GENERAL APPLICATION FORM

							APPLICATION FORM
Small Grants (under $20,000) for all Program Areas
PRELIMINARY INFORMATION

This form is to be used when applying for a grant of $20,000 or less from The Ian Potter Foundation in all
Program Areas except Travel and Conference.

Note: Applications for Small Grants must come from organisations, not from individuals.

1.   Ensure that your applicant organisation is eligible to be considered for a grant from the Foundation.
     Please read the requirements for Eligibility on the Foundation’s website.
2.   Ensure that your project falls within the Foundation’s grantmaking guidelines. Please read the Funding
     Principles section on the website.

3.   Read the Funding Objectives and specific Exclusions for the Program Area of interest to you on the
     website to ensure your project meets the criteria.

4.   Note that all grants applied for on this form are made subject to the Standard Grant Conditions on the
     website, unless those conditions are varied by the Foundation in relation to your project.


GENERAL EXCLUSIONS

     1. Retrospective funding
     2. Recurrent expenditure for which no future provision is in sight
     3. Capital or endowment funds established to provide a corpus for institutions
     4. Research for Undergraduate, Masters or Doctoral students, except in special circumstances at the
        Board's discretion
     5. A DGR where the endorsement relates to a School Building Fund
     6. Auspicing – the organisation applying must be the one which would run the project or program.
Please note that
        The Foundation focuses on major new developments within a university or research institute
        Funding is not provided for projects or items of equipment that might be funded internally or by a
         Government agency such as NH&MRC or ARC
        Applications for projects that have been previously declined by the Foundation cannot be
         resubmitted
        Your application will not be considered if the required information and documentation is not
         received by 5.00pm on the funding round closing date.




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HOW TO PREPARE YOUR APPLICATION

All sections in the application form must be completed.
Applications from all organisations EXCEPT Universities, Research Institutes and Teaching
Hospitals
       Must be signed by the Chief Executive Officer or equivalent of the applicant organisation.
Universities, Research Institutes and Teaching Hospitals
       Applications must be submitted by the Research or Grants Office. Direct applications by individuals
        will not be considered.
       Applications for research projects must be signed by the Head or Director of the research institute,
        the Deputy Vice Chancellor of Research or equivalent office holder of the university, or the Chief
        Executive Officer of the teaching hospital.
       Applications for non-research projects must be signed by the Vice Chancellor of the university, the
        Head or Director of the research institute or the Chief Executive Officer, or equivalent of the teaching
        hospital.
       In your cover letter please state why the application is a priority for the institution as a whole.
       Universities must rank in priority all applications (other than travel grants) submitted in a particular
        funding round.



HOW TO LODGE YOUR APPLICATION

The Foundation must receive your application in both email and hard copy forms by 5.00pm on the closing
date. Late applications will not be considered.
The email form of the application should be sent to applications@ianpotter.org.au with the Program Area
abbreviation and the organisation name in the Subject Line.
Abbreviations: Arts (ARTS), Community Wellbeing (CW), Education (EDU), Environment and Conservation
(ENVCON), Health & Disability (HEALTH), Medical Research (MEDRES), Science (SCI).
Please do not convert the application form to PDF format or send supporting documentation by email.
Note: The sender of the emailed version of the application should receive an automated email
acknowledgement of receipt. To ensure that you receive the automated reply you should add
applications@ianpotter.org.au to your Safe Senders email list. In Outlook select Tools, Options, Junk Email,
Safe Senders and then Add our email address.
The hard copy of the application and other supporting documents should be posted to the address below, or
may be couriered or hand-delivered to the office:
        Mrs Janet Hirst
        Chief Executive Officer
        The Ian Potter Foundation
        Level 3, 111 Collins Street
        Melbourne VIC 3000

Faxed application forms are not acceptable.
You may be asked for further information prior to the Board Meeting at which the application is to be
considered.
You should receive notification of the outcome of your application by mail within four months of the funding
round closing date.




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                                                                          Small Grants - Version: December 2011
FUNDING ROUND CLOSING DATES AND PROJECT COMMENCEMENT DATES

Applicants are encouraged to submit their applications earlier rather than wait until the closing date.

