach Certificate of Incorporation)Not Incorporated Charitable Entity (Complete Section 1a Sponsoring

Organisation)Local Government Other Please specify:

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 1a.

Bank:Account Name:

BSB: Account Number:

1a. 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 AddressAddress/PO Box:City/Suburb/Town:State:Postcode:Organisation Email:Organisation Phone:Organisation Chair: Name Position

Sponsoring Organisation Contact OfficerTitle:Name:Position/Role:Phone:Email:

Healthy Tasmania Community Innovations Grants 2017 Application Form Page 1 of 7

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:

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 descriptive.

Project Start and Finish DateProjects must be completed by 30 October 2018

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)

$ $ or N/A $

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

3. Project Description and ObjectivesYour ProposalDetailed description to support your application (800 words or less)

Office Use


Please link your proposal to the Healthy Tasmania Community Innovations Grants Guidelines 2017. Please address:1. Overview – What is your project and who are you helping? Does it cover healthy

eating, physical activity, smoking cessation and/or community connections?2. Rationale – Why is the project required? Use available data sources where possible.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 diversity 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. Collaboration & Support – who are you partnering with and why?8. Outcomes & Evaluation – What is the project intended to achieve? How will you

measure whether the outcomes have been achieved?9. Sustainability – How will the outcomes continue to benefit the target group or

community after the project?Enter project description here:

4. Partnership and CollaborationYour OrganisationPlease provide a brief description of your organisation and evidence that your organisation and collaborative partners, have the capacity to deliver the project outcomes.

5. 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


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

Yes (Provide details below) No

When was it delivered and how was it funded?

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

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

7. 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 and

salaries will not be funded unless they are new costs explicitly linked to project delivery.In Kind Contributions (provided by the applicant to the project) Cost

Service Delivery (e.g. training, transport, communications, rooms, catering) Cost

Equipment (any equipment critical to the project) 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. fliers, media, ads, invitations) Cost

Skills Provision (project consultants, subject matter experts) Cost

TOTAL $

8. Project Work PlanProject Work PlanOverview of the major activities and milestones for your projectPlease provide an indication of the expected delivery dates for the key project activities.Activity Expected Completion

Date (Month/Year)

9. Monitoring and EvaluationWhat will you do? How well will you do it? Is anyone better off?Evaluation ideas to support your application (500 words or less) Please address:1. Who are your participants? (eg. male, female, age-range, expectant mothers etc.)2. How many people are you expecting to reach with your project (an estimate)?3. What outcomes are you expecting?4. How will you measure if your participants are better off as a result of the project?5. How will you measure if you are delivering services well? (eg surveys comparing beginning and end of

project, quotes, success stories)? If successful in your application, would you like to receive more information on and templates for

evaluating your project? Yes No



Applicant OrganisationWe acknowledge that submitting an application for funding electronically warrants that we are duly authorised to submit an application on behalf of the organisation that is seeking a grant from the Healthy Tasmania Community Innovations Grants 2017. Further, we acknowledge that the absence of a handwritten signature in the application for funding does not invalidate the electronic submission. We also undertake to sign and forward a hard copy of this signature page, along with supporting documentation, where the application was lodged electronically.

Declaration and signature of two persons duly 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 organisationPhone

Date

Submitting ApplicationsApplications close 5:00 pm Friday 15 September 2017. Late applications will not be accepted. Questions? There is a FAQ 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 to [email protected] with the subject line ‘Community Innovations Grants’. In your covering message, please state your organisation, project name, and address. Scan and send the signed signature page and any hard-copy supporting documents.

If you need to submit a hard copy application, please post to:2017 Healthy Tasmania Community Innovations GrantsPublic Health ServicesDepartment of Health and Human ServicesGPO 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.


mailto:[email protected]

mailto:[email protected]

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:An Agreement to Sponsor letter (example letter provided in Attachment)

Supporting Documents, if applicable

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 Form authorisation page.This letter must be provided on the Sponsoring Organisation’s official letterhead.

Date

Chair, Healthy Tasmania Community Innovations Grants Working GroupDepartment of Health and Human ServicesGPO 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 2017 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]
