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Application By Public Benefit Organization For A Grant
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2024-10-31T17:07:47+02:00
FORM 2025 APPLICATION BY PUBLIC BENEFIT ORGANIZATION FOR A GRANT
17
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INSTRUCTIONS
This application form is in six parts and a declaration by the applicant:
Section A: Details of the Organisation
Section B: Financial Information and banking details
Section C: Details of at least two contactable Referees
Section D: Details of previous Ezethu contracts
Section E: Detailed Business Plan for the project to be funded, if granted
Section F: Mandatory documents which MUST submitted with the application form
NB: If there is not enough space for your answers, please attach further pages under Section F
SECTION A:
DETAILS OF YOUR ORGANIZATION
Name of Organisation
*
OrganisationType
*
What kind of a registered organisation are you? (e.g. Non Profit Company, Public Benefit Trust, Non-Profit Organization)
Please select
Non Profit Company
Public Benefit Trust
Non-Profit Organisation
Registration Date
*
Registration Number
*
Income Tax Registration Pin
*
PBO reference number with SARS
SARS PBO Number
*
Expiry Date of SARS clearance
*
SARS tax number
*
Organisation Activity
*
Please select that which best defines the primary Activity of your organisation
ECD & education interventions
Skills development & livelihoods
Community Development Initiatives/Homebased care
Research & Development
Recreational & economic development Initiatives
Food security & farming
Other
Address Information
Postal Address
*
Postal Code
*
Organisations regisitered postal code.
Street Address
*
Postal Code (Street)
*
Organisations regisitered street postal code.
Telephone Number
*
Email Address
*
Cellphone Number
*
Details of the main contact person with executive powers
(
e.g. Manager/Programme Director
)
Name
*
Full Name
Position
*
Telephone Number
*
Email Address
*
SA ID or Passport Number
*
South African Identity Number
Street Address
Country of Passport (if applicable)
Details of a second contact person
(
e.g. Chairperson
)
Name
*
Full Name
Position
*
Telephone Number
*
Email Address
*
SA ID or Passport Number
South African Identity Number
Street Address
Country of Passport (if applicable)
Please provided a list of the Names of the Members of the Management Committee/ Board of Trustees/Board of Directors:
If you do not have 4 for the requirement, you can add Not Applicable (NA)
Full Name
*
Full Name
Full Name
Full Name
*
Full Name
Full Name
Full Name
*
Full Name
Full Name
Are you affiliated to any organisations? If Yes, name them:
Yes
No
Affiliated Organisations
Are you an umbrella body? If Yes, what organisations are affiliated to you?
Yes
No
Organisations Affiliated
Describe the main purpose of your organisation:
Organisation Main Purpose
*
Describe the nature of services and/or products your organisation provides
Nature of Services
*
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SECTION B:
FINANCIAL INFORMATION
Banking Details
Account Name
*
Account Number
*
Bank Name
*
Branch
*
Account Type
*
Please select
Cheque
Savings
Transmission
Branch Code
*
Financial Information
Financial Year End
*
Latest Financial Statements
*
Accountant/Auditor
*
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SECTION C:
REFEREES
Please give details of two referees in support of your application (Referees must be independent and may not be employees, Committee members, trustees or volunteers of the organization)
First Referee
Second Referee
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SECTION D:
PREVIOUS FUNDING
Have you benefited from the Trust before? If so, please provide details of the Trust’s project contract number, date and amount/s received: LIST ALL THE PREVIOUS GRANTS
Contract No 1
*
Project Location
Please confirm WHERE the project will be undertaken in the Nelson Mandela Bay Metropole
Contract Year 1
For what period (e.g. 1 year, 2 years, multi-year)
Contract Amount 1
Contract No 2
*
Project Location
Please confirm WHERE the project will be undertaken in the Nelson Mandela Bay Metropole
Contract Year 2
For what period (e.g. 1 year, 2 years, multi-year)
Contract Amount 2
If more than 2 previous grants please attach list in Section F
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SECTION E:
FUNDS YOU ARE APPLYING FOR AND DETAILS ABOUT PROJECT
Name of Project
*
Where will project take place?
*
Gqeberha
Despatch
Kariega
Amount Requested
*
Briefly describe the project you are applying for and its expected duration:
*
Motivation for the project
*
Prioritized activities, timeframes and outcomes
Activities
*
Time Frames
*
Outcomes for Beneficiaries
*
Project Manager
*
Who is managing the project?
Describe how the project will be sustained.
*
Describe how the project will be sustained. In the case of upgrading of facilities, please also describe how the facilities will be maintained and insured in the future.
Other donors/initiatives contributing to the project
Indicate if there are other donors/initiatives contributing to the project, and the value of the contribution.
Donor 1
Donor 2
Donor 3
Amount 1
Amount 2
Amount 3
Is the project a continuation of a previously funded project?
*
Yes
No
If yes, please indicate the Ezethu Development Trust project number/s. If the project has been previously funded by another funder, name the funder, and the amount granted.
EDT Project Number
EDT Project Number
Amount 1
Amount 2
Explain why additional funding is required.