ARTS / COMMUNITY WELLBEING / EDUCATION
Next closing dates for receipt of applications are:
Monday 12 September 2011 for projects or programs commencing after 16 December 2011
Monday 30 January 2012 for projects or programs commencing after 11 May 2012
Monday 28 May 2012 for projects or programs commencing after 7 September 2012
Monday 17 September 2012 for projects or programs commencing after 21 December 2012

THE FOLLOWING PROGRAM AREAS ARE CONSIDERED ONLY ONCE A YEAR
The closing dates for 2012 are as follows:
HEALTH & DISABILITY
Monday 30 January 2012 for projects or programs commencing after 11 May 2012
MEDICAL RESEARCH
Monday 30 January 2012 for projects or programs commencing after 11 May 2012
SCIENCE
Monday 28 May 2012 for projects or programs commencing after 7 September 2012
ENVIRONMENT & CONSERVATION
Monday 28 May 2012 for projects or programs commencing after 7 September 2012




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                                                                           Small Grants - Version: December 2011
CHECKLIST: Please complete every section
Is your applicant organisation either an endorsed Deductible Gift Recipient (DGR) – Provision for
gift deductibility must be Item 1, or specifically named as a DGR in Subdivision 30-B of the
Income Tax Assessment Act 1997?

Is a copy of the DGR notice of endorsement OR a copy of the section (showing the item number)              YES
in which the applicant organisation is named as a DGR in Subdivision 30-B of the Income Tax
Assessment Act 1997 attached to the hard copy of your application?
                                                   Endorsement date of effect                        NO
                                                                                                           YES
If your organisation is a non government entity - is a copy of the ‘Notice of endorsement for
Charity Tax Concessions’ issued by the ATO on or after 1 July 2005 attached to the hard copy
of your application?                                                                          NO
                                                                                                     N/A

If your organisation is a government entity - is a copy of the letter from the ATO (as detailed on
page 6) attached to the hard copy of your application?
                                                                                                     N/A
Please send a recent print-out of your organisation’s details from the Australian Business
Register

Is the Declaration signed by the person holding a position as specified on page 2 and if not, have
you provided an explanation for the different signatory?

Have you specified which Program Area you are applying to?

In your application have you addressed the Foundation’s funding principles and the funding
objectives for the Program Area for which you are applying?
Have you attached to the hard copy of your application a copy of your organisation’s most recent
Annual Report?
Have you attached to the hard copy of your application a copy of your organisation’s most recent
signed and audited Financial Statement?

! NOTE for Universities: If the Foundation has a copy of your CURRENT Annual Report and
Financial Report on file you do not need to send additional copies. You should confirm that we
have them on file prior to submitting your application.

Have you attached to the hard copy of your application a copy of your itemised budget?

Have you emailed a copy of the application to applications@ianpotter.org.au with the Program
Area abbreviation and the organisation name in the Subject Line?
                                                                         Date emailed




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                                                                        Small Grants - Version: December 2011
DECLARATION
To be signed by a person holding a position as specified on page 2.

I (full name of signatory)

Position held)

Applicant organisation
(Entity Name as per your ABN
am authorised by the applicant organisation named in this application to make this application on its behalf.
I confirm that my organisation is aware of and agrees to the terms and conditions relating to grants from
The Ian Potter Foundation. I confirm that all the information provided in or with this application is true
and complete.

The Ian Potter Foundation may pass on this application to any other grantmaking trust that is administered
by its Trustees or Governors, in which case the application will be treated as an application to that other trust on
the same terms and conditions.

The applicant acknowledges that neither The Ian Potter Foundation nor any other grantmaking trust as
above is under any obligation to make a grant even though the application meets all guidelines and
eligibility requirements.

Signed for and on behalf of the applicant organisation

Signature ……………………………………………..                                            Date …………….………

Print Name ……………………………………………



Note: per, pp, on behalf of, will not be accepted and the signature must be a signed original. Scanned, faxed or electronic
signatures will not be accepted.

Is this Declaration signed by the person holding a position as specified on page 2?
Note: for your application to be considered an explanation must be provided if it is necessary for
someone other than the CEO to sign the Declaration and it must be clear that the signatory is the
next most senior person.




