FAHCSIA
STANDARD APPLICATION FORM FOR FUNDING

			

2009/2010
APPLICATION FORM FOR FUNDING UNDER THE GENDER EQUITY FOR WOMEN PROGRAM
Respectful Relationships

Information for Applicants 

Closing date

Applications must be submitted by 5:00pm AEST 15 October 2009 

How to
Lodge

Application forms must be completed and submitted in hardcopy and must be lodged by the closing date.  Applications postmarked after the closing date may not be included in the assessment process. Postal applications should be mailed to:

			FaHCSIA/09/RFT669
Tender Box
Department of Families, Housing, Community Services and Indigenous Affairs
Module B Reception
Tuggeranong Office Park
Athllon Drive 
Tuggeranong ACT 2900

Following the receipt and registration of applications, there will be an initial screening of applications to ensure: 

­	Eligibility of organisations;
­	Applicants comply with the terms and conditions detailed in the Application Guidelines and Application Form; and
­	Complete information has been provided in the Application Form to enable a fully informed assessment to be made.

Contacts

	Assistance

	Should you have any questions about this application form, please consult the Applictation Guidelines. If you cannot find the information you require please email rr@fahcsia.gov.au.

National Relay Service (NRS)

If you are deaf or have a hearing or speech impairment, you can use the NRS to contact any of the Department's listed phone numbers.  To access a 1800 FaHCSIA number NRS users should phone 1800 555 677 or visit the NRS Website at http://www.relayservice.com.au/

Application Guidelines

If you are completing this application form you should only proceed if you have read the Application Guidelines. Assessment of applications will be based on the information provided in the Application Guidelines.

Fraud

The Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) is committed to the Commonwealth Fraud Control Policy and Guidelines. Applicants should familiarise themselves with the Department’s Fraud Control Policy Statement which also underpins their respective fraud and risk minimisation responsibilities when dealing with the Department (http://www.fahcsia.gov.au/about/doingbusiness/Pages/default.aspx#4). 
One key responsibility is to report all suspected fraud to the relevant contact officer and Fraud Control Manager within FaHCSIA.  

Personal
Information

Any personal information you provide is protected under the Privacy Act 1988.  The Department will not use any personal information for any other purposes unless required by law or you provide your consent to do so. The Department will not disclose any personal information to any other organisation or to any individual unless required by law or you provide your consent to do so. 

Information Use

Please note that in some circumstances, FaHCSIA may use successful applicants’ information, other than personal information that has been provided in the applicants’ application, to assist FaHCSIA State Offices to:

(a)	inform staff negotiating and establishing funding agreements of risks and issues which need to be addressed in the agreement for that program; or
(b)	inform future assessments for applications in the same program; or
(c)	inform assessments for applications for other programs.

Please indicate whether you agree to the Department using the information (not personal information) you have provided in your application for the purposes listed at (a), (b) and (c) above.

I agree          		
I do not agree		

Part 1 				Eligibility

1a. Organisation type and financial status

Is your organisation or lead agency non-government?   Non Government    Government      

Is your organisation or lead agency not for profit?         Not for Profit           For Profit

1b. Organisation entity type

Please tick √ all applicable boxes.

Incorporated Association
Incorporated Cooperative 
             Aboriginal Corporation 
             Organisation established through specific Commonwealth or State/Territory legislation 
Company (Incorporated under Corporations Act 2001)
	 Local Government
	 State Government

If you have not ticked any box from the list above, your organisation is not able to apply for funding. You should refer to the Application Guidelines.

Part 2 		Organisations Eligible to be Funded

2	What is the legal name of your organisation?    
This is the name that appears on all official documents and legal papers. It may be different to your trading name.

	

All further responses within this Application Form must relate to this entity. 
This is the legal entity that FaHCSIA will enter into Funding Agreements with.

 3    What is the trading name of your organisation? 
	This is the name your organisation trades or provides services under.

4   Does your organisation plan to sub-contract any or all of the service provision, if this application is successful?	
 Yes          No

If yes, successful applicants may be asked to provide details of those sub-contracting arrangements and the organisations involved.		             	

5   What is your organisation’s 
     physical address? 

     Enter the contact person’s address if your organisation does not have its own registered address, etc.

