Coronavirus Grant Forms

Your First Name

Your Last Name

Name of Organisation/Project

Address Of Organisation

Town/City of Organisation

Post Code of Organisation

Your Phone Number

Your Email

Charity or CIC Registration Number (if applicable)

Signature for Organisation

I confirm that these funds will be spent only on work/items/activity eligible for COVID-19 funding as set out in the priorities for the fund.

Description of the project, item or activity for which the funding will be used

Please include how the project or activity will meet the aims of this funding

Project/Item/Activity Start Date

Total Cost of Project/Item/Activity

Amount of Covid-19 TC Grant funding requested

Bank Details of your Organisation

If there is a difference between the total cost of project/item/activity and the amount of COVID-19 Grant funding requested, please specify how the gap will be filled, indicating any match funding

I have provided a scanned copy of the organisation’s most recent bank statement

Consent

I have read and agree to the terms and conditions.

Your Signature

Dated

Your First Name

Your Last Name

Name of Organisation/Project

Address Of Organisation

Town/City of Organisation

Post Code of Organisation

Your Phone Number

Your Email

Charity or CIC Registration Number (if applicable)

Position Within/relationship to Organisation

Legal Entity of your Organisation

Legal entity – how you have registered to trade as an organisation. Non-constituted groups without their own, separate bank account, small local businesses and individuals are not eligible to apply and might therefore instead consider linking-up with an eligible body.

Charity Community Interest Company Other

If you have selected Other, please provide details

Have any of the organisation’s principals been disqualified as a director or listed on the individual insolvency register

Yes No

Are you able to claim VAT on this project?

Yes No

Amount of Covid-19 TC Grant funding requested. The maximum amount you can apply for is £2,000. The grant will not be paid as a lump sum one off payment. It will be paid in stages to be agreed with applicants who are selected for funding

Expenditure reason

Description of the project, item or activity for which the funding will be used

Please tell us which COVID 19 Grant Fund priority your project will support. Please tick all that are applicable

Increase resilience Support the local economy Improve connectivity in a safe way Help people to safely access services and information Safely maintain supplies of food, medicines and essential goods for those who are vulnerable or isolated Strengthen and develop virtual community networks Tackle loneliness, isolation, and support mental health and well-being

Project/Item/Activity Start Date

Project/Item/Activity End Date

Please tell us what you propose to do and how you will do it and how your proposal supports the COVI19 Prompt Action Fund priorities

Have you ever done anything like this before?

Yes No

If you have selected Yes, please provide details

Please tell us the number of individuals you expect to support during the project lifetime and how

How many individuals will be supported

What impact will your project have upon the community you are working with

Please provide the key milestones & target dates for your project and briefly explain how you will monitor progress of all project activities

What risks do you consider your project may face that might prevent it being successfully delivered? Please indicate how you intend to minimise this risk

Signature for Organisation

I am authorised to sign on behalf of the above-named organisation and that any funding will be used to benefit the community in line with the priorities of the Fund and will only be used for the purposes specified in the application.

All expenditure will be claimed before 31 March 2021 – if not, the grant will be reduced to accommodate any unspent/uncommitted monies.

That I/we will provide Burnham-on- Sea & Highbridge Town Council with a statement of how the funding has benefited the organisation/local community

That I/we acknowledge and understand that approval of any grant relating to this application does not commit the Town Council to on-going funding

Bank Details of your Organisation

If there is a difference between the total cost of project/item/activity and the amount of COVID-19 Grant funding requested, please specify how the gap will be filled, indicating any match funding

I have provided a scanned copy of the organisation’s most recent bank statement and constitution

Consent

I have read and agree to the terms and conditions.

Your Signature

Dated

If you require any further information about how to apply please contact accounts@burnham-highbridge-tc.gov.uk and mark your email ‘CV19 GRANT’ in the subject line, or call 01278 788088.

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