Application Form Final

Registered Charity No. 274862

Application Form

Please complete all pages of this form and email it as an attachment to: [email protected]

Please adhere to the specified word-limits which are dictated by our grants software.

Please note that we only give grants to registered charities. We do not give grants to individuals or to expeditions. We do not ordinarily award grants to charities whose annual income exceeds £7.5 million.

Date of Application: App. & Req. No (admin use):

Name of organisation applying for grant:

Charity registration number:

Year established:

Contact Name:

Job title:

Address of organisation:

Postcode: Email address: Telephone Number: Website address:

How did you hear about the Trust? Background of Organisation: (150 words maximum) (e.g. Aims of your organisation? What does it do? Which geographical area does it serve? Who does it help?)

Project Name:

Project Summary: (35 words maximum) This statement will appear on your Acknowledgement of Receipt & Contract if your application is successful.

How much are you applying for?

Which of the Trust’s criteria do you meet? Please tick (X) one box ONLY Drug and Alcohol Support Offender Support Homelessness Refugees and Asylum Seekers Hospices Social Welfare/Community Regeneration Human Rights Vulnerable Children/Families Medical Care Women Support Medical Research Developing World Mental Health/Counselling Other – please specify:

Registered Charity No. 274862 Project Overview: (150 words maximum) (e.g. Purposes for which funds are requested?)

Details of Grant Requested: (150 words maximum) (e.g. How would this grant be budgeted?)

Project Costs: When will the project start? How long will it run for? When do you need this grant? Total cost of project?

Have you applied to the Trust before? If so: Month/Year: Amount of grant received OR application rejected

Finance Sheet

Registered Charity No. 274862 In addition to a completed application form, general applications should include the following information:  A copy of your latest signed and audited accounts

 Your budget for the financial year in which the project falls, separating income which relates to the project you want a grant for  Your budget for the project

 Details about other funding received or pending for the project

Please complete the following form which request financial information of the registered charity and not of the proposed project: YEAR ENDED: INCOME Govt (central/local) £ Fees £ Income from activities £ Legacies £ Investment Income £ Trusts/Companies £ Other sources: £ Total £ EXPENDITURE Direct charitable £ Fundraising/publicity £ Admin £ Other £ Total £ Surplus (Deficit) for the year £ Free Reserves: £

For the financial year above, what percentage of your income was from statutory sources?

Describe any material changes to the organisation’s activities, structure or financial position since the date of the most recent accounts:

Registered Charity No. 274862 Staffing: How many staff do you employ? Full time: Part time: Management committee members: Active volunteers:

Premises: (Please delete YES or NO as applicable) Do you rent the organisation’s premises? Yes/No Do you own these premises? Yes/No

Grant cheque (if awarded) should be payable to?

Declaration

I declare that the information given in this application form and in the accompanying documents gives a full and accurate picture of the organisation’s activities and financial position.

I understand that it is a condition of receiving funding that a report must be submitted by us within six months of receiving the grant for the benefit of the Trustees.

SIGNED ……………………………………………………………………

TITLE ……………………………………………………………………

Data Protection Statement

The Peter Stebbings Memorial Charity processes personal data in compliance with the Data Protection Act 1998. The Charity obtains and uses information, including personal data, as part of the process of assessing grant applications and monitoring use of grants. The information, including personal data, which you provide on the grant application forms, or in supporting documentation, may be made public as part of the assessment of applications. Information, including personal data, may be assessed and monitored by external evaluators contracted to the Peter Stebbings Memorial Charity. It will not be used for any additional purposes or disclosed to any third parties without your permission, except for the purpose of determining, preventing or detecting crime, validating the bona fides of contracts or where this is otherwise required by law.

Registered Charity No. 274862