Age Friendly Communities Local Government Grants Program - Application Form

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Date Received:

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Age-Friendly Communities Planning Grants Program

Application Form

Thank you for your interest in the Age-Friendly Communities Planning Grants Program. Before completing this form, please ensure that you have: 1. Read and understood all of the information in the Grant Program Guidelines. 2. Made contact with the Senior Grants Officer, Department of Local Government and Communities, to discuss your project proposal and how this will meet the objectives of the program, on 6551 8700 or at [email protected].

Section One – Local Government Details

1.1 Local Government Name of Local Click here to enter text Government

Postal address Click here to enter text

Suburb Click here to enter text Postcode Click here to enter text

Telephone Click here to enter text 1.2 Contact Person Name the contact person responsible for the daily coordination of the project. Name Click here to enter text

Position Click here to enter text

Telephone Click here to enter text

Mobile Click here to enter text

Email Click here to enter text

1.3 Collaborating Local Governments Joint applications from two or more local governments are encouraged to achieve economies of scale. Is this a collaborative project? Yes ☐ (please list the partnering local government/s below and attach further information if insufficient space provided) No, single local government (please move to Section Two – Project Details) ☐ Name of local Click here to enter text government

Contact Person Click here to enter text

Name of local Click here to enter text government

Contact Person Click here to enter text

Please attach a copy of the collaborating local government/s letter of support, including the organisation’s participation in the project and any monetary and/or in-kind contributions, to this application: ☐ Letter/s of support for all participating local governments is/are attached to this application Section Two – Project Details

2.1 Community Need Please describe how your community, particularly seniors, would benefit from receiving funding to adopt an Age-Friendly Communities approach to planning in your area. Outline the short, medium and long-term benefits to your local government becoming an Age-Friendly Community.

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2.2 Project Description Please provide an overview of your project, in accordance with the information provided in the Guidelines. Ensure that the following are included in the proposal:

 the planned approach to deliver the program and build the internal capacity of the community and the local government

 the intended method to reach target stakeholders

 how the project objectives will be achieved

 a commitment to incorporate the research findings and recommended actions into the Strategic Community Plan of the local government

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2.3 Project Plan

Please attach a detailed project plan that outlines key phases, milestones and community engagement for the proposed activities. Include the project methodology with estimated dates and/or timeframes for completion. ☐ A copy of the Project Plan is attached to this application.

2.4 Outcomes and Evaluation Please list the expected outcomes of the project and how these will be evaluated once the project is complete. It is important to ensure that outcomes are measurable to assist with the assessment of the project’s success. Click here to enter text

2.5 Timeline Anticipated project commencement date: Click here to enter text Anticipated project completion date: Click here to enter text

Please note:

 Projects must be completed within 12 months of the commencement date.

Age-friendly Communities Planning Grants Program Page 3 of 11 Application Form  Assessment of applications may take up to 12 weeks from the date the application is submitted. Please consider this when stating the proposed project timeline.

2.6 Location In which region will the project be implemented?

Gascoyne ☐ Mid West ☐ Goldfields-Esperance ☐ Peel ☐ Great Southern ☐ Pilbara ☐ Kimberley ☐ South West ☐ Wheatbelt ☐ North West Metropolitan ☐ North East Metropolitan ☐ South West Metropolitan ☐ South East Metropolitan ☐ Section Three – Project Budget

It is important to show how you plan to spend the grant and whether you expect any other income to support your project. Use the table below to show where the money for your project is coming from and how it will be spent. Include the Age Friendly Communities Planning grant (maximum of $10,000) and specifically outline what areas the grant and other funding will be allocated to. If you are getting funds from other sources to support your project, it is important you show evidence of where the money is coming from. Please also include your organisation’s cash and ‘in-kind’ contributions. The proposed budget should align to the activities contained in the project plan. Do not include GST in your costings. Budget Items This Grant Other In-kind Source & Status of (i.e. what the money will Amount Funding Support Other Funding or In- be spent on) ($) (ex. GST) Amount Please estimate the kind Support ($) (ex. GST) dollar value of the Please state if confirmed or in-kind support unconfirmed ($) For example: $3,000 – Shire of Information XXX Confirmed 2,500.00 3,000.00 1,000 Gathering and $1,000 – Data Co. Analysis Pending

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Section Four – Grant Conditions

The grant is provided under the following terms and conditions: 1. The grant is to be used solely for the specified purpose approved by the Grantor during the funding period. 2. Written approval from the Grantor must be sought for any requests to vary the approved purpose or seek an extension of the funding period. 3. Any part of the grant funds that are not used in accordance with Condition 1 must be repaid to the Grantor unless prior written approval is obtained.

