Section 1 Organisational Details

NATIONAL LOTTERY APPLICATION FORM 2016

APPLICATION UNDER NATIONAL LOTTERY GRANT SCHEME 2016

Please tick below to specify if your application relates to National Lottery Funding or Respite Care Grant Scheme.

National Lottery Funding …………………. 

Respite Care Grant Scheme……………… 

HSE Reference (office use only) ______

Directorate: Mental Health  Primary Care  Disabilities 

Older Persons  Health & Wellbeing  Community Healthcare Organisation: Check Appendix 3 for your CHO Area:

Section 1 Name of Voluntary Organisation/Group:

Name and Address of main contact / liaison person for the organisation

Name of Organisation: NAME of Contact Person: ______

Address: ______Position Held: ______Tel No: ______

Name and Address of Chairperson Name and Address of Secretary ______Address of Organisation (base/office if applicable)

______

Telephone: Fax: ______

Email: ______Website: ______

Organisation Status/Charitable Status/Tax Clearance Certificate

Please tick all of the following that are relevant to your organisation

Limited Company Yes No Tax Reference No: ______

Registered Charity Yes No Registered Charity (CHY) No: ______

The Organisation holds a Tax Clearance Certificate Yes No

Tax Clearance Certificate Number:

Certificate expiratory date:

Note: If the Tax Clearance Certificate expires within 3 months of closing date for this scheme a further certificate bearing a later expiry date must be sought and submitted with your application.

When was your organisation established? Year Aims and Objectives of the organisation ______

Describe the activities of your organisation ______

Target groups of your organisation (what groups of people benefit from your service) ______

2 Please give details of current numbers of paid, voluntary, community employment, and other workers involved in your organisation

Paid Full Paid Part Volunteers Community Others Total Time Time Employment

All Details in Section 1 are compulsory

Section 2 Describe the project/service for which grant is now being sought or attach details of project/service on a separate page/document. ______

Is the Project? A once off project? Yes No Part of an ongoing operation? Yes No

When did or will the project commence? ______When is it due to end? ______

Why is this project needed? What is the identified need within this CHO that your organisation is seeking to satisfy (please provide relevant information to support application) ______

With this project, how do you propose to address the needs of the clients in this CHO? ______

What are the expected benefits/outcomes of the project to clients of this CHO? ______

3 How does this proposal represent value for money? ______

How will the service/project integrate with other agencies and organisations? ______

Specify clearly (name) the geographic area in which this project will be delivered (e.g. local community area(s) / DED, electoral area, county/counties, Community Healthcare Organisation (CHO) Area, etc.)

Estimated number of clients in the CHO named above that will benefit from this project?

What category of persons are expected to benefit? (older persons, families, etc) ______

State the estimated total cost of the project € ______

State the cost to be incurred in the current year: € ______

State how much the group is contributing to the project € ______

State the amount of grant now sought for the project: € ______

Please outline breakdown of costs associated with the project. Please submit quotations/estimates for all aspects of the project and return with this application form. ______

Has your organisation previously applied for funding from the HSE or another public source? (If yes, please set out details, including details as to any unsuccessful applications) ______

4 Is your organisation currently or has your organisation previously received funds from private sources? (If yes, please set out details) ______

Has your Organisation/Group made, or does it intend to make an application for funding towards this project to any other source (private or public)?

Yes No

If YES state: Sources, amounts sought and result if any:

______

Please give details of amount (in €) and source of National Lottery grants received by your organisation from public funds in the following years (if applicable):

2013______

2014______

2015______

Give details of the amounts (in €) and sources of funds that are available to your Organisation/Group for this project – for example cash in hand, donations, fundraising, other grants, etc,. ______

______

DECLARATION

(To be completed by Chairperson, Hon. Treasurer of Organisation/Group)

On behalf of: ______I,______wish to apply for a grant towards the project/service named above and I declare, that all the information given in this form is true and complete to the best of my knowledge and belief and undertake that upon completion of this project/service named above that a statement will be forwarded to the Executive signed by the CEO or Chairperson of the Board stating that a 2016 National Lottery Grant awarded in respect of this project/service was used for the stated purposes intended.

Signature ______Signature ______Chairperson Treasurer

Date ______Date ______

5 Tel No ______Tel No ______

6 Checklist for National Grant Application

This checklist must be included with applications.

