IMPORTANT: PLEASE READ THESE INSTRUCTIONS BEFORE FILLING OUT FORMStep 1: Fill out the application form. This fillable PDF form will allow you to put information into the application and save it on your computer or print out the form and fill it in manually.

Step 2: Once you’ve completed the form, email it to mcpp@gov.mb.ca and attach any supporting documentation you have in an electronic version and your application will be forwarded to your regional office. Applications can also be mailed to your Regional Office (listed on page 8) and must be submitted or postmarked no later than May 28, 2018. Make sure to keep a copy for your records.

Note: For emailed applications, mail only the supporting documentation that you were not able to attach in your email and make sure to indicate your organization’s name on your documentation. Do not send hard copies of your application form or other documentation that was already emailed to us.

Please do not bind your supporting documentation.

Deadline May 28, 2018

www.manitoba.ca/cpp

Community PlacesCommunity Building Partners

APPLICATION FORM

Helping Build Communities Since 1986

COMMUNITY PLACES PROGRAM - GUIDELINES

Continued on last page.

WHAT IS COMMUNITY PLACES?The Community Places Program provides funding and planning assistance to non-profit community organizations for facility construction, upgrading, expansion or acquisition projects.

Eligible projects are those which provide sustainable recreational and wellness benefits to communities.

WHO CAN APPLY?Eligible applicants include recreational, cultural, heritage and other non-profit community organizations in Manitoba.

A non-profit organization is defined as one whose legal incorporation specifies that its activities will be carried on with no financial gain to any of its members. Upon dissolution of the corporation, its property or the proceeds thereof will be turned over to a charitable organization.

Note: Public schools, universities, hospitals, nursing homes, businesses, commercial cooperatives and federal, provincial and City of Winnipeg departments and agencies are not eligible.

WHAT PROJECTS ARE ELIGIBLE?Projects involving the upgrading, construction or acquisition of facilities available to the general community are eligible under the Community Places Program. Community Places gives priority to proposals involving critical repairs to extend the life of well-used, existing facilities.

Projects once completed must result in a safe, secure and usable facility.

Projects involving new construction or major renovations must be consistent with Manitoba’s Green Building Policy for example, LEED Silver, Integrated Design Process, Manitoba Hydro Power Smart.

Ineligible projects include those primarily involving housing, space for worship or congregational purposes, cemeteries, tourism signage, portable tools, equipment, furniture, municipal works such as roads, bridges, municipal service buildings, and sewer and water i nstallations. Note: Exceptions may exist where community use can be measured. Contact your regional office listed on page 8 to obtain a form designed to help us determine your eligibility.

Operating costs and building maintenance costs are not eligible.

Project costs related to activities undertaken before grant approval and certification are not eligible for reimbursement under the Community Places Program (except for some professional design fees).

APPLICATION INSTRUCTIONS For assistance in developing proposals and in completing the Community Places Program application form, contact your regional office as early as possible. (See page 8)

Applicants are also encouraged to seek assistance through the program’s facility consultation service, which offers facility design advice, project planning and budgeting assistance. All proposals concerning existing facilities and new construction plans are reviewed by the program’s facilities consultants, so applicants generally benefit from arranging for a facility consultation as soon as possible.

HOW DOES THE PROGRAM WORK?

Community Places Program grant requests can not exceed 50% of the first $15,000 of eligible project costs and up to 1/3 of any eligible costs over that amount. Grants of up to a maximum of $50,000 may be approved. Please note this grant can not be greater than the total cost of paid project expenses.

Applicants’ contribution to project costs can include fundraising, local government funding, other provincial government funding*, federal government funding, other sources, volunteer/donated labour, donated materials and loaned heavy construction equipment. In communities under the jurisdiction of the Northern Affairs Act, Manitoba Aboriginal and Northern Affairs may provide the local government portion of eligible project costs.

* Please note that funding from all provincial government sources combined can not exceed 50% of total project costs.

Where projects include specialized work such as electrical and mechanical installations, this work must be under taken by licensed tradespeople. Complex projects and those involving significant volunteer labour components must be supervised by a full-time, qualified tradesperson.

If your project is approved you must ensure that all necessary permits are obtained such as building, development, electrical, plumbing, gas, environmental and occupancy.

Donated property can be calculated as part of the project value only if the donor purchased the property specifically for the project’s purpose.