                                                              -5–
1. TAX STATUS REQUIRED

Non government entities: DGR and TCC
A non government entity is ineligible to receive a grant from the Foundation if it does not have both
DGR (where Provision for gift deductibility is Item 1) and TCC status.
If your organisation is a non government entity please provide:
 1 EITHER a copy of the applicant organisation’s endorsement as a Deductible Gift Recipient issued by
   the ATO;
    OR a copy of the section (showing the item number) in which the applicant organisation is specifically
    named in Subdivision 30-B of the Income Tax Assessment Act 1997;
    AND
 2 A copy of the applicant organisation’s ‘Notice of endorsement for Charity Tax Concessions’ (TCC)
   issued by the ATO on or after 1 July 2005.


(1) Has the applicant organisation’s DGR or TCC status been revoked or expired? Yes              No

(2) Is the applicant organisation a Public Ancillary Fund or a Private Ancillary Fund? Yes        No

NOTE: If you have selected Yes to either (1) or (2) your organisation is not eligible to apply to the
Foundation.

(3) Are you aware of any circumstances that may give rise to the applicant organisation’s DGR or TCC
status being revoked?
NOTE: If you have selected Yes to (3) please provide details.                         Yes         No


Government entities
If your organisation is a government entity please provide:
 1 EITHER a copy of the applicant organisation’s endorsement as a Deductible Gift Recipient (where
   Provision for gift deductibility is Item 1) issued by the ATO;
    OR a copy of the section (showing the item number) in which the applicant organisation is specifically
    named in Subdivision 30-B of the Income Tax Assessment Act 1997;
    AND
  2 A letter from the Australian Tax Office [ATO] indicating that ‘but for a connection with government’ your
    organisation would be a charity and that it is a tax exempt entity.


(1) Has the applicant organisation’s DGR status been revoked or expired?            Yes         No
NOTE: If you have selected Yes, your organisation is not eligible to apply to the Foundation.

(2) Are you aware of any circumstances that may give rise to the applicant organisation’s DGR status being
revoked?
NOTE: If you have selected Yes to (2) please provide details.                        Yes        No




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                                                                          Small Grants - Version: December 2011
2. APPLICANT ORGANISATION DETAILS
Applicant organisation - Entity Name exactly as per your ABN – refer to the Australian Business Register


Applicant organisation – Trading name
(if applicable – the Trading Name must be listed with
your Entity Name on the ABR website )

Australian Business Number (ABN)

Universities should include: Faculty

Full name of School / Department / Centre etc

Research Office primary contact
Include prefix eg Mr / Ms / Dr / Prof

Research Office primary contact’s title

Research Office primary contact email

Research Office telephone

Medical Research Institutes should include name of:

Department / section etc

Postal address

                                                        State                    Postcode

Street address (if different from above)

                                                        State                    Postcode

Web address

Name of primary contact for project
Include prefix eg Mr / Ms / Dr / Prof

Position and title of primary contact

Email

Telephone          (   )                                Mobile



2. ABOUT YOUR ORGANISATION
(a) Please provide a brief description of your organisation, including its history and mission.
Note: if your organisation is a university the information should relate to the faculty / department / school /
centre which is applying.




(b) Who are your clients?




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                                                                            Small Grants - Version: December 2011
(c) What programs and activities does your organisation offer?




(d) How many paid full and part-time staff members are employed by your organisation? What is the level of
volunteer involvement?




(e) Names of current Patron(s) and Board Members

Patrons:

Board Members:

(f) What are the sources of your income?



(g) The Foundation assumes that all organisations strive to develop a financial reserve.
       What is the size of your financial reserve?
       If this project is of high priority for your organisation, what is the reason why the reserve cannot be
         used to fund it?




3. ANNUAL REPORT and FINANCIAL STATEMENT
Please attach to the hard copy of your application
       A copy of your organisations most recent Annual Report AND
       A copy of your organisations most recent signed and audited financial statement.

! NOTE: If you are unable to provide an Annual Report you should note this in a cover letter and include
additional material such as AGM Minutes, Newsletters from the past year, or brochures detailing your
activities.
! NOTE for UNIVERSITIES: If the Foundation has a copy of your CURRENT Annual Report and Financial
Report on file you do not need to send additional copies. You should confirm that we have them on file prior
to submitting your application – call 03 9650 3188

(a) Please advise of any significant organisational or financial information that has impacted on your
    organisation since your most recent Annual Report and audited financial statement.
   e.g. change in business, or program direction; funding received/discontinued; acquired property.




