Appendix 1

1. Name and address of the group or organisation making this proposal:

2. Name and status of person responsible for preparing and submitting this proposal

3. Contact details of person responsible for this proposal

Office telephone no:

Mobile phone number:

E-mail Address

4. Background information on your organisation / project sponsor:

5. Date your organisation/project established:

6. Please list below the main services / activities provided by your organisation;

7. List the main achievements of the Organisation:

8. Legal status of organisation / group:

9. Company registration number:

10. Expenditure in last financial year: Year: Expenditure:

11, List the main sources of income of your group/organisation;

Department of Employment Affairs and Social Protection

An Roinn Gnóthai Fostaiochta agus Coimirce Sóisialaí

Proposal for funding under the Activation & Family Support Programme (AFSP)

Details of project for which you are seeking part-funding under the AFSP

12. What is the name of the project?

13. How was the need for this project identified?

14. Why is the project necessary?

15. What is the main aim of the project?

16. What are its key objectives?

17. Is the programme located in a RAPID or Clár area?

18. If the programme is in a RAPID area, was it initiated at Area Implementation Team (AIT)

level?

Target group /number of beneficiaries

19. Total number of people that will take part in this program: ________

(All participants must be social welfare recipients or their adult dependant and of working

age)

20. How were the participants identified?

21. Was each participant interviewed to determine their suitability for this course? If so, who

interviewed them?

Names of Participants

22. Name of participants

PPS number Type of social welfare payment

participant is currently receiving

23. What are the circumstances of the target group?

24. If the proposed project involves providing a structured training course, please provide the

numbers you expect to participate.

Male:

Female:

Total:

25. If the proposed project involves providing a service (e.g. counselling, guidance, job

search support), please provide the numbers you expect to use the service:

Male:

Female:

Total:

For projects involving training courses

26. Please describe the content and format of proposed course/programme:

27. What are the main learning outcomes you are seeking?

28. List the main modules that will be provided;

29. What is the proposed duration of the course?

30. Is the course part-time or full-time? (e.g. two half-days per week on Mondays & Fridays)

31. How many contact hours of tuition are to be provided to each participant?

32. Who will provide the course?

33. What are the qualifications of the course provider?

34. How will participant progress be assessed?

35. What organisation is the course accredited by?

36. Do you have strategies in place for addressing issues such as abuse (physical and

otherwise) and addictions as they arise during the programme?

37. Do you have strategies in place for appropriate referral, after-care as well as monitoring

and reporting outcomes?

For projects involving services

38. Expected outcomes of proposed project?

39. What are the main benefits that participants will obtain in the short and long term?

40. How will these benefits be assessed?

Timetable for the project

41. Proposed start date:

42. Proposed completion date:

43. Describe the main milestones involved in implementing the project?

Project costs

44. Total cost of project - €

45. Amount of part-funding being sought from the Department of Employment Affairs and

Social Protection?

(If you are applying for funding from the Department which is in excess of €6,350, please attach a

current Tax Clearance Certificate for your group/organisation).

€

46. Please state the amount of funding that your own organisation will provide towards your

project? €

47. Have you sought funding from any other organisations (e.g. ETB) for this project? If so,

what was the outcome?

(If you have not applied for funding to these organisations, please do so before submitting this

proposal to the Department).

48. If matching funding is being provided by another organisation(s), please give details

If another organisation intends to provide funding in excess of €10,000, please attach a letter

from that organisation confirming the amount and purpose of the funding.

For projects costing in excess of €30,000, please provide the names and tax reference

numbers of the service providers.

Name of organisation providing matching funding Amount of funding (€)

49. Please provide an itemised list of projected costs of your programme and the name of

organisation(s) covering the costs where applicable:

Once-off funding

50. The Activation and Family Support Programme fund is administered on a once-off basis.

If you intend to run this programme again in the future, how do you propose to fund it?

Declaration

On behalf of I wish to apply to the

Department of Employment Affairs and Social Protection for funding of €

under its Activation and Family Support Programme as outlined above. I declare that

all of the information contained in this proposal is true and accurate to the best of my

knowledge and belief. I have also read and understood the terms and conditions

pertaining to receipt of funding under this Programme and I confirm that they will be

implemented in full.

Signed:

Date:

Status of signee in group/organisation:

When fully completed, this proposal form should be signed and dated (in ink pen) and

posted, along with any supporting documentation, to Department of

Employment Affairs and Social Protection,

Please note that we can only accept this proposal form in hard copy format.

Checklist:

Please ensure that you send the following documents to the Department:

Check()

1. This Proposal Form (Appendix 1) fully completed and signed/dated.

2. Bank mandate form (Appendix 2) giving details of your organisation’s bank account.

3. Information and conditions for receipt of funding (Appendix 3) under the Activation and Family Support Grant with declaration signed/dated.

4. A current Tax Clearance Certificate (only required if the funding being sought exceeds EUR 6,350).

5. A letter from any other organisation that is part-funding your course/programme by EUR 10,000 or more (if applicable).

Appendix 2

Order for Payment - Activation & Family Support Programme

From: To:

Client /

Project Name:

Date proposal

received:

With reference to the attached invoice/proposal, details of which are set out below, I certify that the

proposal is in order for payment, and the proposal has not been included in any previous payment.

Signed: ________________________ Date: _______________

Case Officer

Approved: _____________________ Date: _______________

Area Manager

AUTHORISED BY: ____________________________ (Budget Holder

GRADE: _________________

DATE: _________________

PAYEE NAME:

ADDRESS:

COST CENTRE: V5465

PAYEE tax reference no:

INVOICE NO.:

AMOUNT: €

PERIOD COVERED:

NATURE OF SERVICE:

NO. OF PEOPLE ASSISTED: TARGET GROUP:

RAPID AREA: CLAR AREA:

Appendix 3 - SUPPLIER SET-UP FORM V05-2017

NOTE: YOU MUST RETURN ORIGINAL OF THIS FORM ONLY Part 1: To be completed by the Company / Individual / Organisation where details have not been previously submitted or have changed. Part 2: ONLY To be completed by authorised Bank Official if changing bank account details currently held by the Department of Employment Affairs and Social Protection.

