Ka Hao Tangata Grant Fund

Application Form

Section one: About your organisation
1.	Legal name of your organisation: [insert text here]
2.	Name of organisation (trading name): [insert text here]
3.	Legal status: [insert text here]
4.	Company registration number: [insert text here]
5.	Have you previously been funded by MSD (if yes please provide detail): [insert text here]
Do you have Social Services Accreditation Level 4 (if yes please include your provider number): [insert text here]
If you do not have Social Services Accreditation Level 4 please provide the following information with your application: Organisational structure, governance and management details. Current and ongoing solvency (latest audited accounts and any other relevant material). Also confirm that should your application be successful your organisation will start the approval process to obtain Social Services Accreditation Level 4 within six months of the grant start date. The Social Sector Accreditation Standards and Application form can be found at: http://www.msd.govt.nz/what-we-can-do/providers/approvals/accreditation-standards.html
6.	Physical address: [insert text here]	Postal address (if different): [insert text here]
7.	Please provide details of the person we can contact if we require more information. This person will receive all communications from the Ministry of Social Development:
Name:	[insert text here]
Position title:	[insert text here]
Email:	[insert text here]
Phone number:	[insert text here]
Mobile number:	[insert text here]
8.	Please provide contact details of at least one referee who has a good standing in the community.
Referee 1 Name: [insert text here]	Contact details: [insert text here]	Position in the community: [insert text here]
Referee 2 Name: [insert text here]	Contact details: [insert text here]	Position in the community: [insert text here]
Referee 3 Name: [insert text here]	Contact details: [insert text here]	Position in the community: [insert text here]
Section two: About your Service
1.	What is the name of your service? [insert text here]
2.	Is the service currently being funded by any other government agencies?	Yes	No
Note: If the answer to this question is yes, then the service is not eligible to be funded through the Ka Hao Tangata Grant Fund.
3.	Tell us about the service you would like funded? How will your service be delivered? What outcomes are you wanting to achieve? How will you know if the service is effective? (limit 300 words) [insert text here]
4.	How will your service assist individuals significantly disadvantaged in the labour market and who require long-term support to achieve increased work readiness? [insert text here]
5.	How many individuals do you anticipate will participate in your service and what is the target group for your service? [insert text here]
6.	How will your organisation engage with the community to encourage people to participate in your service? [insert text here]
7.	When do you anticipate the service will start and finish? [insert text here]
8.	How much will your service cost? (GST exclusive)	$ [insert amount here]
9.	How much of this are you asking for from the fund?	$ [insert amount here]
10.	If the service costs are greater than the amount you are applying for from the fund, how much of this difference has been secured and/or confirmed?	$ [insert amount here]
11.	In the table below, please provide a description of what the fund will be used for and the amount:
Description/expense	Amount (GST exclusive)
$
$
$
$
$
$
Ka Hao Tangata Grant Fund total requested	Amount (GST exclusive)
Secured and/or confirmed funding	$
Other funders’ contribution (if any)	$
Any ‘in-kind’ contributions (if any)	$
Total cost of service:
Note: The maximum grant amount available for each project is up to $100,000.00 (GST exclusive). Financial management policies and procedures will need to be provided for applications that request the maximum amount.
Section three: Applicant declaration
1.	This section needs to be signed by two people in your organisation who have authority to commit the organisation to enter into a funding agreement. We acknowledge that: the details given in this application, or supplied by us in support of our application, are true and correct to the best of our knowledge our organisation has the necessary skills and experience to manage this project, and we have the authority to commit our organisation to this application before the granting of any funds, the Ministry of Social Development may disclose to, or obtain from, any other government department or agency, private person or organisation, any information about our organisation and the project for which we are seeking funding Information contained in this application may be used to inform any future evaluation of the Fund that the Ministry of Social Development or contracted evaluators may conduct.
Full name:
Position/designation in organisation:
Signature:
Date:
Full name:
Position/designation in organisation:
Signature:
Date:
Note: Please submit your completed application form to: Ka_Hao_Tangata_Grant_Fund@msd.govt.nz