PROJECT FUNDING APPLICATION FORM
Hertfordshire Healthy Homes 2015/16 Local Initiatives Fund
Please read carefully the accompanying Guidance Document to ensure you
provide all the correct information and you submit a proposal that contributes
to achieving the Herts Healthy Homes project outcomes.
Section C of the Guidance Document confirms how and when to apply.
Please note that the deadline for returning all applications:
12 NOON, MONDAY 23rd MARCH 2015
Please refer to Section A of the Guidance Document for details of who
can apply for Herts Healthy Homes Local Initiatives funding
1. Applicant Details
1.1 Organisation/Group
1.2 Please describe the
purpose of your organisation
and an overview of your
main activities
1.3 Please explain why you
feel your organisation/group
is best placed to deliver the
project being proposed
1.4 Contact Name
1.5 Address
1.6 Phone/Mobile Number
1.7 Email address of contact
Please refer to Section B of the Guidance Document for details of the
requirements for successful project proposals and details of how much
you can apply for
Please also refer to Section D, which sets out the criteria we will be
using to assess bids
2. Proposal Details
2.1 Proposed Project Title
2.2 My Organisation/ Group
are applying for
A project/initiative costing at least £20,000
(Please go to question 2.3)
A Small Grants Fund of up to £20,000 so you can
administer your own fund for project proposals costing
less than £20,000 (Please go to question 10)
A project/initiative costing under £20,000 from a Small
Grants Fund – you should only be applying for this if
you have received this application form from an
organisation administering a small grants fund
(Please go to question 3)
2.3 How have you identified
that there is a need for this
specific project? (please
include any supporting
evidence)
3. Proposal Summary – Describe your proposal: (Word limit = 200 words)
4. Project Aims: Describe how your proposal will address the key priorities and themes of
Herts Healthy Homes (HHH). Your description should also address the other criteria in
section D1 of the Guidance Document. Please ‘bullet point’ key themes to be achieved:
(Word Limit = 500 words)
5. Project Plan: Give a brief summary of your project plan, including when projects will start
and finish, key milestones and when things will be delivered. Projects must be completed by
the end of February 2016 and evaluation submitted by the end of March 2016.
6. Project Costs: Please provide brief details of the costs of the project, separately
identifying any communications and consultancy/ management fees
(see sections B3-B5 of the Guidance Document)
Details
Costs
1.
2.
3.
4.
5.
6.
TOTAL cost of project:
7. Targeting: From the list below, please select the keywords that best describe the
beneficiaries of the proposal and the approximate number of beneficiaries to be targeted
Beneficiaries
Tick 
Approx No.
Over 75 years old
Frail
Pre-existing cardiovascular or respiratory illnesses and other
chronic medical conditions
Severe mental illness
Dementia
Learning difficulties
Arthritis, limited mobility or otherwise at risk of falls
Young children
Living in deprived circumstances
Living in homes with mould
Fuel poor (needing to spend 10% or more of household
income on heating home)
Elderly people living on their own
Homeless or people sleeping rough
BME communities
Rurally isolated communities
Carers
Other (please state)
Total number of individuals who will benefit from this
project:
8. In which district(s)/borough(s) of Hertfordshire will your project/initiative be
delivered?
Please refer to Section E of the application form for details of how we
will monitor and evaluate the success of projects
9. Evaluation – Describe how you will evaluate the success of the proposed project:
(word limit = 300 words)
Please only answer questions 10 and 11 if you are applying for a
Small Grants Fund so you can administer your own small grants process
10. Small Grants Fund
How much do you want to apply for? (See Section B2 of the Guidance Document)
11. Your process
Describe how you will:
 Set up a small grants process
 Promote your Small Grants Fund
 Ensure that projects you fund address the Herts Healthy Homes aims and priorities
 How you will report on the success of the projects funded
(word limit = 500 words)
12. Declaration and data protection:
Data Protection Statement (Data Protection Act 1998): Hertfordshire County Council will use the
information you give in this form, and in your application form to process your claim for project
funds support. The Council may share the information supplied to other Council departments and
Herts Healthy Homes partners.
Project funding applications paperwork is kept in accordance with the Council’s retention policy.
The Council is the data controller for the purposes of the Data Protection Act 1998.
By signing this declaration, I accept/confirm:
1. The terms and conditions of the project funds as set out in the Guidance Document
2. My organisation/group meets the conditions set out in section A of the Guidance Document
3. The information is true to the best of my knowledge
4. That I have authority on behalf of the club/group to make this application and accept the
project funds offer
5. That I have read and understood the Data Protection Statement
Signed:
Name:
Date:
Address:
Telephone:
E-mail:
Position in organisation:
For applications for projects costing £20,000 or more or for a Small Grants Fund:
please return the application form and all documents to: tracy.webber@hertfordshire.gov.uk
or by post to: Tracy Webber, Community Wellbeing Team, Hertfordshire County Council,
SFAR202, Farnham House, Six Hills Way, Stevenage, SG1 2FQ.
For applications for projects costing under £20,000: please return to the organisation
that sent you the form, together with any information they have requested.