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									For office use only:
 Date received                            App number                       District

                                  PORT COMMUNITY FUND
                               Grant Application Form – Part A
Before completing this form, please read our guidelines, which are available on:
The information on this form will help us process your application more quickly. We hope you will find it quite
easy to complete, but if you have any questions, please call Julie Rose on 01473 786912.

Please return your completed, signed form and supplementary documents to: The Suffolk Foundation, The Old
Barns, Peninsula Business Centre, Wherstead, Ipswich, Suffolk IP9 2BB.

The Suffolk Foundation is a registered charity (1109453) and a company limited by guarantee (5369725).

About your organisation
Name of your organisation:

Organisation address details
 Address Ln1
 Address Ln2
 Address Ln3
 City/Town                                              Postcode
 Main phone                                             E-mail

                  Main Contact Person
         (these are the details that will be used for                 Second Contact Person
                correspondence purposes)
 Title                                                  Title
 Forename                                               Forename
 Surname                                                Surname
 Role                                                   Role
 Daytime Tel No.                                        Daytime Tel No.
 Evening Tel No.                                        Evening Tel No.
 Fax No.                                                Fax No.
 Mobile No.                                             Mobile No.
 Email                                                  Email
 Address Details (if different from Org address)        Address Details (if different from Org address)
 Ln1                                                    Ln1
 Ln2                                                    Ln2
 Ln3                                                    Ln3
 Town                                                   Town
 Post Code                                              Post Code
When did your organisation start?

What local authority/authorities does your organisation work in?

What is the status of your organisation?

Registered charity                                 Charity number:
Applying for charitable status
Company limited by guarantee                       Company number:
Community Interest Company
Part of a larger regional or national charity
(Please state which one)
Other (Please specify)

How many people are involved in your organisation?
 Full time Staff / Workers                         Members
 Part Time Staff / Workers                         Volunteers
 Management committee                              Volunteers under 25

What is the purpose of your organisation? Please briefly describe why your organisation was set up,
what its aims and objectives are and who primarily benefits from your organisation.

What was your organisation’s total income for last financial year?

What was your organisation’s total expenditure for last financial year?   £

    The Suffolk Foundation                       Page 2 of 9                         Issue 5.4
What are your organisation’s current unrestricted reserves?      £

About the project your organisation is seeking a grant for

Which local authority will the activity take place in?

Which area (estate, town, village, borough) do most of the people who will benefit come from?

What do you want a grant for? Please be specific in your reply. Please note that ‘project’ is meant to
describe the project you are seeking funding for, and not your organisation.

What is the need that a grant would help your organisation address?

    The Suffolk Foundation                         Page 3 of 9                         Issue 5.4
Please explain the specific outcomes and benefits as a result of a grant?

When will the project start?

When will the project finish?                             or is the project ongoing? Yes / No

Are you working with any other organisations on this project?    Yes / No

If yes, please state the names of these groups and the nature of the relationship.

About the beneficiaries of the grant
How many different individuals do you expect to benefit directly from the project on an annual basis
(or for its duration if less than 12 months)?

    The Suffolk Foundation                       Page 4 of 9                           Issue 5.4
Primary Beneficiary

Enter into the box a single option from the list below. This should represent the primary beneficiary
group who will benefit from this grant.

Other beneficiary groups who will benefit, (please tick all that apply)
     Children and Young
                                     People with physical disabilities           Carers
                                     People with mental health
     Adults                                                                      Local residents
                                     People with weight / obesity
     Older People                                                                People in Rural Areas
     NEET *                          Alcohol / Drug Addiction                    People in Urban Areas

     Long term unemployed            Homeless people                             Refugees / Asylum Seekers
     Disadvantaged / Low
                                     Ex Offenders and Prisoners                  Migrant workers
                                     Lesbian, Gay, Bi-sexual &
     Lone parents                                                                Men
                                     Transgender groups
     People with general
                                     BME groups **                               Women
     health issues
     People with learning
     Others (please state)
* Not in Education, Employment or Training        ** Black and Minority Ethnic

Primary Ethnic Group

Enter into the box a single option from the list below. This should represent the primary ethnic group
who will benefit from this grant.

Other ethnic groups who will benefit, (please tick all that apply)
                                                     Asian and Asian        Black or Black           Chinese or
        White                    Mixed
                                                         British                British              other group
                             Black Caribbean
    British                                            Indian                Caribbean                 Chinese
                             and White
                             Black African and
    Irish                                              Pakistani             African                   Any Other
                             Asian and White           Bangladeshi           Other Black
    Gypsies &                Other Dual
                                                       Other Asian           Any other
    Travellers               Ethnicity
    Other White

Primary Issues

Enter into the box a single option from the list below. This should represent the primary issue that
your project will address.

