Community Grants Financial Acquittal and Feedback Form

1. Grant Details

Organisation Name *

Grant Purpose *

Grant Amount *

2. Financials

Please list items of expenditure (eg equipment, advertising, contractors) and costs excluding GST *

Total Grant Expenditure

Please attach Copies of Invoices / Evidence of Expenditure *

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

Total Project Cost (excluding GST) *

3. Project Evaluation

Was the project completed on schedule *

YesNo

If not, please provide an explanation

Was the project completed in accordance with the project plan and were the expected outcomes achieved? Please elaborate on the outcomes, including how many people benefited and how they benefited from the project. *

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

Please attach evidence of project outcomes and acknowledgement of Shire of Northam

4. 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.

Position Held *

Name *

Organisation Name *

Date *

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Community Grants Financial Acquittal and Feedback Form

1. Grant Details

2. Financials

3. Project Evaluation

4. Declaration

Administration Centre

Postal Address

RANGERS - After Hours Emergency Number

WORKS - After Hours Emergency Number