1

Project Name

Facility Name

Project Site Address and City, Town or Village

Organization Mailing Address City/Town/Village

Organization Fax #

Postal Code

Project Primary Contact

Title

Email (required)

Primary Phone Number Alternate Phone Number

Mr.

Mrs.

Ms Project Secondary Contact

Title

Email (required)

Primary Phone Number Alternate Phone Number

Mr.

Mrs.

Ms

1 Indicate your language preference:

2 Legal name of your organization. Use the name that appears on your Articles of Incorporation:

3 Enter the permanent mailing address and email of your organization:

4 Names and contact information of your organization’s representatives who will be overseeing the project:

5 Enter your facility name, project site address and city, town or village:

6 Is your property or facility owned or leased? If leased, name the owner:

7 Project Name:

English French

Legal Name

Include a copy of your incorporation papers and latest Annual Return of Information.

Organization Email (required) Organization Phone #

Important to provide organization email and/or fax in order to receive communication.

Owned Leased Name of Owner

Include a copy of your minimum five-year lease and a letter from the owner authorizing the project.

Deadline Date May 28, 2018 Community Places Program (CPP) Municipal Relations

Application Formfor office use only Applications must be received or postmarked no later than May 28, 2018.

Once you’ve completed the form, email it to mcpp@gov.mb.ca and attach any supporting documentation you have in an electronic version and your application will be forwarded to your regional office. Applications can also be mailed to your Regional Office (listed on page 8) and must be submitted or post marked no later than May 28, 2018. Make sure to keep a copy for your records.

Cette information existe également en français : www.manitoba.ca/cpp/index.fr.html

2

8 Organization InformationProvide a description of your organization and its purpose (attach up to one additional page if required):

9 Project DescriptionProvide a description and a rationale for your project and explain how your project will benefit your community (attach up to one additional page if required): Please note that surveys and/or letters of support for your project from your users and from other community groups will enhance your application, please include.

11 Is this project ordered by a regulatory agency (for example, Office of the Fire Commissioner, Public Health, Liquor or Child Care Licensing, Manitoba Conservation, Workplace Safety and Health, Building Inspectors) or resulting from the findings of a facility assessment (for example, engineer's report, Community Places Facilities Consultant)?

If Yes, who has ordered the project and please include documentation.

12 Does your project involve critical repair? If Yes, please provide details:

Yes No

Project Start Date Project End Date

10 Anticipated Construction Start and End Date – work cannot begin until after grant approval and an agreement has been signed. Projects must be completed by March 31, 2019.

Regulatory Agency

3

13 Project Objectives – Check (✓) those that apply to your project:

14 Facility Condition (complete this section only if your organization currently occupies a building):

14a Age of building

14b Building Features – Check (✓) the features that are currently in your building and provide their approximate age:

Sq. Ft.

Age in years Age in years

Food preparation kitchen

Artificial ice plant

Fresh air ventilation system

Emergency lighting system

Fire alarm

system Roofing

Heating system

Years Years

Years Years

Years Years

Approximate size/square footage of buildingYears

Years

14c Please include last year's financial statements with your application and provide the annual costs for the following:

$Capital Reserve Fund*

* It is best practice to annually contribute approximately 3.5% – 5% of the total capital value of your facility in a Capital Reserve Fund otherwiselong term deterioration is likely.

15 Community Sustainable Development Benefit Local and green purchasing builds the strong local economies needed to support healthy, productive and sustainable communities.

Use workers who are local?

Use materials and services from local suppliers?

Use materials manufactured within Manitoba?

Use project materials that are reused/recycled or green/environmentally friendly/sustainable technologies? For example, LEED Silver, Integrated Design, Manitoba Hydro Power Smart, dual flush toilets, LED lighting, air source heat pumps, Forest Stewardship Council (FSC) harvested millwork or lumber, formaldehyde-free millwork (MDF, particle board), natural play, etc. Please describe and include documentation to support the use of any reused/recycled materials or green technologies.

All Community Places Program projects will, wherever possible, make efforts to incorporate labour and materials that are local (the nearest location to you for the supplies or services required) and environmentally responsible.