Age-friendly Communities Planning Grants Program Page 5 of 11 Application Form 4. Should the approved purposed of the grant cease or should the grant agreement be terminated on account of breaching the any of these Conditions, then: (a) the balance of any grant funds, unspent on approved items, must be repaid to the Grantor within ten (10) business days; and (b) any property acquired with grant funds must be transferred to another not-for-profit organisation with similar objectives and purposes to the organisation, upon approval by the Grantor. 5. Providing a grant does not mean that any further funding will be provided than that specified in the grant agreement. 6. The Grantor will not be held responsible for the success of the approved purpose for which the grant is provided or for any losses or additional costs incurred that are associated with the approved purpose. 7. Any documents or information relating to the grant or the approved purpose must be provided to the Grantor within ten (10) business days of the request. 8. All payment conditions and/or reporting requirements must be met, as specified by the Grantor. 9. The Auditor General for the State of Western Australia, or an authorised representative, must be granted access to, and be permitted to examine, records and information concerning this grant. 10. All Local, State and Commonwealth laws applicable to the approved purpose must be abided by and complied with at all times. 11. Any project that involves working with children must ensure that the organisation and all employees and volunteers comply with the Working with Children (Criminal Record Checking) Act 2004. Please refer to the Working with Children Check website for further information Working with Children. 12. The Grantor is not liable for any accident or negligence resulting in any claim or damage arising from activities undertaken as part of the grant. 13. Recipient organisations are required to be appropriately incorporated and be responsible for ownership of the appropriate insurance policies. This includes, but is not limited to, Public Liability, Volunteer Insurance, Workers’ Compensation, and Professional Indemnity. 14. An acknowledgement of funding assistance provided by the Grantor must be included in any advertising and on any material relating to the project. 15. Any individuals involved with the project must not be exposed to significant promotions for alcohol or unhealthy food and drinks during the project. 16. Goods and Services Tax (a) For the purposes of Conditions 17 and 18: (i) “GST” means the goods and services tax applicable to any taxable supplies, as determined by the GST Act; and (ii) “GST Act” means New Tax System (Goods and Services Tax) Act 1999 (Cth) and includes all associated legislation and regulations; (iii) the terms “supply”, “tax invoice”, “taxable supply”, and “value” have the same meanings as in the GST Act. (b) If the supply of anything under the grant agreement is a taxable supply under the GST Act, the grant funds shall be inclusive of GST. (c) The parties hereby agree that: (i) the Grantor will issue a Recipient Created Tax Invoice (RCTI) in respect the grant payment and which complies with the GST Act; (ii) the Organisation will not issue tax invoice in respect of that supply; (iii) the Organisation warrants that it is registered for the purposes of GST and the Organisation will notify the Grantor in writing if it ceases to be registered for the purposes of GST during the term of the agreement; (iv) the Grantor warrants that it is registered for the purposes of GST and the Grantor will notify the Organisation in writing if it ceases to be registered for the purposes of GST, or if it ceases to satisfy the requirements of the GST Act during the term of the agreement; and (v) the Grantor will indemnify and keep indemnified the Organisation for GST and any related penalty that may arise from an understatement of the GST payable on the supply of the project for which the Grantor issues a RCTI under this Agreement. 17. If any of the terms or conditions are breached by the recipient organisation, the Grantor has the right to terminate the grant agreement at any time and without giving prior notice.

Age-friendly Communities Planning Grants Program Page 7 of 11 Application Form Section Five - Declaration

This declaration is made by the applicant:

 I declare that I am currently authorised to sign legal documents on behalf of the organisation*.

 I declare that all of the information provided in this application, including all attachments, is true and correct.

 I declare that the organisation is financially viable and is able to meet all accountability requirements.

 I give permission to the Department of Local Government and Communities, if applicable, to contact any persons or organisations in the processing of this application and understand that information may be provided to other agencies, as appropriate.

 If a grant is provided, I am aware the Grant Conditions as outlined in section four will apply to ensure projects are appropriately completed and accountability requirements are met.

 If a grant is provided, I agree to ensure that appropriate insurances are in place (e.g. worker’s compensation, volunteers, professional indemnity, public liability, motor vehicle etc.).

 If a grant is provided, I agree to run the project as stated and provide: o a final acquittal report within the acquittal term specified in the grant agreement; and o a statement of income and expenditure for the project (signed by the authorised signatory); to the Department of Local Government and Communities by the agreed date, to demonstrate how the grant funds were expended. Name of the local government: Click here to enter text

Legally authorised officer name: Click here to enter text

Legally authorised officer position: Click here to enter text

Legally authorised officer telephone: Click here to enter text

Legally authorised officer email: Click here to enter text

Legally authorised officer signature:

Witness name: Click here to enter text

Witness signature:

Date: Click here to enter text

*Important: The application must be signed by the person legally able to enter into contracts on behalf of the organisation. The application may be signed by a formally authorised delegate, according to the organisation’s constitution or as bound by law. Please note: All formal correspondence will be sent directly to the legally authorised officer.

Age-friendly Communities Planning Grants Program Page 9 of 11 Application Form Application Checklist

Before you submit an application for funding please ensure you have completed the following and check each item once completed. Check Item box

The program guidelines have been read and understood by the authorised ☐ signatory and project officer.

Contact the Senior Grants Officer, Department of Local Government and ☐ Communities, to discuss your proposed project and application.

Complete all questions in the application form. ☐

Ensure that the application has addressed all selection criteria specified in the program guidelines. ☐

Provide written confirmation of participation and support from any local governments that will collaboratively deliver this project, including a ☐ commitment to collectively match (at least) the requested grant funding.

Provide a project plan. ☐

The legally authorised officer has read and completed the declaration in section five of the application form. ☐

Attach appendices to support your project (i.e. references, studies, etc.), as applicable. ☐ Please list any attachments included with this application: Click here to enter text Applications

Please submit applications to: Email (preferred): [email protected] Please ensure that a scanned copy of the signed declaration is included with email submissions. If it is not possible to include a scanned copy of the signed declaration, please post the original copy to the Department within five working days. Please note, as there is a limit to the size of attachments that can be accepted by email, supporting documents can be sent via post where required. Please make reference to this in the email should additional information be posted. Post: Senior Grants Officer Department of Local Government and Communities GPO Box R1250 Perth WA 6844 Fax: (08) 6552 1555

Age-friendly Communities Planning Grants Program Page 11 of 11 Application Form