    		
	                               Physical Address (Not a PO Box)	

Building / Floor	

	

Street No. and name 	

	

Suburb / Town	

	

State	
	
Postcode	

	
6   What is the postal address of your organisation?

Same as above  	                                 
                               Postal Address 	

Building / Floor	

	

Street No. and name or PO Box	

	

Suburb / Town	

	

State	
	
Postcode	

	

7	 What is the outlet name, where the service will be delivered? (If different, to Q2 or Q3.)

8 What is the outlet’s physical address?

     	                                 Physical Address (Not a PO Box)

Building / Floor	

	

Street No. and name	

	

Suburb / Town	

	

State	
	
Postcode	

	

9   If more than one outlet is going to be used to deliver the service please list
     Enter the contact person’s address if your organisation does not have its own registered address, etc.	                                 Physical Address (Not a PO Box)

Building / Floor	

	

Street No. and name	

	

Suburb / Town	

	

State	
	
Postcode	

                                 Physical Address (Not a PO Box)
Building / Floor	

	

Street No. and name	

Street number and name	

Suburb / Town	

	

State	
	
Postcode	

	

10   Who are the authorised Contact Persons for this application?

	Preferred Contact	Alternative Contact	
Title			
First name			
Surname			
Position in Organisation			
Telephone number			
Mobile number			
Fax number			
Business Email address			

 Part 3 				Financial Details
FaHCSIA is unable to fund your organisation if you do not provide bank account details.

12 Does your organisation have an 
	Australian Business Number (ABN)? 	   Yes           No

If Yes, what is the ABN of your 		
	organisation? 

If your organisation has an ABN 
	Branch number, please provide it here. 

13 Is your organisation registered for GST? 

(Questions on GST requirements should be addressed to the Australian Taxation Office.) 	

 Yes                      No

14 If you would like Recipient Created Tax Invoices (RCTI’s) to be sent to an alternative email address to that of the “Preferred Contact” listed in Q10, please provide the new email address here.

If this is left blank RCTI’s will be sent to the “Preferred Contact” email address at Q10.	

15 Please provide details of your organisation’s bank account for payment should your application be successful.

Record the account details of the organisation listed at Q3 only. FaHCSIA will not make cheque payments or payments to a third party.		

BSB Number	

	

Account Number	

	

Account Name	

	

		

Part 4 			Financial Viability and Governance

16   Please attach the following information:
                                                                                                                                                    
•	Your Organisation’s most recent audited financial statements (with previous year for comparison)

Are these statements fully compliant with Australian accounting standards            
                                                                                                                                            Yes       No

      If “No” what is your rationale for preparation of Financial Statements which are not fully      
            compliant with Australian Accounting Standards.

            

•	a current financial statement (income and expenditure, balance sheet, and statement of equity - this statement does not need to be audited), 
•	an income and expense budget, for the financial year for which funding is sought. (Excluding the funding being applied for in this Application.)

17   Please indicate if your organisation has the following:
	
Please tick where applicable(√ )

a)	an organisation chart………………………………………………………

b)	duty statements for all positions………………………………………….

c)	financial policy and procedures (systems manual)…………………….

d)	delegations, (authorised financial delegates…………………………...
       or decision makers)

e)	business plan……………………………………………………………. .

f)	risk management plan……………………………………… …………...

g)	minutes of board meetings……………………………………………... 

As a part of our financial viability verification process you may be asked to provide copies of these documents.             
Can you provide copies of these documents within 7 days of a request by us?              
                                                                                                                              Yes         No

18   Please tick (√) if any of the following apply to your organisation. 	

•	Any form of litigation or enquiry during the past three years, current or pending. 
             NOTE: If you have settled a claim on confidential terms, please indicate this 
              in your response………………………………………………………………………  
•	Any significant financial matter which may impact on the organisation, 
             E.g. insolvency or voluntary administration.………………………………………… 
•	Future commitments or contingent liabilities that might materially affect the organisation…………………………………………………………………………….   

If you have ticked any of the above (Q18) please provide a short explanation here.  
(Further information may be requested.)

Does
 19   Has your organisation recently applied for any other FaHCSIA funding?	

FaHCSIA program name
	
Amount of funding	
Period of funding	
Date of application	
, 

				

Does
 20   Has your organisation applied for funding from any other source to deliver the same services covered by this application?	

Program or funding source name
	
Contact Officer	
Date of application	
, 

			

Recent Funding Applications
Part 5 	Program Specific Questions
(Please note: If there are no Specific Questions for your process write “Not Applicable” and continue to Part 6).

Target Groups
3   Please list the services your organisation is proposing to deliver		

	

1   Please list your proposed target groups here.		

	

2   Enter the State or Territory the proposed service will be provided in.

Enter the Local Government Area which will be covered by the proposed service.

    Enter postcode(s) of the location which will be covered by your proposed service.	State or Territory	

Local Government Area	

Postcode(s)	

	

Part 6 		Responses to Selection Criteria

1.	Program delivery and design
Describe your Respectful Relationships program and how the proposed service delivery model will be made operational in the proposed community to achieve positive outcomes for young people (12-24 years) within your proposed budget.

­	Describe how the program will be delivered and operate,
­	Provide information such as budget and financial management plans that will help determine value for money in social service delivery.
(These dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)

	

2.	Need for the program
Demonstrate a need for respectful relationships services in the proposed community.  Describe how the proposed service delivery model will achieve the intended outcomes of the program in the proposed community. 