Will your project:

Yes No

Yes No

Yes No

Yes No

Fuel - Gas Utility $ Hydro Utility $

Comply with fire code and safety regulations

Comply with health codes and sanitary standards

Compliance with Green Building Policy

Support the use of green technologies

Reduce operating costs

Increase revenue in facilities

Support multi-use shared developments

Community use of schools

Support heritage activities

Increase participant numbers in physical/wellness activities

4

Check () Each Applicable User Group

Standard Hours

16a Please list all current or proposed functions/activities offered to the community which take place within your entire building/facility including sports fields and out-buildings (for example: hockey, skating, curling, soccer, baseball, fitness classes, child care, drop-in, fundraising events, socials, arts and crafts workshops, worship, playground, library, programming, training, etc.).

Check () the people/groups who are or will be served by your facility for each function/activity:

16b How busy is your facility, i.e. what is the approximate number of individual visits to your facility annually? (Every time a user enters the building for a function/activity). Please note that we only require approximate numbers.

16c What are the current or proposed hours your facility is/will be available for community use?

16 Community Use of Your Entire Facility

Functions/Activities A B C D E F G

e.g. Hockey D G

e.g. Socials

e.g. Youth Drop-in A B D

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

A B C D E F G

Approximate Number of Individual Visits Per Year Please include documentation to support the annual use/users of

your facility (for example, event calendar(s), program schedule(s), latest annual report, long-term facility/community plan, needs analysis, etc.).

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Open

Close

A Adults

B Children

C Youth

D Seniors

E Aboriginals

F Visible Minorities

G Persons with Disabilities

5

Component 1

Preferred Contractor:

Component 2

Preferred Contractor:

Component 3

Preferred Contractor:

Component 4

Preferred Contractor:

Component 5

Preferred Contractor:

Component 6

Preferred Contractor:

Component 7

Preferred Contractor:

Component 8

Preferred Contractor:

Component 9

Preferred Contractor:

17a Project Components and Related Cost Estimates Construction value should be supported by at least two contractors’ estimates or quotations (whether the work or materials are donated or not). If two estimates are not available, please include a letter explaining why.

Enter only the preferred contractor. Identify components and costs by type of work (for example, electrical, plumbing, drywall, washroom renovations, new construction, roof replacement, landscaping).

Include all estimates or quotations, along with your preliminary project plans, with your application.

Eligible costs: PST & GST, building permit fees, labour, materials, equip ment rentals and utility hook-ups. These costs may be paid directly by project sponsors or indirectly through contractors. Land and building purchase and design/engineering costs are eligible only if they are part of a project that will result in a secure, usable community facility.

Ineligible costs: Tools, equipment and furniture, legal fees, financing charges, on-going maintenance, administrative costs, meals and travel costs.

Note: If your grant is approved three estimates for projects valued at $100,000 or more will be required before work can begin.

All taxes must be shown on estimates or quotations in order to be eligible.

If any of the components listed above are donated resources, please check () the corresponding number(s).

17b

$

$

$

$

$

$

$

$

$

Total Project Value $

17 Project Value

1 2 3 4 5 6 7 8 9

6

18 Project Resources

18a Market value of donated resources (must be supported by contractors’ estimates or quotations). Please note that if your project is approved you will need to arrange for insurance coverage and expert supervision if you are using volunteer labour.

18b Funds on hand available to be used for this project – please include the most recent statement from your financial institution.

Total $

$

Donated Labour

Donated Material

Loaned Heavy Equipment

$

$

$

18c Provincial grants, other funding and financing/lines of credit (please name and include documentation). Please note that funding from all provincial government sources combined can not exceed 50% of your total project costs.

If the funding sources listed are not approved, how are you planning on addressing any financial shortfalls? For example, using funds on hand, loans/credit, scale back on scope of project, etc. Please provide proof of available funds/financing in the event that you should require it.

Confirmed

$

$

$

$

$

$

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

18d Total Applicant’s Resources - total of all values: 18a + 18b + 18c $

19 Enter "Total Project Value" from line 17b (page 5) $

$20 GRANT REQUEST

Community Places Program grant requests can not exceed 50% of the first $15,000 of eligible project costs and up to 1/3 of any eligible costs over that amount. Grants of up to a maximum of $50,000 may be approved.

IMPORTANT - incomplete applications may not be considered.The completeness of this application and the supporting documentation is critical in the consideration of your proposal. See checklist on next page to ensure you have included all the necessary documentation. Note: supporting documentation will not be accepted after the deadline.

