Please Read the Sustainable Community Fund Application Guidelines Before Commencing The

1. 2. 3.

4. Pacific Hydro

5. Codrington/Yambuk

6. Sustainable Communities Fund

7. 2014

8. 9. The following communities are within the funding area: Codrington Yambuk Port Fairy Kirkstall Orford Koroit 10.

12. Please read the Sustainable Community Fund application guidelines before commencing the application.

13. A. Contact Details Please complete all fields: Contact (Name and Title) ……………………………………...... ………………………… Position ……………………………………...... ………………………… Organisation/Community group name: ...... ………………………...... ………………………… Name on cheque: ……………………………………...... ………………………… ABN: ……………………………………...... ………………………… Physical address: ……………………………………...... ………………………… ……………………………………...... ………………………… ……………………………………...... ………………………… Postal address (if different from above: ……………………………………...... ………………………… ……………………………………...... ………………………… ……………………………………...... ………………………… Phone numbers: ……………………………………...... ………………………… E-mail address: ……………………………………...... ………………………… Pacific Hydro aims to limit our environmental footprint wherever we can. If you would prefer all correspondence regarding the Sustainable Communities Fund to be sent via email, please tick this box Pacific Hydro aims to ensure all community groups are aware of the Sustainable Communities Fund. By answering this question, it helps us to ascertain if we are promoting the Fund in the correct places. Where did you hear about the Fund? Moyne Gazette Warrnambool Standard Radio Poster Word of mouth Direct notification Other ………………………………………………………………

14. Applications must be made by a representative or member of the organisation applying for funding. Third party applications will not be accepted.

15. Please sign this declaration and submit with your application. I (Name) ______declare that I am a representative or member of (Organisation) ______and I will not personally receive any commission or any part of any funding awarded as a result of this application. Signed: ______(If applying electronically, please type your name) Date: ______16.

17. B. Project Details Project name ______Summary of the proposed project for which you are seeking funding: What do you want to do? (NB: The Sustainable Communities Fund will not grant funding for individual pursuits, salaries, political campaigns or organisations, religious organisation for religious purposes, fundraising events, producing or distributing printed material or advertising materials, one off events, public schools (unless good reason is indicated) or Government projects. Please see the Sustainable Communities Fund guidelines for a full list). ______What do you hope the project will achieve? ______Why is this important? ______

Who will benefit from your project? Please be as specific as possible and provide an estimate number of community members who will benefit ______

Is anyone else providing this service?

Yes No If yes, please explain:

______Where will the project be located? Local or Regional (Please specify) NB: Please refer to the front cover of this application for relevant funding areas. Applications outside of this funding area must demonstrate why they believe they are eligible. ______What contribution will the community make towards the project? (e.g. labour, materials, other funds – please be specific) ______

Please attach two letters of support for your organisation and this project. Referees must not be associated with Pacific Hydro (this means Landholders are unable to provide a reference). They should be familiar with your organisation, the project and this application. It is preferable that support letters come from community members who will use your services. Local council references are not necessary as we consult with them during the selection process. 18. C. Brief history of the organisation Tell us about your organisation. ______What are you trying to do? ______What are the services and activities of the organisation? ______Not-for-profit Yes No

(If not, please describe why the organisation is seeking funding for the project) ______

21. D. Project Management How will the project be managed and by whom? ______What is the schedule for implementation of the project? Include or attach a timetable of activities or a list of milestones. ______Please list the key members of your organisation’s executive management and Board ______22.

23. E. Evaluation and Reporting Please provide 3-4 key indicators that will be measured to determine the success of the project. 1. ______2. ______3.______4. ______Report Back Form Pacific Hydro requires a report back form to be completed at the end of the six month project implementation period. If Pacific Hydro does not receive the form your organisation may be disqualified from funding in future rounds. We do this to ensure transparency and accountability of the program for both the community and Pacific Hydro. Please assist us by sending back this form. Do you agree to provide this form? Yes No Sponsorship Agreement Pacific Hydro requires a ‘Sponsorship Agreement’ to be completed, if you are successful, before receiving the grant cheque. This is an agreement between you and Pacific Hydro outlining your agreement to spend the funds in line with your application form and letter confirming success. Do you agree to provide this form? Yes No 24. F. Financial Management Please attach:  Information about your organisation’s financial status; and  A specific budget for this community project, including projection of revenue from all sources and expenditure How much money is being sought from Pacific Hydro (in total)? Requests of $10,000 or less are more easily accommodated under the grants program. For transparency and auditing purposes Pacific Hydro requires fund distribution to be specific, please attach a written quote and a breakdown of where funding is going. $

For annual events, how many years do you require the funding? Year 1 – $_____ Year 2 – $_____ Year 3 – $_____ Will the amount requested from Pacific Hydro fully fund this project? (If not, please tell us how you intend to find the rest of the money. Projects must be completed within six months of receiving the grant unless prior arrangement is made with Pacific Hydro) Yes

If not: What other sources of funding are, or may be, involved? (Please list names and amounts. If funding has not been sought on any Government level, please explain why not. Please also indicate if funds have been approved or your organisation is still waiting on approval.) Local Government

State Government

Federal Government

Philanthropic trusts

Fundraising

Other (please specify) ______We may seek financial details, including the latest annual report or accounts of the organisation. What tax concessions does the organisation have from the Australian Taxation Office (ATO)? ______Please attach copies of your endorsement notices as a Tax Concession Charity (TCC) (previously known as Income Tax Exempt Charity (ITEC)) and Deductible Gift Recipient (DGR) if you have them. Neither endorsement is necessary to be eligible, but they may assist in the evaluation process. Is there anything else that we haven’t asked that you believe is critical to this application? ______

Thank you for taking the time to complete this application. Pacific Hydro will consider all applications that fit within the guidelines of the Sustainable Communities Fund. Requests of $10,000 or less are generally more easily accommodated due to the large numbers of requests we receive. Please do not send any items which you deem valuable and cannot be replaced as we cannot guarantee their safe return. Please direct any queries about your application or the Fund to Communications Officer, Remi Gordon, on (03) 8621 6478 or [email protected]. We wish you every success with your application.