Community Grants Financial Acquittal and Feedback Form

1. Grant Details

Organisation Name*

Contact Person*

Contact Phone Number*

Contact Email

2. Project Summary

Provide a brief overview of the project for which you received funding*

3. Project Evaluation

Was the project completed in accordance with the project plan and were the expected outcomes achieved?*

How many people were involved in the project?

Number of people directly involved?*

Number of people indirectly involved?*

Please detail how the Shire of Northam’s contribution to the project has been recognised and acknowledged.*

Please attach evidence of how you acknowledged the Shire of Northam

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4. Financials

Income (Amount $)

Amount granted from the Shire of Northam (including any withheld funds)*

Amount contributed by your organisation*

Amount contributed by other grants or sponsorship

In-kind contribution (calculate volunteer general labour at $20/hour, volunteer specialist labour at $45/hour, donated good at their purchase/hire price if not donated)

Total Income*

Expenditure (Amount $)

How were the Shire funds spent? Please list items purchased or services supplied*

Please attach copies of receipts / invoices / evidence of expenditure*

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Other Expenditure (please list)

In-kind Contribution (matched to in-kind income above)

Total Expenditure (NB income & expenditure total should be the same)*

Any unspent grant funds must be returned to the Shire of Northam.

5. Declaration

I declare that the Shire of Northam Community Grant as specified above has been spent in accordance with the purpose and conditions for which it was granted. The attached financial acquittal and project evaluation are a true and correct record of the transactions and outcomes of the project.

Name*

Position Held*

Organisation Name*

Date*

Please attach:

Photos, feedback, statistics from your project if possible
Invoice for withheld funds (if applicable)

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Community Grants Financial Acquittal and Feedback Form

1. Grant Details

2. Project Summary

3. Project Evaluation

4. Financials

Income (Amount $)

Expenditure (Amount $)

5. Declaration

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