18d

Financial Shortfall Strategy:

7

Copy of incorporation papers and your latest Companies Office Annual Return of Information. (Section 2)

If your property is leased, include a copy of your five-year lease agreement and a letter from the owner (for example, municipal government, landlord, First Nations, etc.) authorizing the project. (Section 6)

If your project is ordered by a regulatory agency please include documentation. (Section 11) For example, Office of the Fire Commissioner, Public Health, Liquor or Child Care Licensing, Building Inspector, Engineer’s Report, etc.

If your project incorporates the use of environmentally friendly/sustainable technologies (for example, LEED Silver, Integrated Design, Manitoba Hydro Power Smart, eco-labelling, dual flush toilets, LED lighting, air source heat pumps, Forest Stewardship Council (FSC) harvested millwork or lumber, formaldehyde-free millwork (MDF, particle board), reused/recycled materials, natural play, etc.) please attach a description. (Sections 13 & 15). Please obtain this information by consulting your supplier, contractor or the internet.

A copy of last year’s financial statements. (Section 14c)

If your organization has developed a purchasing policy that favours workers, suppliers and manufactured or reused/recycled materials from within your trading area please attach a copy. (Section 15)

Documentation regarding the viability and programming plans for your completed project (for example, event calendars, program schedule, hours of operation, annual users, letters of support, surveys, needs analysis, long-term facility/community plan) which support this project. (Section 16)

Preliminary project plans (drawings/sketches, site plan, cross sections, elevations and floor plans) that illustrate the type and scale of intended construction or renovation. Full professional working drawings are not recommended at this time. Please ensure that any drawings provided are legible and in large enough scale to review. (Section 17)

At least two contractors’ estimates or quotations for all work to be done. If two estimates are not available, please include a letter explaining why. (Section 17)

A current professional appraisal of any property to be purchased. (Section 17)

Confirmation of funding sources (for example, current bank statements, letter from bank, letters from other funders, etc.) (Section 18)

If the unconfirmed funding sources listed in your application are not approved, how are you planning on addressing any financial shortfalls? For example, using funds on hand, loans/credit, scale back on scope of project, etc. Please include an explanation if applicable. (Section 18).

Have you discussed your project with all local permit granting authorities? (Guidelines)

Is your facility worship, business, health care, housing or educational? If so, have you called for your form to determine your eligibility?

APPLICATION AND DOCUMENTATION CHECKLIST

Please include all of the following items with your completed application:

Information collected using this form is required for the administration of the Community Places Program of Municipal Relations and may be shared with other government departments and/or agencies in order to determine eligibility for funding and assistance under the program or for a use that is consistent with that purpose. Personal information is protected by the Protection of Privacy provisions of The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of personal information, please contact the Access and Privacy Coordinator, 600-800 Portage Ave., Winnipeg, MB, 204-945-1856.

I understand that by signing or typing my name below constitutes a legal signature confirming that I hereby certify that I am an authorized signing officer of the applying organization and that this application is accurate to the best of my knowledge and is endorsed by the organization that I represent.

Please do not start work – Project costs related to activities undertaken before grant approval and certification are not eligible for reimbursement under the Community Places Program.

Signature (Primary Contact) Position Date

SAVE PRINT PRINT EMAIL FORM

8

Regional OfficesContact your regional office as early as possible to discuss your project and application.

www.manitoba.ca/cpp

Region: Address: Toll Free: Phone Number: Fax Number: E-mail Address:

Central 1-866-346-5219 204-822-5418 204-822-2915 cindy.kowalski@gov.mb.ca225 Wardrop St. Morden MB R6M 1N4

Eastman Box 50, 20 1st St. S. 1-800-665-6107 204-268-6021 204-268-6070 roger.langlais@gov.mb.ca Beausejour MB R0E 0C0

Interlake Box 1519, 62 2nd Ave. 1-866-259-5748 204-642-6006 204-642-6080 dave.cain@gov.mb.ca Gimli MB R0C 1B0

204-627-8213 204-627-8236 wayne.huculak@gov.mb.ca Norma n Box 2550, 3rd St. and Ross Ave. The Pas MB R9A 1M4

Parkland Box 14, 27 2nd Ave., S.W. 204-622-2022 martijn.vanLuijn@gov.mb.ca Dauphin MB R7N 3E5

Westman Room 335, 340 9th St. 1-800-259-6592 204-726-6066 204-726-6583 kris.doull@gov.mb.ca

Brandon MB R7A 6C2

1-800-894-3777 204-945-0502 204-948-1065 mcpp@gov.mb.ca Community Places 600-800 Portage Ave Winnipeg Office Winnipeg MB R3G 0N4

EASTMAN

PARKLAND INTERLAKE

WESTMAN

CENTRAL

NORMAN

204-622-2298

9

Other Important Telephone Numbers

Permit Authorities City of Winnipeg Projects City of Winnipeg Building Permit Office 204-986-5140

204-945-3322 Rural ProjectsOffice of the Fir

204-480-5900

Code Compliance Requirements First Nations Projects Manitoba Hydro 204-480-5900 1-888-624-9376

Note: CPP funding is contingent upon proof that a project meets building code standards.