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                                                                            Small Grants - Version: December 2011
4. PROJECT DETAILS
(a) Which Program are you applying to? (please select).

Arts                                               Health & Disability

Community Wellbeing                                Medical Research

Education                                          Science

Environment & Conservation
We realise that projects may fall into more than one of these Program Areas, but you should select one
only. Note that the Foundation may apply a different categorisation from the one you indicate.

(b) Please indicate the geographic scope of the project
    If the initiative is not Australia-wide, indicate the relevant State(s) and the project’s geographic reach.

Australia wide

ACT            NSW              NT           QLD             SA           TAS           VIC            WA


Metropolitan                      Regional                        Rural                    Remote


(c) One of the Foundation’s six guiding principles is an emphasis on the “innovate, evaluate, disseminate”
strategy. In line with this principle, we usually support new projects, although at times support is given to an
existing project that is introducing an innovative element. Does your application relate to a new project, or is
it seeking support for an innovative element of an existing project?

This is a new project

This is an existing project with an innovative element



If this is an existing project with an innovative element, please describe the innovative element.


(d) Title of project


(e) Describe your proposed project in no more than 100 words clearly stating what you want to do with the
    funds.

This grant will enable us to...

(f) How does your project relate to the nominated Program Area’s funding objective(s) and the Foundation’s
    Funding Principles?



(g) Total cost of the project

(h) Amount ($) being requested over number of years
Eg. $10,000 over 1 year;
$7,500 per annum for 2 years for a total of $15,000


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                                                                             Small Grants - Version: December 2011
(i) Project start date         !                              ! NOTE: the Foundation will not fund
                                                              retrospectively. Project start dates must be no
                                                              earlier than the date indicated with the closing
Project completion date        !                              date on page 3 of the application.


Proposed use of the requested grant

(j) What is the problem you wish to address?




(k) Who is the target population?



(l) Where will your project take place?



(m) What are your desired outcomes?



(n) How will you achieve these outcomes? (What steps will you take to reach your goals?)



(o) How will you monitor your progress towards these outcomes, and evaluate the success of your project?




(p) What is your timeline for the project? i.e. Key dates and/or stages etc




(q) If relevant, how will you sustain your project after the grant has been expended?




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                                                                              Small Grants - Version: December 2011
5. PROJECT BUDGET SUMMARY: An accurate budget is an essential element of your application,
and all line items in the budget summary below must be completed as accurately as possible. On Lines 3
and 4, please include a total of other funding that has been confirmed and applied for – we are pleased to
be one of a number of funders of a project.

! We also require a separate itemised budget with details of the line items that are listed in this summary. It
is important that you be as specific and as accurate as possible.

INCOME                                                                                          $

1. Amount sought from The Ian Potter Foundation

2. Cash contribution from the applicant organisation

3. Confirmed funding from
    •   other foundations
    •   governments or
    •   outside sources
(include letters of confirmation and specify details on a separate sheet)

4. Applied for but unconfirmed funding from
       other foundations
       governments
       outside sources
(include details on a separate sheet)

5. Income projected to be generated from the project

6. Other sources of income relevant to the project
(include details on a separate sheet)
7. In-kind* contributions (include details on a separate sheet)

TOTAL INCOME                                                                                              $0.00


EXPENDITURE                                                                                     $

1. Capital equipment (include details on a separate sheet)

2. Salaries and wages (specify payees and amounts on a separate sheet)

3. Office supplies eg stationery, postage, printing
  (include details on a separate sheet)

4. Advertising and/or promotion

5. Travel/transport (include details on a separate sheet)

6. Other projected costs or overheads (specify on a separate sheet)

7. In-kind* contributions (include details on a separate sheet)

TOTAL EXPENDITURE                                                                                         $0.00
Note that the budget must balance i.e. the total income must equal total expenditure.
*In-kind contributions are the non-cash contributions of equipment, materials, time and services. An
estimated value should be given for each item. In-kind contributions should be listed as both an income and
an expense item.
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