Communities Mental Health and Wellbeing Fund for Adults - Round 5 Application Form 2-Year Small Grant

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Section 1 - Contact Details

Organisation Name

Street

Town

Postcode

Telephone

Website

General / Office Email

Are you part of a larger regional or national organisation?

Main contact person

These are the details that will be used for correspondence purposes

Title

Forename(s)

Surname

Job Title

Work / Office Phone

Mobile Phone

Secondary contact person

These are the details that will be used for correspondence purposes if the main contact is unavailable

Title

Forename(s)

Surname

Job Title

Work / Office Phone

Mobile Phone

Section 2- About your Organisation

When was your organisation established?

What type of organisation are you?

Please check the relevant box(es) and input the charity and company numbers where appropriate. All Scottish charity numbers start with SC. Please enter your number without spaces i.e. SC012345 not SCO 12345.

Charity Number

Company Number

Staffing and volunteers - How many of each of the following are involved in the organisation?

Full time staff

Part time staff

Trustees

Volunteers (excluding management committee)

Briefly describe the purpose of your organisation, outlining the main activities and services you provide and to whom.

Section 3 - Financial details

What was your total income over last accounting year?

Your annual income must be no more than £1million. If you are part of a national organisation, this amount would refer to the income specifically for Dumfries and Galloway.

Please state the name, position and company details of the independent examiner who has signed your accounts.

Bank Account Name

Do NOT provide the name of the Bank/Building Society.

Bank Account Number

Bank Sort Code

Do NOT enter spaces or dashes

If your account name is different to the name of your organisation, please state the reason why.

Section 5 - Details of grant funding requested

What is the total cost of the project?

How much money is being applied for?

If you are not applying for 100% of the total project cost, please tell us where else your project funding is coming from.

Funder	Amount	Status
	£

Please provide a full breakdown of the grant requested according to your Year 1 and Year 2 budget.

Ensure the breakdown adds up to the amount you have applied for, and not the project total cost. Please provide the calculations for each item in the tables below.

Year One

YEAR ONE BUDGET AMOUNT TO BE SPENT BETWEEN 01/04/26 AND 31/03/27

Item/Description

Cost

Sum of budget costs as described above for year one

Year Two

YEAR TWO BUDGET AMOUNT TO BE SPENT BETWEEN 01/04/27 AND 31/03/28

Item/Description

Cost

Sum of budget costs as described above for year two

Combined total for Year One and Year Two

Please ensure this total matches the amount being applied for.

If you have applied for capital amount (under £5,000), please tell us about your exit strategy.

Section 6 - Supporting documents & confirmations

Please confirm you have the appropriate policies and procedures in place to deliver this project.

I confirm

Please confirm you have a safeguarding policy if your organisation’s core work or the project you are applying for involves children or vulnerable adults

I confirmNot applicable

Please confirm that you have an EDI (Equality, Diversity, and Inclusion) policy.

I confirm

This funding is subject to meeting the principles of the Fair Work Framework as described in section 3.1.5 of the guidance. Please confirm that you will adhere to these requirements.

I confirm

If your grant request is for any item(s) costing more than £3,000 please confirm that you obtain at least two quotes for each of those items.

I confirmNot applicable

A copy of a recent bank statement with your bank name, account name, sort code and account number will be uploaded with your application.

A copy of your constitution (or other governing document) submitted with the application is the most up-to-date version adopted by the members of the organisation.

If you do not have the bank statement available electronically, please submit the application and email it as soon as possible to wellbeingfund@tsdg.org.uk

All your documents must be received within 5 days of submitting or by the application deadline, whichever is sooner.

Please note that your application may not be processed for assessment until all the required documents, listed above, have been received.

Section 7 - Declaration

I declare that the information contained in this application is correct, and that I am authorised to make the application on behalf of the named organisation and with whom it has been discussed. I understand that decisions made by the scoring panel are final.

Full name

Date

By submitting your application, you agree to allow Third Sector Dumfries and Galloway to retain your personal data on its database to process your application. We will use the information you give us to help assess your application and administer any grant we award you. We may also publish this information on our website or use it to analyse our grant making for our own research or for others. We may give copies of this information to individuals and organisations we consult when assessing applications, when monitoring grants and evaluating our programmes. We may also use this information for training purposes. This is in line with our Privacy Notice which you can read at www.tsdg.org.uk

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