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APPLICATION FORM FOR FIRST TIME APPLICANTS AND EMERGING ORGANISATIONS FOR GRANTS NOT MORE THAN R500,000.00

FORM 2010/2

INSTRUCTIONS

1	If you are applying for a grant less than R500 000, please indicate (with a cross in the relevant box) if your application for funding is in terms of:

	Charities (Section 28 of the Act)

	Sport and Recreation (Section 29 of the Act)

	Arts, Culture and National Heritage (Section 30 of the Act)

	Miscellaneous Purposes (Section 31 of the Act)

2 This application form is in four parts:

In section A: Tell us about your organisation

In section B: Tell us about your project / programme / services

In section C: Organisational Funding History

In section D: Mandatory Documents.

(Please note that the section headings does not correspond with the sections headings in the form)

NB: If there’s not enough space on this form for your answers, please use and attach further sheets of paper

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SECTION A

A1 Name of organisation: ....................................................................................................

A2 Postal address: ...............................................................................................................

Postal code: ....................................................................................................................

A3 Street address: ................................................................................................................

........................................................................................................................................

Province: .........................................................................................................................

A4 Telephone number: …………………………. A5 Fax number: ............................................

A5 E-mail address: ................................................................................................................

A6 When was your organisation formed? ..............................................................................

A7	What kind of registered organisation are you? (E.g. Non-Profit Organisation, Non-Profit Company, Public Benefit Trust):

………………………………………………….........................................................................................

A8 When was your organisation registered? ...........................................................................

A9	Registration number: ................................... (Please attach a copy of your registration certificate)

A10	Details of the main contact person with executive powers (e.g. Manage/Programme Director)

Name: .................................................. Position: ...........................................................

South African I.D. Number: .................................................. (Attach Certified Copy of ID)

Address: ............................................................ Tel: ......................................................

A11 Details of a second contact person (e.g. Chairperson):

Name: .................................................. Position: ............................................................

South African I.D. Number: .................................................. (Attach Certified Copy of ID)

Address: ..............................................................Tel: ......................................................

A12	Names and positions of the Management Committee: (Members are required to attach certified copy of ID):

1 Name: ................................................. Position: .........................................

I.D. Number: ....................................... Tel: .................................................

2 Name: ................................................. Position: ..........................................

I.D. Number: ....................................... Tel: ..................................................

3 Name: ................................................. Position: ..........................................

I.D. Number: ....................................... Tel: ..................................................

4 Name: ................................................. Position: .........................................

I.D. Number: ....................................... Tel: ..................................................

5 Name: ................................................. Position: .........................................

I.D. Number: ........................................ Tel: .................................................

A13	Are you affiliated to any organisation? ................ If yes, name them

......................................................................................................................................

A14 Describe the main purpose of your organisation: ............................................................

.......................................................................................................................................

......................................................................................................................................

A15	Describe the nature of services and/or products that your organisation provides the people who will benefit from the service and/or product:

.......................................................................................................................................

......................................................................................................................................

A16 In which province/s do you operate? (Tick next to the province/s that apply to you)

Eastern Cape ..................... Free State .................. Gauteng ..........................................

KwaZulu Natal .................. Limpopo ..................... Mpumalanga ……………......................

Northern Cape .................. North West ................ Western Cape .................................

A18 Please fill in the information below on your staff composition

(Please note numbering error as published in Gazette No. 38687)

NO OF PAID STAFF

NO OF VOLUNTEERS

No. of full-time staff

No. of part-time staff

No. of full-time volunteers

No. of part-time volunteers

SECTION B: THE FUNDS YOU ARE APPLYING FOR, AND HOW WILL YOU USE THEM IF GRANTED

B1	Are you applying for: (Tick the relevant box?)

	A grant in support of your overall operations? OR

	Funding for specific projects? If Yes, they are:

	Already in existence?

	An expansion?

New?

B2	What amount of money are you requesting? ..................................................................

B3	For what period? (EG. 1 year, 2 years, multiyear etc.) .......................................................

B4	Please attach a detailed budget with a motivation on the utilisation of grant. For capital expenditure attach supporting documents such as quotations, architectural and proof of ownership.

B5	Indicate which groups of people will benefit from the funding, if granted and how many? [Give members]

Children: .............................................. Women: ............................................................

Children with disabilities: .................... Adults with disabilities: .....................................

Youths: ................................................ The elderly:........................................................

People living with HIV/AIDS:................. The chronically ill:..............................................

Drug Abusers: ...................................... Criminal Offenders:............................................

The Unemployed: .................................. The homeless: ..................................................

Other (specify) …………………………………………………………………………………...................................

B6	Indicate the specific areas where the people who will benefit from the funds reside:

.........................................................................................................................................

..........................................................................................................................................

B7	Have you benefited from the fund before? If yes fill in the box

Project Number	Year	Amount received and what for?	Have you submitted all the progress reports?

B8	If you applied but were not funded, please give reasons ..................................................

.........................................................................................................................................

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SECTION C: INFORMATION ON YOUR ORGANISATION'S

C1 Bank details

Name in which the account is held: ...................................................................................

Name of Bank: ...................................................................................................................

Type of account: ................................................ Account number: ....................................

Branch: ............................................................... Branch Code: .........................................

C2 List 3 people who are authorised to sign cheques on your account/s:

Name: .......................................... Position in Organisation:...............................................

SECTION D: REFEREES

Please give the details of three credible referees from the community in support of your application e.g. police commissioner, religious leader, local councilor, etc. (Referees must be independent and may NOT be employees, committee members or volunteers)

1.	Name: ................................................. Position: ........................................................

Tel: .................................................

2.	Name: ................................................. Position: ........................................................

Tel: .................................................

3.	Name: ................................................. Position: ........................................................

Tel: ..................................................

SECTION E: MANDATORY DOCUMENTS

The following documents should be attached to this form as applicable

Organisational founding documents (this requirement is applicable to organisations that

have not previously been funded by the NLDTF or if the objectives of the organisation have

since changed)

-	Constitutional / Trust deed

-	Institutions established by an Act of Parliament must only cite the enabling Act

-	Proof of registration for non-profit organisations, Non-Profit Companies, Public Benefit

Trusts and schools registered with the d Department of Education (except private schools)

-	(Tertiary Institutions are excluded from this requirement but they must cite the enabling

Act).

Details project business plan

Details Project Budget (Specific line items with unit cost, quantities, total cost per item)

Project Motivation

Applications for declared heritage site development/renovations must be accompanied

by letter of support from Municipality or Tribal

Authority for the project

Any additional documents required in the guidelines issued by National Lotteries

Commission

Financial Records

Declaration

I .................................................. confirm, on behalf of: .................................. (Name of organisation) that I am authorised to sign this declaration, and that to the best of my knowledge all answers to the questions on this form are accurate. If this application is successful, this organisation will use the grant only for the specified in this applications, and will comply with all the terms and conditions attached to the grant.

I confirm that the organisations have the power to accept the grant subject to conditions and repay the grant if the conditions are not met.

Name: ..........................................................................................................................

South African Identity number: .....................................................................................

Position in organisation: ...............................................................................................

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

Lotteries Act, 1997 (Act No. 57 of 1997)

Regulations

Direction for the Distribution Agencies in Determining Distribution of Funds from the National Lottery Distribution Trust Fund

Form 2010/2 : Application Form for First Time Applicants and Emerging Organisations for Grants not more than R500,000.00