Part 1 Company / Individual / Organisation Details

Payee Name ______________________________________________________________

Medcert Panel No/DSP Payroll Number (if applicable)__________________________________

Payee Address ____________________________________________________________

Email address _______________________________________________________________ ____

Email address for Purchase Orders (if Applicable)______ _________________________

Tax Registration No/PPS No __________________Telephone No ______________________

If payment/s exceed €10,000 in a twelve month period please supply the following:

Tax Clearance Access No (TCAN): __ __ __ __ __ __ OR attach copy of current Tax Clearance

Cert

Bank Name_______________________________________________________

Address _____________________________________________________________

Account Holder _______________________________________________________

BIC/SWIFT Code

IBAN Number

Payee Signature _________________________ Block Letters ________________________

Date: ______________________________________________

If the payee is not the account holder then the account holder must sign here

Account Holder Signature __________________________ Block Letters

_______________________ Part 2 ONLY To be completed by authorised Bank Official if changing bank

account details currently held by the Department of Employment Affairs and Social Protection.

Bank Official

Signature: _______________________________

Date: _______________________________ OFFICIAL BANK STAMP

DSP use only

Supplier No: Site:

Input by:

Checked by:

Appendix 4

Conditions for Award of Activation & Family Support Programme In the event of acceptance and payment of proposal, the following conditions

apply:-

1. All participants on the programme funded must be in receipt of a qualifying social protection payment or must be the dependents of social welfare recipients and/or their families. Examples of social protection payments include:

o Jobseeker’s Allowance and Jobseekers Transition (incl. Casuals) o Jobseeker’s Benefit (incl. Casuals) o Blind Pension o Deserted Wife's Benefit (DWB) o One-Parent Family Payment (OFP) o Signing on for credits o Carers Allowance

2. Where a proposed programme has participants who are not in receipt of a SW

payment or who are not a dependent of a SW recipient funding will only be provided on a proportionate basis.

3. Details must be provided to the Case Officer of participants including name,

address, PPSN, & the scheme under which they are being paid before funds can be released.

4. The programme provider must have strategies in place for addressing issues

such as abuse (physical or otherwise) and addictions as they arise during the programme. This may involve referral to qualified counsellors or to other appropriate supports.

5. The Case officer must be allowed to visit the training course/project etc from

time to time by prior appointment to see how it is progressing.

6. An evaluation of the programme/project must be submitted to the Department within one month of its completion. A template is available for the evaluation. In the absence of the completed evaluation, the Department will not consider any future applications for the organization for other projects.

NB: If for any reason the programme/course does not go ahead then the Department's Case Officer/Area Manager must be informed immediately or within one week of the proposed start date and arrangements must be made to refund the monies to the Department. 7. Funds provided for the course or project can only be used for the purpose for

which they are provided. Details of expenditure including invoices & receipts must be available for inspection if/when required by the local Case officer.

8. Where the total cost of the project exceeds €30,000 the name(s) and relevant

reference number(s) of the service provider(s) must be stated on the application.

9. Any unspent funding at the end of the programme may not be used for any

other purpose. Such unspent funding must be returned to the Department without delay.

Declaration

Name of group/organisation

__________________________________

I hereby confirm

(1) Receipt of grant of €

(2) The conditions specified above governing the use of funds allocated by

the Department of Employment Affairs and Social Protection is acceptable to

my organisation/company/group and will be implemented.

Signed: _______________ Date___/____/20

Block capitals

Status /Title in organisation

Appendix 5 An Roinn Gnóthai Fostaiochta agus Coimirce Sóisialaí

Department of Employment Affairs and Social Protection

Activation and Family Support Programme

Evaluation Questionnaire

1. Name & address of the organisation which operated the project:

2. Name of project (if applicable):

3. Status and contact details of person

Office phone number

Mobile phone

E-mail address

4. Location(s) where project took place:

5. Was the project in a RAPID or Clár

area? RAPID Clár

6. Were procurement guidelines fully

adhered to by the programme provider?

(please circle as appropriate)

Yes No

7. If no, please elaborate

8. Please state the main groups of

people who benefitted from the project?

Outcomes for project course /programme

9. How many participants started the

course(s) programme provided?

Starters Male Female

Total

10. How many participants completed the

course(s) programme provided?

Completers Male Female

Total

11. How many participants obtained

certification?

Certs Male Female

Total

12. State the certification level (e.g. QQI

level) and the awarding authority.

13. Progression status of participants/

beneficiaries following the

course/programme

Name PPSN

Male Female Total

Employed

Self-employed

Further training

Further

education

On employment

programme

Seeking work

Other

14. What was the main objective of the

project?

15. Details of how course/programme

performed against the original objectives as

outlined in funding proposal

(please circle as appropriate)

Yes

No

If no, please outline the reasons:

16. How were the benefits of the

project/programme for participants or

beneficiaries assessed?

Project Costs

17. What was the total expenditure

associated with implementing this project?

18. What was the total cost incurred by the

Department of Employment Affairs and

Social Protection?

Please list these costs.

19. Was the funding provided by the

Department of Employment Affairs and

Social Protection for this programme fully

used up?

(If not, any unused funding should be

returned to the Department immediately)

20. List the names of other organisations

who co-funded the project and the amounts

involved

Organisation

Amount (€)