Describe the activities completed and activities still to be funded to complete the project.
E5. BUDGET REQUESTED
As applicable and subject to the criteria per the guidelines, the budget should be split into three parts and detailed lists provided if necessary – E5.1 Capital budget for upgrade of facilities or new facilities E5.2 Equipment budget (list Description, number requested and unit cost per item and total requested inclusive of VAT) E5.3 Capacity Building Programmes (include detailed breakdown of costs, and be aware that the Trust does not generally funds operational overheads, wages, stipends etc)
Description of item/s
Item 1
Amount requested (inclusive of VAT)
Amount Requested 1
Inclusive of VAT
Capital Budget
Capital Budget
Equipment Budget
Equipment Budget
Capacity Building Programmes
Capacity Building Programmes
Item 2
Amount Requested 2
Inclusive of VAT
Capital Budget
Capital Budget
Equipment Budget
Equipment Budget
Capacity Building Programmes
Capacity Building Programmes
Item 3
Amount Requested 3
Inclusive of VAT
Capital Budget
Capital Budget
Equipment Budget
Equipment Budget
Capacity Building Programmes
Capacity Building Programmes
Item 4
Amount Requested 4
Inclusive of VAT
Capital Budget
Capital Budget
Equipment Budget
Equipment Budget
Capacity Building Programmes
Capacity Building Programmes
Item 5
Amount Requested 5
Inclusive of VAT
Capital Budget
Capital Budget
Equipment Budget
Equipment Budget
Capacity Building Programmes
Capacity Building Programmes
TOTAL AMOUNT REQUESTED
*
Inclusive of VAT
Inclusive of VAT
Please prioritize the budget Items:
*
Does the project require any pre requisites before it takes off, for example Other Funding?
*
Yes
No
If yes please provide the details of the other pre requisites:
*
Any other information you believe will be useful in evaluating the application
If applicable, please provide supporting documentation and proof of ownership /tenure for fixed property
Supporting Documents
If applicable, please provide supporting documentation and proof of ownership /tenure for fixed property
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SECTION F:
MANDATORY DOCUMENTS TO BE SUBMITTED WITH THE APPLICATION
Company Registration Certificate
Please attach a copy of your registration certificate
Upload Registration Document
No Company Registration Certificate
No Company Registration Certificate
No Company Registration Certificate
If N/A, please provide Explanation
Constitution Document
No Constitution Document
No Constitution Document
No Constitution Explanation
If N/A, please provide Explanation
Memorandum of Incorporation
No Memorandum of Incorporation
No Memorandum of Incorporation (or Articles and Memorandum of Association)
Memorandum of Incorporation Explanation
If N/A, please provide Explanation
Trust Deed
No Trust Deed
No Trust Deed
Trust Deed Explanation
If N/A, please provide Explanation
Bank Account Confirmation Letter
Latest Bank Statement
No Copy of latest bank statement, showing bank and account details
No Copy of latest bank statement, showing bank and account details
No Copy of latest bank statement, showing bank and account details Explanation
If N/A, please provide Explanation
SARS Tax Clearance PIN
*
No SARS Tax Clearance PIN
No SARS Tax Clearance PIN
No SARS Tax Clearance PIN Explanation
If N/A, please provide Explanation
SARS PBO Registration Document
*
No Proof of registration as PBO (SARS letter)
No Proof of registration as PBO (SARS letter)
Proof of registration as PBO (SARS letter) Explanation
If N/A, please provide Explanation
Annual Financial Statements - Latest Available
*
Annual Financial Statements - Latest Available
No Annual financial statements Current year Explanation
No Current Year Financial Statements
Annual financial statements Current year Explanation
If N/A, please provide Explanation
Annual financial statements - Prior Year to Latest Available
*
Annual financial statements - Prior Year to Latest Available
No Annual financial statements Prior Year
No Annual financial statements Prior Year
No Annual financial statements Prior Year
If N/A, please provide Explanation
Detailed Project Cost/Quotations Breakdown
No Detailed project costs
No Detailed project costs
No Detailed project costs Explanation
If N/A, please provide Explanation
Main Contact Person's Copy of SA ID or Passport
*
Second Contact Copy of SA ID or Passport
*
Details Of Previous Ezethu Development Trust Grants
Any Other Relevant Documention You Wish To Submit
Have you uploaded all documents?
Yes
No
I
(full name)
*
confirm on behalf of
(name of organization)
*
that I am authorised to sign this declaration, and that to the best of my knowledge all answers to the questions in this form are accurate. If this application is successful, this organization will contract to use the grant only for the purposes specified in the application, and will comply with all terms and conditions attached to the grant, including reporting on expenditure. I confirm that the organization, a registered Public Benefit Organization, has the power to accept the grant subject to conditions imposed and will repay the grant if the grant conditions are not met.
Name:
Name:
*
SA ID/PASSPORT number:
SA ID/PASSPORT number
*
Position in organization:
Position in organisation
*
Email Address:
Email Address
*
Date:
Date
*
Confirmation
I herby confirm that all the relevant information has been completed and the necessary documentation has been uploaded.
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