Community Grants Financial Acquittal and Feedback Form

Organisation Name *

Grant Purpose *

Grant Amount *

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 Statement of Income and Expensiture

Please attache Copies of Invoices / Evidence of Expenditure

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

You are required to complete the statement of income and expenditure, unused funds (if applicable), schedule of donated materials and volunteer labour (if applicable) and to provide copies of invoices and / or other evidence of expenditure for all items expended with Shire of Northam funding.

Applicant Cash towards project / event (including GST)

Amount provided by the Shire of Northam

Other grants / sponsorship towards project / event (including GST)

Other funding towards project / event (including GST)

Total Income (including GST)

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

Total Cost (including GST)

Did the project commence on schedule *

YesNo

Did the project commence on schedule *

YesNo

If not, why and what was the commencement date?

Was the project completed on schedule *

YesNo

If not, why and what was the completion date?

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 provide evidence of outcomes including attendance figures etc.) *

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

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