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    Date Received (For Office use):

    Organisation Information
    Address

    Organisation Name*
    Type of Organisation* (Please select one from the list below)
    Purpose of Organisation*
    Organisation Main Category* (The broad category of the organisation)
    Organisation Sub-Category* (The specific category of the organisation)
    -
    Organisation Incorporation Number*
    New Zealand Business Number*
    (Your NZBN number may be found at www.nzbn.govt.nz)
    NZ Charities Registration number if applicable (NZCRN)
    Website*
    (URL must contain http:// or https://)
    Address*
    Street Address & PO Box Number)
    Are you GST Registered?*
    GST Number*

    Main Contact Person of the Organisation
    Name*
    Position*
    Address*
    Email*
    Mobile*

    Application Info
    Have you used a professional fundraiser to assist you with this application?*
    Is there a Conflict of Interest* (If yes, please summarise the conflict of interest)
    Conflict of Interest Details (Please provide details)
    Grant Application Purpose*
    Specific reason for grant application* (the purpose of this application grant i.e. what it will be used for) - (0/375 characters)
    Please ensure the application is for items which have not already been purchased.
    Total Amount Requested* (Please ensure the amount requested indicates if it is GST inclusive or exclusive)
    $ 
    Has the application organisation applied for funds for the same purpose from any other source*
    If yes, give full details
    Duplicate Grant Application - Is this a subsequent grant application attempt to Akarana for the same grant for the same amount and the same purpose?*
    Does the grant application relate to high performance and/or elite sports persons?
    Are cash prizes or large non-cash prizes on offer at the event?
    Does your organisation pay any sports person for playing (no matter how modest or infrequent)? If so, please detail:
    Details of Payments*
    Please Detail Benefiting Individuals Gender* (Gender of the recipients the funding will benefit)

    Territorial Authority and Region*
    Please detail the territorial authority in which your organisation's headquarters are located:
    Please select the main territorial authority that will benefit from the funding:

    Please select all other territorial authorities that will benefit
    001 - Far North District002 - Whangarei District003 - Kaipara District011 - Thames - Coromandel District012 - Hauraki District013 - Waikato District015 - Matamata - Piako District016 - Hamilton City017 - Waipa District018 - Otorohanga District019 - South Waikato District020 - Waitomo District021 - Taupo District022 - Western Bay of Plenty District023 - Tauranga City024 - Rotorua District025 - Whakatane District026 - Kawerau District027 - Opotiki District028 - Gisborne District029 - Wairoa District030 - Hastings District031 - Napier City032 - Central Hawke's Bay District033 - New Plymouth District034 - Stratford District035 - South Taranaki District036 - Ruapehu District037 - Whanganui District038 - Rangitikei District039 - Manawatu District040 - Palmerston North City041 - Tararua District042 - Horowhenua District043 - Kapiti Coast District044 - Porirua City045 - Upper Hutt City046 - Lower Hutt City047 - Wellington City048 - Masterton District049 - Carterton District050 - South Wairarapa District051 - Tasman District052 - Nelson City053 - Marlborough District054 - Kaikoura District055 - Buller District056 - Grey District057 - Westland District058 - Hurunui District059 - Waimakariri District060 - Christchurch City062 - Selwyn District063 - Ashburton District064 - Timaru District065 - Mackenzie District066 - Waimate District067 - Chatham Islands Territory068 - Waitaki District069 - Central Otago District070 - Queenstown - Lakes District071 - Dunedin City072 - Clutha District073 - Southland District074 - Gore District075 - Invercargill City076 - Auckland888 - National999 - Area Outside Territorial Authority

    Please detail the items that you are applying for and the cost of each item (continue on a separate sheet if necessary):

    Item Supplier 1 – Preferred Quote Cost (ex GST) Supplier 2 – Competitive Quote Cost (ex GST)
    Total Requested

    Please complete the section below if you are applying for wages or salaries.

    Person Title Annual Salary or Hourly Rate Total Hours Worked Per Week

    CONDITIONS OF GRANT

    As required by section 115A of the Gambling Act 2003, grant money must only be used for the specific purpose for which it was granted and in accordance with the conditions of the grant. Breach of section 115A is a criminal offence ($10,000.00 maximum fine).

    Copies of invoices, receipts and bank statements must be provided to Akarana Community Trust within 6 months of the grant being made to verify that the grant has been used in accordance with the purpose approved.

    Any grant money which is not spent on the purpose approved must be returned to Akarana Community Trust within 6 months of the grant being made. We agree to reimburse Akarana Community Trust for all costs incurred (including legal costs on a solicitor/ client basis) in recovering any outstanding grant money.

    We agree to comply with any request from an officer of the Department of Internal Affairs and/or a representative from Akarana Community Trust for additional information in relation to how the monies received from Akarana Community Trust have been spent.

    We also agree that an officer of the Department of Internal Affairs may direct an audit or inspection of the books, accounts, or data systems in which the proceeds of the grant have been deposited, by a Chartered Accountant and/or an officer of the Department of Internal Affairs.

    We agree that the audit or inspection will be carried out in such a manner approved by the Department, within the time frame specified by the Department.

      I agree to the terms and condition.

    Grant Application Requirements

    Please complete the checklist below

    Please attach two quotes or other evidence that the amount sought is reasonable.Please attach evidence of affiliation to a national body.Please attach a printed bank deposit slip. The account name must be the same as the recipient organisation.Please ensure the application is for items which have not already been purchased.Please ensure you have not applied for funds for the same purpose from any other source.Please attach a copy of your certificate of incorporation.Please attach a copy of your signed full meeting minutes that record your organisation’s resolution to apply for funding to Akarana Community Trust.For grant applications greater than $15,000 please attach a copy of your latest audited annual accounts.Please attach a list detailing the names of all your committee members or the members of your board of trustees and detail any association with an Akarana trustee or Akarana venue.Please ensure that this application is completed in full and signed by two senior members of your organisation.

    DECLARATION

    We declare that:

    • The information provided in this application form is true and correct to the best of our knowledge.
    • We have the authority to make this application on behalf of the applicant.
    • This application has not been completed by a person who has any management or ownership interest in a Akarana Community Trust venue that hosts gaming machines (“a gaming machine venue key person”).
    • When any grant money is obtained the persons who decide how that money is spent will not be Akarana Community Trust gaming machine venue key persons.
    • When any grant money is obtained a check will be undertaken and no payment will be made from grant money to any Akarana Community Trust gaming machine venue key person for any goods or service.

    We (the undersigned) make a solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.

       I certify that the facts stated above are true and correct to the best of my knowledge and belief.


    Signature 1 Signature 2
    Name Name
    Position Position
    Date Date
    For Akarana Trust Community Use Only
    Approved/Declined
    Amount approved
    Grant number (Net Proceeds Member)
    Date approved
    Date funds deposited (Net Proceeds Member)
    Cheque No/Direct Debit details
    (Net Proceeds Member)
             
    (Net Proceeds Member)

    PH: (09) 263 4622