<p> 1</p><p>CLARE & GILBERT VALLEYS COUNCIL</p><p>All correspondence directed to – 4 Gleeson Street Clare SA 5453 Telephone: (08) 8842 6400 Facsimile: (08) 8842 3624 Email: [email protected] Web: www.claregilbertvalleys.sa.gov.au ABN 82 461 007 206 Community Asset Grant Scheme 2012</p><p>Application form</p><p>Due by: 5 pm Friday 20 April 2012</p><p>(9 pages including checklist)</p><p>THIS FORM IS ALSO AVAILABLE ELECTRONICALLY FROM CLARE AND GILBERT VALLEYS COUNCIL.AND ON THE WEBSITE: www.claregilbertvalleys.sa.gov.au Word format available on request</p><p>Community Asset </p><p>Council Asset </p><p>1. Title of proposal</p><p>2. Location of project 2 3. Organisation Details</p><p>3.1Name of organization</p><p>3.2Contact person</p><p>3.2.1 Name</p><p>3.2.2 Position in organization</p><p>3.2.3 Address (postal)</p><p>3.2.4 Phone</p><p>3.2.5 Fax /Email 3 4. Type of organisation (please circle)</p><p> Incorporated</p><p> Community/non- profit</p><p> Government funded</p><p> Section 41 committee of Council</p><p> Other</p><p>5. ABN if applicable</p><p>6. Certificate of incorporation (if applicable) – please attach</p><p>7. Detailed description of the project, if this project is part of a larger development please provide a brief outline of the whole development planned. Please include/ attach:  Maps  Photographs  Quotes  Evidence of use of contractors or qualified trades people  Any additional material that would strengthen your submission 4</p><p>8. Please list the other community groups that are involved in or would benefit from your project (if applicable). Please provide details</p><p>9. Demonstrate the community need for this project please provide as much evidence as possible (i.e. survey forms, letters of support, strategic plan etc) 5</p><p>10. Does the project involve any works being undertaken on or in a council owned asset or land?</p><p>10.1 If so have you received written permission or planning and /or building approvals from Council?</p><p>10.2 Please provide details</p><p>11. Do you need any licenses, registrations, or other approvals to undertake the project? These applications should meet all statutory requirements i.e. Occupational Health and Safety Regulations, Building Regulations, Equipment Standards etc. Licensed Trades People should be used if applicable</p><p>11.1 If so please provide details 6</p><p>12. What results are expected from this project?</p><p>13. Has your organisation received Clare and Gilbert Valleys Council’s Asset Grant Scheme funding previously? (Please Circle)</p><p>Yes No</p><p>If yes when? 7</p><p>14. Detailed outline of costs and expected funding sources Please include details of any free works (in kind) provided by your or any other organisation/business associated with this project. eg, labour provided for removal of fences, loan of equipment (A suggested value for voluntary labour is $25 for unskilled and $40 for skilled) 8</p><p>Please print name ______</p><p>Position Held in Organisation______</p><p>Funding source (all areas are to be completed) Clare and Applicant Item/ Activity Other organisations Gilbert (your organisation) Valleys Council Cash In Kind Name Cash In Kind (max $2,000) Eg: fencing materials Jo Blo Fencing $600 Eg Labour $1000 Eg Pavers $2000</p><p>Sub totals TOTAL COST Inc GST if applicable</p><p>Signature ______</p><p>Send Applications to:</p><p>Clare and Gilbert Valleys Council 4 Gleeson Street CLARE SA 5453</p><p>Or 9</p><p> [email protected]</p><p>By 5pm Friday 20 th April 2012</p><p>Please phone Lol Hill on 08 8842 6400 </p><p>Or email on [email protected] for any further information</p><p>Check List for Asset Grants 2012</p><p>The following checklist has been devised to assist in preparing the application; some of the list below may not be applicable to your application. Inclusion of sufficient data for evaluation is necessary to ensure consideration.</p><p>Please ensure that:</p><p> Application will be postmarked or received by Council by 5pm on Friday April 20 2012 (can be emailed)  All questions have been answered  Approvals for works on Council land have been obtained if applicable  The application been signed by the appropriate person and contact details have been included  The budget has been completed 10</p><p> o The financial totals have been placed in the correct budget columns</p><p> o The Grant amount requested has been placed in the Clare and Gilbert Valleys Council column</p><p> o If funding is being sourced from “other organisations” these organisations are named</p><p> o The volunteer hours have been calculated and included </p><p> Support letters are attached</p><p> Quotes are attached</p><p> Photos are attached</p><p> Plans are attached </p><p> The application has been proof read</p><p> Please secure applications and attachments with a paper clip- do not bind your applications as copies are made  A cover page is not necessary  Please submit your application in a single sided format</p>