application form - Riverside

MERSEY SOUTH
COMMUNITY CHEST FUNDING
GRANT APPLICATION FORM (Small Awards)
SECTION 1 - ABOUT YOUR ORGANISATION
1. Organisation Name:
2. Postal Address:
3. Main Contact:
4. Email Address:
5. Telephone Number:
6. If you are working with a partner organisation, please state who it is
7. What type of group are you? (please tick)
Voluntary or community group
Community/Social Enterprise
Charitable company limited by guarantee
Local branch of national organisation
Registered charity
Awaiting registration
Other
If a registered charity, please state number:
8. What are the main activities of the organisation?
9. If your organisation has made any previous applications for funding please indicate
Project Name
Date

SECTION 2 - ABOUT YOUR PROJECT
10. Project Title:
11. Area/Neighbourhood:
12. Where will the main activities of the project take place?
see guidance notes for neighbourhoods we will fund activities in
13. If you're application is successful when will it start?
14. Please indicate what type of project it is?
Worklessness Digital Inclusion Education
Financial Inclusion Health Neighbourhood Mgt
Green Spaces
Arts and Sports
15. Please describe the main activities of the project:
16. What evidence do you have that there is a need for this project?

17. If your organisation was awarded a grant, what outputs are likely to be achievable?
Outputs 1
2
3
18. If your organisation was awarded a grant, what outcomes are likely to be achievable?
Outcomes 1
2
3
19. How will you measure the outcomes and outputs of the project?
20. How will the project be promoted?
SECTION 3 - FINANCE
21. What is the total cost of the project? £
22. If you are applying to other organisations for funding, state how much and from where
£
£
£
£
Total £
23. If you have already secured funding, state how much and from where
£
£
£
£
Total £
24. How much are you requesting from Riverside? £
25. If we award funding, how do you intend to use the Riverside grant?
£
£
£
£

SECTION 4 CHECKLIST
26. All sections of the application form have been completed
27. I have enclosed a signed copy of our constitution/governing document
28. I have enclosed a signed copy of our accounts of the last financial year
29. I have enclosed a copy of our most recent bank statement
30. If applicable, the organisation has public liability insurance
31. How did you hear about the Riverside Community Chest Fund?
Contract
I confirm that the group/organisation making the application (as named on this application form) has
authorised me to sign this agreement on their behalf. I certify that the information given in this application
is true and confirm that the enclosures referred to on the checklist are current, accurate and adopted or
approved by the organisation making the application.
Terms and Conditions:
1. If the application is successful we will use any grant for only for the purposes set out in this application.
2. We will not sell or dispose of any equipment or other assets bought with a grant without first receiving
Riverside Group’s agreement in writing. We will not use the grant to pay for goods or services bought or
ordered before we receive the award letter confirming a grant.
3. If we receive a grant for a pilot project, we understand that Riverside Group will not automatically fund
any later projects.
4. We will comply with any relevant legislation affecting the way we carry out our project.
5. We will acknowledge Riverside Group’s grant in our annual report, our Chair’s or Secretary’s report at
our AGM, the accounts which cover the period of the grant and in any publicity materials produced about
the project.
6. We will show the grant separately in our annual accounts as a ‘restricted fund’ and will not include it
under general funds.
7. Riverside Group can use our name(s) and the name of the project in its own publicity materials. 8. We
will inform Riverside Group of any situation where confidentiality is a particular issue.
9. We understand that Riverside Group will not increase the grant if we overspend.
10.We will keep all financial records and accounts, including receipts for items bought with the grant, for
at least two years from receiving the grant. We will make these available to Riverside Group if asked. We
understand that this does not release us from our legal responsibility to keep records for longer periods.
11. We understand we are required to compile and return, within six months of the project completion
date, all monitoring information as requested by Riverside Group.
12. Riverside Group may hold back a grant or ask us to repay a grant, in whole or in part, in the following
circumstances:
a) If we fail to keep to this contract in any way;
b) If the application form was completed dishonestly or the supporting documents gave false or
misleading information;
c) If we do not follow equal opportunities practice in employing people, recruiting new members and
providing our services;
d) If any member of our governing body, staff or volunteers acts dishonestly or negligently in their work for
us at any time during the project;
e) If the project closes down and we sell or dispose of equipment or assets provided via the grant without
first receiving Riverside Group’s agreement in writing.
Declaration:
I confirm the group/organisation making this application agree to the above terms and conditions
Name:
Date:
Signature:
Position
If partner organisation is acting as your banker, they must also sign the application form
Name:
Date:
Signature:
Position:

OFFICE USE ONLY
Amount Requested
Date Received
Reference No.
All sections of the application form have been completed
I have enclosed a signed copy of our constitution/governing document
I have enclosed a signed copy of our accounts of the last financial year
I have enclosed a copy of our most recent bank statement
If applicable, the organisation has public liability insurance
Additional Information Required?
Yes
No
Should this application be submitted to the CISG
If NO, for what reasons?
Yes
No
Date to be considered
Approved Deferred Rejected
Amount £
If deferred, reasons:
If rejected, reasons:
Signed
Name
Signed
Letter Sent
Monitoring Form Sent
Name
Payment Requested
Monitoring Form Returned