Please ensure that all the accompanying information is provided and this will ensure applications are processed as quickly as possible.

Please note that all incomplete applications will be returned to the organisation/group and will not be regarded as valid until all appropriate information is provided

Checklist Yes No

Annual Report

A completion Statement for any 2015 National Lottery Grant(s) received if not already submitted *

Fully completed copy of the Application Form, (per Sections 1 & 2) signed and dated

Copy of Architects, Contractor’s or other estimates

Charitable Status

Tax Clearance Certificate (If the Tax Clearance Certificate expires within 3 months of closing date for this scheme a further certificate bearing a later expiry date must be sought and submitted with your application

Last Available Audited accounts (or other statutory accounts) or an Income and Expenditure Account certified by the Chairperson of the Organisation must be provided, whichever is deemed appropriate

*A statement signed by the CEO or Chairperson of the Board stating that any National Lottery Grant(s) awarded in 2015 was/were used for the stated purposes intended

COMPLETED APPLICATIONS MUST BE SUBMITTED TO THE LOCAL COMMUNITY HEALTHCARE ORGANISATION (See Website for Details) IN A SEALED ENVELOPE AND CLEARLY MARKED “NATIONAL LOTTERY APPLICATION 2016” TO ARRIVE NO LATER THAN 5PM ON 27TH OF MAY 2016

7 APPENDIX 1

HSE –CRITERIA & CONDITIONS FOR GRANT ASSISTANCE

1. The approved grant must be expended for the purpose outlined in your application and at the end of the year the chairperson must send in a statement certifying that the funding was spent and for the purpose it was intended. . 2. A Tax Clearance Certificate (from the Revenue Commissioners) and/or a Charitable Status Number (from the Revenue Commissioners) must be provided with the application and at any subsequent times when requested by the HSE.

3. (a) Applicants for grant funding should have sufficient public liability insurance in respect of any services projects or activities that they deliver or engage in using HSE funding and the HSE will not accept liability in respect of any event arising from the delivery of services/projects. The adequacy of public liability is a matter for the grantee and their insurance company. The Recipient will indemnify the HSE for all losses, damages, costs and professional incurred.

4. Estimates of expenditure must be provided.

5. An income and expenditure account certified by the Chairperson of the organisation must be provided and must separately identify the contribution received from the HSE. This must be submitted on completion of the project/service.

6. Organisations must keep records of expenditure e.g. receipts, which will be available for inspection by the HSE if required. The HSE reserves the right to inspect and/or audit the accounts of the grant-aided body. The HSE may require access to documents, files, staff and premises associated with the project/service. The trustees of the project/service agree to provide any information and documentation/invoices requested by the HSE.

7. Where the funds cannot be expended immediately on the project/service, the project/service sponsors will act as trustees with the relevant HSE area in relation to the funds and comply with the Trustees (Authorised Investments) Act 1958, and all Orders made thereunder) until such time as the project/service is completed. In such circumstances, a statement of the investments undertaken together with a corroborative certificate from an approved deposit taker or investment manager must be provided at least annually. In the event of the project/service not proceeding or progressing significantly within the revised timescale, the funds provided must be returned to the HSE. The HSE retains the right to require the return of funds, on the basis of its own determination that the circumstances warranting such return have occurred.

8. Where funding is from the National Lottery, the National Lottery may engage in publicity of selected beneficiaries, and co-operation with the National Lottery Company is a condition attached to all grants issuing from National Lottery proceeds.

9. The HSE should be notified where there is a change in officers (e.g. Chairperson, Treasurer or Secretary of the funded agency.

10. The organisation must acknowledge funding on the receipt of funding form attached to the agreement

8 11. That the work of the grant aided body comes within the legally permitted area of concern of the HSE.

12. That the grant aided body is based locally within the community and its function is important to the health and welfare of that community.

13. That the grant aided body can show its effective and efficient use of the funds based on sound administrative and clerical support.

14. That the grant aided body complies with the requirements of the Revenue Commissioners.

15. That the accounts and financial statements of the grant aided body are available to the auditors of the HSE for inspection at all reasonable times.

16. That the provision of grant assistance does not constitute State Aid.

I/we acknowledge that I/we have read the above conditions and that I/we agree to comply fully with all of the terms.

Signed on behalf of ______

Signature: ______

Status of Signatory: ______

Date ______

Witness: ______

Address of Witness: ______

Date: ______