Contact Point and Deadline

Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs Arts & Culture Capital Scheme 2016-2018 Application Form STREAM 3

 This form should be completed having regard to the eligibility criteria of the scheme and the guidelines attached.  On completion please forward the form and accompanying documentation to: Arts Capital Unit, Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs, New Road, Killarney, Co. Kerry, V93 A49X OR e-mail to: [email protected]  Applications will be accepted until 12 noon on 16 June 2017. Applications received outside of this timeframe will not be considered.

1. ORGANISATION DETAILS AND STRUCTURE 1A. Legal Name Trading Name (If different) Address

PostCode Contact Name for correspondence Position in organisation Telephone No. Email

1B. Structure of Organisation (please tick relevant entity) Not for Profit Voluntary Organisation Company Limited by Guarantee Trust Other, please specify No. of employees Please attach a copy of the Memorandum & Articles of Association or Constitution of the Organisation

1C. Applicant Tax & Related Details Tax Reference Number: Charity Number (CHY) (if applicable): VAT Registration Number: (if applicable) Is the organisation eligible to claim back VAT

1D. The Code of Governance for Community and Voluntary Organisations Is the organisation compliant with the Governance Code? YES______NO______OR Is the organisation on the adoption journey towards compliance? YES______NO______

Please provide Charities Regulator Reference Number (RCN)______(please note that this is different from your CHY number above)

1 | P a g e 1E. Organisation Description Please provide a brief description of your organisation (no more than 200 words for this section)

2. PROJECT OUTLINE Please provide short summary of the proposed project under the following headings (no more than 700 words in whole section) List the main objectives of the project?

What are the planned outcomes of the project?

Proposed commencement date

Proposed completion date Please provide a brief description of the proposed works / project to be undertaken

Please provide details of how your project meets the selection criteria set out in Section 7 of the Guidelines.

2 | P a g e 3. CAPITAL COSTS

The purpose of this section is to establish the total capital cost involved in the project. Costs must be shown net of VAT.

Total project costs €______(Excluding VAT)

COST DESCRIPTION COST EX VAT VAT

At least one professionally prepared quotation or pre-tender estimate must be provided for all aspects of the works being applied for. This can be one or more documents but must cover everything being applied for.

The following types of documents are acceptable as quotes: 1. An estimate prepared by a technical supervisor 2. A quote from a contractor/supplier including details of who is providing the quote 3. Extract from a catalogue/website (for equipment only)

4. FUNDING SUMMARY

3 | P a g e The Scheme proposes to fund projects up to a maximum 70% of the total eligible cost, subject to a maximum grant payment of €20,000, with the balance of 30% to be funded from the project’s own resources. Please provide details of this matched funding basis as follows: Source Details € Grants (where applicable )

Own Funding (where applicable )

Borrowing (where applicable)

Other, specify

A. Confirmation of the availability of own funds in the form of a bank statement dated within 3 months of application deadline should be provided. B. Confirmation of the availability of borrowing in the form of a bank facility letter should be provided if applicable; a sample letter is attached at Appendix A of this document. C. If you use OTHER, it must be secured by a written undertaking from the relevant source confirming that the funding will be forthcoming if the project is approved.

Amount of grant sought under this application €______

5. FINANCIAL STATEMENTS VERY IMPORTANT – PLEASE NOTE One copy of your most recent financial statements must be provided with your application

6. SITE OWNERSHIP /TITLE

Do the Promoters currently have:

Ownership / Satisfactory lease on premises Yes NO SEE A BELOW If lease, please state term of lease

Planning Permission YES NO N/A

Other Statutory Consents YES NO N/A

If the answer is no, please provide details A. Please provide with your application a written statement from your solicitor or owner/landlord outlining the legal status of the property to be developed. The project promoter should have at least a 3 year minimum leasehold interest in the property that they occupy or the property is owned outright. 7. DECLARATION This proposal has been completed by me/completed on my behalf and I declare that the information provided is true and correct. I am aware that incomplete applications and/or applications that are not accompanied by the required documentation will not be considered.

4 | P a g e Signed: Date: ______

Name: ______

Capacity: ______Telephone: ______email: ______

Contact point and deadline

Applications will be accepted up until 12.00 noon on 16 June 2017.

N.B. Applications received by the Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs outside of this timeframe will not be considered.

You may post or email your application.

If posting, please post to;

Arts Capital Unit Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs New Road Killarney Co Kerry V93 A49X

If emailing please e-mail to: [email protected]

PLEASE COMPLETE CHECKLIST ATTACHED ON NEXT PAGE

5 | P a g e 8. CHECKLIST The following is a list of items which must accompany your application. If you require any clarification of these items please consult the guidelines or contact the Arts Capital Unit of the Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs at (064) 6627213, 6627355, 6627333 or email [email protected]

DOCUMENT TYPE Y/N SECTION 1 ORGANISATION DETAILS AND STRUCTURE

1B. A copy of the Memorandum & Articles of Association or Constitution of the Organisation MUST be attached;

1E. Organisation description must be within 200 words

SECTION 2. PROJECT DETAILS Please note that this must be strictly within the 700 word limit for the whole section

SECTION 3. CAPITAL COSTS At least one professionally prepared quotation or pre-tender estimate must be provided for all aspects of the works being applied for

SECTION 4. FUNDING SUMMARY A. Confirmation of the availability of own funds in the form of a bank statement dated within 3 months of application deadline should be provided.

B. Confirmation of the availability of borrowing in the form of a bank facility letter should be provided where applicable. Ensure Appendix A is fully completed and attached to your application if relevant.

C. If you use OTHER, please provide details and confirmation, ensuring that this funding is secured prior to submitting your application.

Have you filled in 'Amount of grant sought under this application'

SECTION 5. FINANCIAL STATEMENTS One copy of the organisation's most recent financial statements must be provided with your application

SECTION 6. SITE OWNERSHIP /TITLE Letter confirming legal status of property being developed from solicitor or owner/landlord and if relevant confirmation of length of lease from the landlord of the property being developed

SECTION 7. DECLARATION

Has this been signed and dated.

6 | P a g e Appendix A – Sample Loan offer letter If the level of own funding includes a loan, you must confirm this with a letter from the financial institution involved indicating the amount of the loan and that it is not conditional on a grant allocation being approved. An example of a suitable loan offer letter is detailed below. You must either have this letter completed, signed and stamped by your financial institution or provide a letter from your financial institution containing the information sought in the sample letter.

Name of organisation

What is the amount of the loan?

What is the purpose of this loan?

Is the granting of the loan dependent on the applicant receiving a grant from the Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs?

Has the applicant any other loans outstanding from this financial institution?

What term is the proposed loan?

What are the monthly repayments?

Is loan fully approved or approved in principle?

When will loan be available for draw down?

______Please print name ______Signature ______Financial Institution Stamp Job Title

7 | P a g e