Local Heritage Assistance Fund Application Form

LOCAL HERITAGE GRANTS APPLICATION FORM 2021-2022

Proudly funded by the City of Canada Bay in association with the NSW Government

Application for Financial Assistance

Please refer to guidelines before completing this application. Minor works approval for the proposed work is generally required to be obtained prior to undertaking the work. If unsure, please discuss with Council’s Heritage Coordinator.

For further information or questions regarding this form, please contact Council via 9911 6555.

Applicant Details

Surname *

First Name *

Mailing Address *

Postcode *

Contact number: *

Email *

Property details

Property address: *

Property Postcode: *

Is this a conservation area? *

Yes No

Is this a heritage item? *

Yes No

Description of works undertaken: *

Present use of building: *

Consent of ALL Owner/s

Please ensure all property owners sign the owners consent.

Is the owner a company/strata company? *

YesNo

Full Company Name *

Company Owner Signature *

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Please upload a copy of your strata seal

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Owner 1 Full Name *

Owner 1 Signature *

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Owner 2 Full Name *

Owner 2 Signature *

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Owner 3 Full Name *

Owner 3 Signature *

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Owner 4 Full Name *

Owner 4 Signature *

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Owner 5 Full Name *

Owner 5 Signature *

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Please upload a letter of consent with ALL names/signatures of owners *

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Requested Grant

Have you received funding in the past from the Local Heritage Grants Program? *

Yes No

Year *

Grant amount sought: *

Cost of works *

Note that funding is generally on a dollar-for-dollar basis, with maximum grants limited to:

• 50% of amount spent or $3,000 (whichever is less) for a heritage item;

• 50% of amount spent or $2,000 (whichever is less) for a contributory property in a heritageconservation area

Minor Works Approval

Has a minor works approval been obtained? *

YesNo

Please provide application no. *

Cost of Work

Work Undertaken *

Contractor *

Contractor ABN *

Invoice Amount (Exl GST) *

Invoice amount (incl. GST) *

Supporting documentation

Please upload Tax Invoices (Evidence of the cost of the work undertaken) *

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e.g. Tax invoices

Plans/sketches of the works *

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Photographs before the works *

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You can upload multiple documents within this field

Please upload photos of the works in progress *

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You can upload multiple documents within this field

Please upload photos of after the works are completed *

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You can upload multiple documents within this field

Minor works approval letter

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Information required by Heritage NSW

The number of tradespeople who worked on the project *

The number of hours worked by tradespeople *

The number of volunteers who worked on the project (not to include the property owner) *

Declaration

I/we hereby confirm that the work has been undertaken as described in this application and that the contractor/s who undertook the work have been paid the amount nominated in the cost of works.
I/we hereby give consent for The City of Canada Bay Council and Heritage NSW to use before, during and after photographs for the promotion of heritage, including the Local Heritage Assistance Fund.
I/we, the applicant(s), hereby apply for financial assistance under the Local Heritage Assistance Fund for worksthat have been undertaken and paid for as described in this application on the land specified in the application. I hereby confirm that the work has been undertaken as described in this application and that the contractor/s whoundertook the work has been paid the amount nominated in the cost of works.

Applicant full name/s *

Capacity *

Applicant Signature (1) *

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Applicant Signature (2)

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Date signed *

Grant Payment Details

Payee Name *

Payee Address *

Payee Postcode *

Bank Account Name: *

Bank BSB: *

Account Number: *

Rams

(For Internal Use Only)