    The Suffolk Foundation                             Page 5 of 9                                 Issue 5.4
Other issues addressed, (please tick all that apply)

     Arts and Culture                         Health and Wellbeing                   Social Inclusion

     Community Support and Development        Housing                                Social Services and activities

     Counselling/Advice/Mentoring             IT / Technology                        Sport and Recreation

     Crime                                    Poverty and disadvantage               Supporting family life

     Disability and Access issues             Racial and Cultural Integration        Transport Issues

     Education and Training                   Religion                               Volunteering

     Employment and Labour                    Rural issues
                                              Social Enterprises
     Others (please state)

Primary age group

Enter into the box a single option from the list below. This should represent the primary age group
that will benefit from this grant.

Other age groups that will benefit, (please tick all that apply)
      Early Years (0 – 4)                Young People (13 – 18)                  Seniors (65+)

      Children (5 -12)                   Young Adults (19 – 25)

About the budget for the project
What is the total cost of the project?                   £

How much of a grant are you applying to us for?          £

Please provide a full breakdown of costs including hourly staff rates and VAT, if applicable.

                 Type of Cost              Project                                        Details
                                                                         Please include rates of pay i.e. amount per
 Staff costs
                                                                         hour including NI
 e.g. salaries
 Volunteer costs
 e.g. travel, training
 Operational/Activity costs
 e.g. equipment, venue hire, childcare
 Office, overhead, premise costs
 e.g. rent, postage, telephone/fax,
 Capital costs                                                           Remember to include quotes
 e.g. computer equipment, photocopier
 Publicity costs

 Other costs

    The Suffolk Foundation                           Page 6 of 9                                 Issue 5.4
Please list the funds that you have raised so far for this project.
 Source                                                                                    Amount (£)

                                                                      Total fundraising:

What other funders have you applied to for further funding for the project?

 Funder                                                                                    Amount (£)


If this is an ongoing project, how will it be funded and sustained when the grant ends?

    The Suffolk Foundation                         Page 7 of 9                               Issue 5.4
                             Grant Application Form – Part B

Your organisation’s bank details
If you are successful we will make payment by cheque. Please enter the details of your
bank/building society below.

Name of Bank/Building Society
Sort Code                                           Account Number
Who should the cheque be made payable to?

Can you confirm that you have at least two unrelated signatories for authorisation of cheques to
your account? (Please note that signatories must not live at the same address.) Yes / No

About your organisation’s independent referees
You must provide us with details of TWO independent referees. Your referee must be a person with a
professional or public position whose status we can check. They must be completely independent of
your organisation but know its work well and know about the project for which you are requesting
funds. Please do not give the details of a relative, friend, partner another member of the group, or
anyone who would benefit from a grant being awarded to your project.

All information provided will be kept in accordance with our data protection policies.

                  First Referee                                     Second Referee
Title                                             Title
Forename                                          Forename
Surname                                           Surname
Occupation                                        Occupation
Daytime Tel No.                                   Daytime Tel No.
Evening Tel No.                                   Evening Tel No.
Mobile No.                                        Mobile No.
Email                                             Email
Address Ln 1                                      Address Ln 1
Ln 2                                              Ln 2
Ln 3                                              Ln 3
Town/City                                         Town/City
Postcode                                          Postcode

    The Suffolk Foundation                        Page 8 of 9                            Issue 5.4
Supplementary documents checklist
Please post the following documents with your signed application. We will only process the
application when we have received them. Please tick the boxes to confirm the documents are
enclosed. They should be your latest documents, and in the case of accounts should be no more
than 12 months old.

      Constitution or signed set of rules (essential)
      Last year's annual accounts or financial statement signed by your treasurer (essential)
      Copies of written quotes or catalogue pages, if asking us to fund capital costs
      Latest annual report, if you have one
      Business plan or current year's budget forecast
      Equal Opportunities Policy, signed by your Management Committee (essential)
      Child Protection Policy, if applicable, signed by your Management Committee
      Vulnerable Adults Policy, if applicable, signed by your Management Committee

   1. I am authorised to make this application on behalf of this organisation.
   2. I certify that the information contained in this application is correct.
   3. If the information in the application changes in any way, I will notify The Suffolk Foundation.
   4. I give permission to The Suffolk Foundation to contact other parties (specifically specialist
      advisors/experts and community referees) who will help the processing of this application.
   5. I give permission for The Suffolk Foundation to record the information in this application
      electronically and to contact the organisation by telephone, post or email to discuss its
      activities and funding opportunities.

Signed                                                                      Date

Three last questions
Will you give us permission to use your organisation for publicity? Yes / No

Where did you hear about The Suffolk Foundation?

We are sometimes asked by other funders to recommend projects for funding. Are you happy for us
to pass this application, if appropriate, to another potential funder for consideration without further
reference to you?      Yes / No

    The Suffolk Foundation                              Page 9 of 9                             Issue 5.4

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