•	Provide information which demonstrates the need for services under this program. 
•	Provide evidence that relates your intended approach to the desired outcomes of this program. 
(These dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)

	

3.	Expertise and experience
Demonstrate your expertise and experience of working within the school system, or in other learning communities, to deliver respectful relationships or similar educational services to young people (12-24 years).  This includes the strategies you will use to gain the necessary expertise or qualified staff for the program and detail of what measures will be taken to support staff for the life of the funded program. 

•	Provide information about the expertise or qualifications of staff working with specific target groups or specific service delivery skills.
•	Provide information on your experience of working within the school system, or in other learning communities.
•	Detail recruitment or training strategies that will assist your organisation to meet program requirements.
•	Consider and list qualifications of project / financial management staff detailed in criterion one.
(These dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)

	

4.	Past performance
Demonstrate your experience in developing, delivering, managing and monitoring effective respectful relationships or similar programs to achieve positive outcomes for young people 
(12-24 years).

•	Provide details of your organisation’s experience in managing this type of program 
•	Describe how you will monitor your progress to achieve the desired outcomes of this program. 
(These dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)

	

5.	Capability
Demonstrate your ability to manage government funded programs to an agreed standard and to achieve quality outcomes for young people (12-24 years).

•	Provide information about your experiences and ability to manage government funded programs.
•	Detail strategies that will assist your organisation to achieve quality outcomes for young people.
(These dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)	

	

6.	Financial Viability
Demonstrate that your organisation is operating on a financially sound basis and will remain financially viable for the duration of the contract period.

•	Provide information as previously requested.

	

7.	Capacity
Demonstrate your willingness and capacity to participate in a national evaluation of the Respectful Relationships education program.  Participation in the evaluation will involve ongoing liaison and communication with an independent researcher. 

•	Provide information about your experience working with independent researchers on program evaluation.
•	Detail strategies that will promote your capacity and ability to participate in a national evaluation program.…
(These dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)	

	

8.	Program adaptability
Describe features of the proposed Respectful Relationship program that would enable implementation in alternative settings and geographic locations if the opportunity presented.

•	Provide information about the potential of your respectful relationships education program to adapt to alternative settings.
•	Detail strategies that will enable your program to be adapted to alternative settings and ensure quality outcomes in those settings.
(These dot points are provided to assist you to develop your responses. They are suggestions only and you should add any further information, within the word limit, that will assist us to assess your application.)

	

 Part 7				Declaration

     Please complete the declaration

NOTE: 
Applications being submitted by post MUST be signed.	I declare that:
­	The information, including financial information, contained in this form is true and accurate.
­	I have read the Application Guidelines.
­	I have read, understood and accept the terms and conditions of funding and my organisation will be able to fully comply with those conditions. 
­	I understand that incomplete applications may not be considered.
­	I agree to receiving Recipient Created Tax Invoices (RCTI’s) for this funding should this application be successful.
­	consortium members (if applicable) will be those specified in the Application: from the time the Application is received by the Department, and through assessment and any Funding Agreement negotiations,
­	if a consortium is used and there is any change to its composition, I will notify the Department prior to signing any funding agreement,
­	consortium members (if applicable) have given permission for their organisation’s information to be made available to the Department,
­	If and where any personal details of a third party are included, the third party has been made aware of, and given their permission for, those details to appear in this application.

If any financial information requested at PART 4 has not been submitted please list any missing documents here. 

	
	Signature		Date	
				
	Name (please PRINT)		Position in your Organisation	

Funding Agreement
Successful applicants must agree to and sign a funding agreement with the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA).  

	If this form was completed by an organisation with less than 20 employees, please provide an estimate of the time taken to complete this form.
Include:
•	The time actually spent reading the instructions, working on the questions and obtaining the information.
•	The time spent by all employees in collecting and providing this information.
	
			Hours		Minutes	

Part 8  				Application Checklist 

To ensure that your application is complete, use the following checklist.

Part 1	Eligibility: Have you responded to all relevant areas?

		
Part 2	Organisation Details: Completed          		
Part 2a	Consortium Details:            (If applicable)
•	Consortium members and roles listed?
•	Memorandum of Understanding attached, signed by members?

	
Part 3	Financial Details: All questions completed?		
Part 4	Financial Viability: Have you provided the documents requested at Q16, and completed all questions?		
	•	Short explanation to question 18 has been attached if required		
Part 5	Program Specific Question: All questions answered?		
Part 6	Responses to Selection Criteria: Have you addressed selection criteria 1 to 6, in this Application, in line with the Application Guidelines?		
Part 7 	Declaration: Have you read and completed the declaration carefully? 		
Part 8	Application Checklist (this part): Have you completed the application checklist?		
General	The following numbers of applications have been completed
Original,  2 copies and a CD (if required)  

Note: Applications that are incomplete may not be considered.