Application worksheet
A printable version of Clutha District Council - Reimbursement of Community Facility Hire and Rents's application questions, extracted from their official form. Use it to plan your answers - then submit through the funder's real form.
View the original PDF →Application worksheet
Application for Reimbursement of Community Facility Hire and Rents Clutha District Council
Clutha District Council - Reimbursement of Community Facility Hire and Rents
This worksheet mirrors the questions on the funder's official application form. It is NOT the official form. Submit your final answers through https://www.cluthadc.govt.nz/community/grants-and-funding/reimbursement-of-community-facility-hire-and-rents.
1. Type of Council Reimbursement being sought:
Tick one*
2. Applicant Details
Name of Organisation:*
Contact person:*
Postal Address:*
Post Code:*
Phone:*
Email:*
3. Description of project/activity (or organisation for a Rent Reimbursement):
Date of project:*
4. Financial Information
Total income received for the project (or annual income for Rent Reimbursement)*
Total cost*
Total expenses incurred for the project (or annual expenses for Rent Reimbursement)*
Total income:*
Total value of Council reimbursement being sought: (max $1,500 )*
Bank Account Number:*
Note: Please provide a bank deposit slip.
5. Consent Under Privacy Act 1993
I (name) consent to Clutha District Council collecting the personal contact details provided above, retaining and using those details for mailing and contact lists and disclosing them to any agencies for the purpose of reviewing the Council’s funding schemes. I undertake that I have obtained the consent of the other contact person to provide these details. I acknowledge my right to have access to this information. This consent is given in accordance with the Privacy Act 1993.*
Name:*
Signature:*
Date:*
Documents to attach
- Please complete all sections, including the financial sections.
- If grant is for reimbursement of hire fees, attach a copy of the invoice/receipt.
Worksheet generated by All Too Human (alltoohuman.nz/grants). Source: official PDF. This is not an official submission form.