Environment Act Licences Conservation and Water Stewardship 204-945-8321 1-866-626-4862 ext. 8321

Incorporation and Registration Companies Office 204-945-2500 1-888-246-8353

Workers Compensation Board 204-954-4321 1-800-362-3340

Manitoba Green Building Policy Green Building Coordination Team 204-782-8050

Other Funding Sources to Consider Imagine CanadaA national organization that can assist in fundraising by providing key information resources about Canadian Foundations. Toll free 1-800-263-1178 www.imaginecanada.ca

Natural Resources CanadaFunding for energy efficiency and sustainable development-related projects through various programs at the Office for Energy Efficiency. Toll free 1-877-360-5500 www.oee.nrcan.gc.ca

Family Choices Building Fund Funding for the development or improvement of licensed child care facilities. Toll free 1-888-213-4754 www.gov.mb.ca/fs/childcare/resources/forms_apps.html

Manitoba HydroAdvice and funding available for projects ranging from lighting upgrades to energy efficiency improvements to tree planting. Toll free 1-888-624-9376 www.hydro.mb.ca

Sustainable Development I nnovations FundFunding for the development, implementation and promotion of environmental innovation and sustainable development projects. Toll free 1-800-282-8069 ph. 204-945-1211 www.gov.mb.ca/sd/annual-reports/sdif/index.html

Phone Number: Toll Free:

1-800-282-8069 ext. 3322

1-888-624-9376 e Commissioner

Manitoba Hydro

The Community Places Program places a priority on project proposals involving critical repairs that extend the life of well-used existing facilities.

The project will be used by a significant portion of the community.

Provides a multi-use function for a variety of user groups and activities and is well used.

The project will result in greater and more diverse community use of public school facilities.

The project will benefit your local economy through the purchase and use of workers, suppliers and manufactured or recycled/reused products, from sources within your trading area.

The project will complement existing facilities in the catchment area.

The project is part of a long-term facility/community plan.

Project planning is sufficiently detailed (for example, site plans, study plans) so as to convey a clear understanding of functions, proportions and types of construction intended. Final construction drawings and/or engineered plans are not recommended at the time the application is submitted, but if available, should be retained by applicants for viewing.

Contractors’ costing is complete, competitive, based on plans/specifications and covers all aspects of the project. Cost estimates rather than fixed cost quotations are sufficient for the application.

The project is ready to start upon grant approval and is adaptable to the possibility of grant funding which may be less than requested.

The applicant group’s project resources are confirmed.

The applicant group has shown sufficient realistic revenue and/or support to cover operating and maintenance costs, and to maintain a capital reserve fund.

The project is consistent with the Manitoba Green Building Policy and/or emphasizes environmentally positive technology and/or the delivery of environmental programming.

The programs, services and activities to be offered through this project are primarily or entirely focused on the needs of seniors, youth, children, persons of Aboriginal ancestry, persons with disabilities and/or members of a visible minority.

The project will serve a community or neighbourhood where incomes are lower and/or unemployment is higher than provincial averages.

The applicant has provided organizational information such as Articles of Incorporation, Letters Patent and latest Annual Return from Manitoba Finance.

The applicant has provided documented user/community support for the project (for example, letters of support, hours of operation, annual users, surveys, needs analysis, events calendar).

ALL APPLICATIONS WILL BE EVALUATED AGAINST THE FOLLOWING:

March 2018

Community Places Program grants are paid to project sponsors as reimbursement for approved, paid project cost expenditures and, if applicable, the approved value of volunteer labour, donated materials and loaned heavy construction equipment contributed to the project.

Project sponsors claim reimbursement by submitting Financial/Activity Reports on forms supplied by the program. Reimbursements will be consistent with the level of completion of the project.

COMMUNITY PLACES PROGRAM - GUIDELINES (continued)

HOW ARE GRANTS PAID?