The Corporation of the
City Of North Vancouver
LOWER LONSDALE LEGACY FUND
APPLICATION FORM
SUBMISSION DEADLINE: 5:00 pm
☐ March 31, 2014
☐ October 15, 2014
This application must be typed. Please use the space provided for your responses.
Attachments, faxes, handwritten, and/or late applications will NOT be considered.
APPLICANT INFORMATION:
Organization Name: Click here to enter text.
Address: Click here to enter text.
Telephone: Click here to enter text.
City: Click here to enter text.
Fax: Click here to enter text.
Project Contact Person: Click here to enter text.
P. Code: Click here to enter text.
E-mail: Click here to enter text.
Position: Click here to enter text.
Your Organization’s BC Society No.: Click here to enter text.
Your Organization’s Charitable Registration No.: Click here to enter text.
Brief History and mandate/purpose of the organization delivering this project:
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APPLICATION SUMMARY:
Project Title: Click here to enter text.
Project Description (Please provide a one sentence summary of the project):
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Project Timespan From: Click here to enter text. To: Click here to enter text.
Click here to enter text. % of total participants that will be Lower Lonsdale residents.
Click here to enter text. # of total participants that will be Lower Lonsdale residents.
Amount requested $ Click here to enter text.
Total project budget: $ Click here to enter text.
Goal (Overall purpose):
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Outcomes - What will be achieved through this project? Statements should be specific, measureable and attainable
within the project timeline.
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Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969
PROJECT INFORMATION:
What are the proposed activities and corresponding timeline? Projects are to be completed by September 2013.
Activity Plan (Specific action steps to meet desired outcomes).
Corresponding Timeline
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ADDITIONAL KEY FACTORS THAT WILL FORM THE BASIS OF REVIEW AND APPROVAL:
1 COMMUNITY DRIVEN: Identify the population(s) to be served, how they will benefit from the project, and how
they were involved in project planning, implementation and evaluation.
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2 VOLUNTEERS: Describe how you will promote, encourage and facilitate the involvement of volunteers. If known,
include the number of volunteers to this project.
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3 COLLABORATION/PARTNERSHIPS: Identify and describe the extent to which collaborating agencies,
community groups, and individuals are supporting or participating in the project (include contact names and telephone
numbers).
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Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969
4 SENSE OF COMMUNITY: Describe how the project will contribute to a sense of the Lower Lonsdale
community.
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5 COMMUNITY NEED: Describe how this project meets an identified community need recommended for action in
the Lower Lonsdale Social Development Strategy Report.
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Is this project a duplication of an existing project?
☐ YES
☐ NO
6 INCLUSIVE: List the strategies you will implement to ensure that the project is inclusive and accessible (e.g.
services are culturally appropriate, facilities are wheelchair accessible, materials are translated, etc.)
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7 EFFECTIVE EVALUATION: An evaluation report from funded projects is due within two months of project
completion. The evaluation report should include information on the following:
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Goals achieved and factors influencing outcomes;
Any major changes to the project from the original application;
Completion of the proposed Action Plan and corresponding timelines
Evidence of community impact;
Attendance figures;
Demographics and origin of participants (if available);
A final accounting of revenues and expenses compared with the original budget; and
How the City’s contribution was recognized.
Repeat applications will not be considered without an evaluation of the previous project.
PROJECT BUDGET – Itemize all the expenses and all sources of revenue, including your agency's and
other "in-kind" contributions.
Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969
Expenditures:
Revenue:
Salaries/benefits
$
Contract Fees
$
Honoraria
$
Rent/ Utilities/
Phone
Printing/ copying
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Travel
Request from
$
LL Legacy Fund
(use this amount to
complete details in
Section below)
Your Organization’s
$
Cash
contributions
$
In-Kind
List Additional Revenue Sources (specify):
Confirmed?
Yes/No
Contact & Ph #
Others (specify)
Total Expenditures
Total Revenue
(including request from
$0
.
$0
LL Legacy Fund)
Note: The Budget must balance. Expenditures must be the same amount as the
Revenue.
HOW DO YOU ANTICIPATE YOUR LOWER LONSDALE LEGACY FUND GRANT $’S TO BE EXPENSED?
Itemize the expense type and the amount. (Expense types could include: Salaries/benefits, Contract Fees,
Honoraria, Rent/utilities/phone, Printing/copying, Travel)
Expense Type
Amount
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$
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$
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$
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$
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$
Total (equals grant requested from LLLF)
$0
APPLICANT’S SIGNING AUTHORITY:
Signature of President/Executive Director/Senior Staff Person:
Signature of Board Chair/President:
Name
Name
Date: .
Date
MAIL, HAND-DELIVER, SCAN / EMAIL OR COURIER YOUR COMPLETED APPLICATION TO:
City of North Vancouver, Community Development Department
141 West 14th Street, North Vancouver, BC V7M 1H9
Attention: Paul Penner, Community Planner or Edytha Barker, Committee Clerk
Please remember your application should be typed, not to exceed these 4 pages, has no attachments, not to be faxed,
and delivered to the City of North Vancouver Community Development Department on or before the deadline date at
5:00pm. Late applications will not be accepted.
Lower Lonsdale Legacy Fund Application – 2014
Document: 1135969