North North East Nillumbick, Banyule, Darebin, Whittlesea <frankie.gallagher@dhhs.vic.gov.au> 9479 0381 Outer Gippsland Wellington, East Gippsland <jill.ayres@dhhs.vic.gov.au> 5144 9140 South Inner Gippsland Latrobe, Baw Baw, South Gippsland, Bass Coast <tania.cake@dhhs.vic.gov.au> 5136 2569 Southern Melbourne Cardinia, Greater Dandenong <denise.olsson@dhhs.vic.gov.au> 8765 7330 South Bayside Peninsula Frankston, Mornington Peninsula, Kingston, Bayside, Glen Eira, Stonnington, Port Philip <emma.robinson@dhhs.vic.gov.au> 9784 3140 West Barwon Geelong, Surf Coast, Queenscliffe, Colac-Otway <renee.williams@dhhs.vic.gov.au> 5226 4692 West Wimmera South West Area Warrnambool, Glenelg, Southern Grampians, Corangamite Northern Grampians, Horsham, West Wimmera, Yarriambiack, Hindmarsh, <catherine.darkin@dhhs.vic.gov.au> 5561 9436 <dianne.stewart@dhhs.vic.gov.au> 5358 8406 West Central Highlands Ararat, Pyrenees, Ballarat, Hepburn, Moorabool, Golden Plains <melissa.collier@dhhs.vic.gov.au> 5333 6804 West Brimbank, Melton 9479 0268 West Western Melbourne Melbourne, Maribyrnong, Wyndham, Hobsons Bay, Moonee Valley <sally.moonie@dhhs.vic.gov.au> 9275 7531 Men’s Grant Application 2018 Which category of funding is this application for? Mark with an ‘X;’ as applicable. Building a NEW men’s shed (up to $60,000)
Yes No Is the shed group part of an Aboriginal Community Controlled Organisation? Mark with an ‘X;’ as applicable. Yes No Does the men’s shed need an auspice for this project? If the men’s shed group is not incorporated, an incorporated organisation must be engaged to manage the grant funds. This organisation will be the ‘auspice’ organisation for the project the organisation details should be provided in Part B. Mark with an ‘X;’ as applicable. Yes, I need an auspice organisation for this application (If yes, complete Part B: Auspice organisation details) No, I do not require an auspice organisation for this application If no, complete Part C: Contact details for project manager or key contact person) Part B: Auspice organisation details (if applicable) Name of organisation: Main street address: Town/suburb: Postcode: Postal address (if different from above): Town/suburb: Postcode: State: Authorised person (This is the person who is authorised to make the application on behalf of the auspice organisation) First name: Last name: Position: Telephone: Mobile:
Section 4 – Project budget Please provide details of the income and expenditure for the project, excluding GST. Note that the total income must equal total expenditure. Please ensure that the details clearly show how the required 2:1 funding ratio is being met. Applicants are required to submit the project budget using the categories provided. If additional space is required please provide a summary here and the details on a separate sheet (or sheets) using the same categories. Ensure that all budget contributions are confirmed in writing, by a letter or email. Include copies of those letters/emails in the application pack. Income Amount Expenditure Amount Grant amount requested from this program $ Project construction $ state government funding $ Contingencies and escalations $ Local government funding $ In-kind labour $ Federal government funding $ In-kind – support $ Funds from the men’s shed group $ Registered Commercial Builder Management $ from other community organisations $ Other (please specify below) $ Funds from business contributions $ $ Funds from philanthropic contributions $ $ In-kind support from the men’s shed group participants $ $ In-kind support from other sources $ $ (please specify) $ $ income $ Total expenditure $ Declaration I that the information in this application and attachments is to the best of my knowledge true and correct. I will notify the Department of Health and Human Services (the department) of any changes to this information and any circumstances that may affect this application. I acknowledge that the department may refer this application to external experts or other government departments for assessment, reporting, advice, comment or for discussions regarding alternative or collaborative grant funding opportunities. I understand that the department is subject to the Freedom of Information Act 1982 and that if a freedom of information request is made, the department will consult with the applicant before any decision is made to release the application or supporting documentation. I understand that this is an application only and may not necessarily result in funding approval. To be signed by a person with delegated authority to apply – such as chairperson, secretary, or treasurer of the men’s shed group, or if an auspice is being used, from the auspice organisation. Signature: Print name: Date: Position: