Department of Justice Canada

Ministre de la Justice Canada

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FUNDING APPLICATION FORM

National Victims of Crime A areness !ee" #$1%& WE ALL HAVE A ROLE
1' APPLICANT INFORMATION&
Name of Organi(ation& Com)lete Mailing A**ress& P+one N,m-er& !e-site A**ress& Name an* Title& P+one N,m-er& Email A**ress& Fa. N,m-er&

PRO/ECT ADMINI0TRATOR CONTACT INFORMATION&

#' DE0CRI1E 2OUR ORGANI3ATION&

Please )ro4i*e a -rief s,mmar5 of 5o,r organi(ation an* man*ate' (Maximum 150 words) !+at t5)e of organi(ation are 5o,6 (Please select one) Aboriginal organization Community coalition or network Educational institution or association Private sector organization, association or society Not-for-profit organization, association or society or group Public sector organization (e g !ospital, sc!ool" #t!er (please specify"$ !+at 5ear as 5o,r organi(ation esta-lis+e*6 Is 5o,r organi(ation incor)orate*6 No +es , 8 At +at le4el is 5o,r organi(ation incor)orate*6 At +at le4el is 5o,r organi(ation acti4e6 7Please select all t!at a""l#) %ocal &unicipal 'egional Provincial()erritorial National *nternational

* Please include a copy of the certificate and the articles of incorporation OR the letters patent in your email submission.

%' FOR 9U:1EC ORGANI3ATION0 ONL2

Are t!e ma-ority of your members from t!e .u/bec public sector (i e appointed by t!e 0overnment of .u/bec, a government agency, a municipal body, a sc!ool board, or anot!er public agency"1 +es No *s your personnel appointed in accordance wit! t!e Public 2ervice Act (of .u/bec" (c!apter 3-4 5 5"1 +es No *s more t!an !alf of your financing derived from .u/bec public funds (i e from t!e consolidated revenue fund, a government agency, a municipal body, a sc!ool body or anot!er public agency"1 +es No

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Department of Justice Canada

Ministre de la Justice Canada

PROTECTED ONCE COMPLETED Page #

;' INFORMATION A1OUT 2OUR PRO/ECT

Pro<ect Title& (Maximum o$ 10 words) Pro<ect start *ate& Pro<ect en* *ate&

=' PRO/ECT DE0CRIPTION

Most )ro<ects t+at ta"e )lace *,ring NVCA! fall into one of t+ree general categories' Please c+oose t+e categor5 > categories from t+e list -elo t+at -est *escri-e 5o,r e4ent' If 5o,r e4ent *oes not fall it+in one of t+e categories liste*? )lease in*icate +at 5o,r )ro<ect ill -e in t+e section mar"e* @ot+er'A M5 )ro<ect ill -e a7nB& 0eneral or specific awareness-raising campaign, event, or ceremony (e g $ a proclamation ceremony at City 6all, newspaper ad campaign etc " Event t!at draws specific attention to skills ( researc! ( advancements made respecting victim issues (e g $ training session, works!op etc " Event t!at recognizes t!e dedication of t!ose t!at work to support and assist victims of crime (e g $ volunteer recognition event, award ceremony etc " #t!er (please specify"$ In t+e s)ace -elo ? )lease -riefl5 *escri-e t+e acti4ities t+at ill ta"e )lace? +5 5o, ant to ta"e on t+is )ro<ect an* +o ill -e affecte* -5 t+e )ro<ect' (Maximum o$ 150 words)

Antici)ate* Date7sB of E4ent7sB&

,, Please note t!at your event must take place between April 75 and 78, 7954 Planning and :wrap-up; activities may take place prior to and after t!ese dates (between <anuary 5, 7954 and &ay 54, 7954"

!+at is t+e a))ro.imate )o),lation of 5o,r comm,nit56

Co man5 )eo)le are 5o, e.)ecting at 5o,r e4ent6

D' PARTNER0CIP0
Are 5o, s,-mitting t+is a))lication on -e+alf of a formali(e* )artners+i) 7for t+e ),r)ose of t+is )ro<ectB it+ one or more organi(ations6 +es No *f you !ave indicated :yes,; please submit a signed letter of confirmation from eac! partner organization as a part of your application Please in*icate -elo t+e names of 5o,r )artner organi(ations? an* a contact )erson from eac+' Partner Organi(ation E1$ Contact Name at Organi(ation E1$ Partner Organi(ation E#$ Contact Name at Organi(ation E#$ Partner Organi(ation E%$ Contact Name at Organi(ation E%$ *f you !ave more t!an 4 organizations partnering for t!e purpose of t!is pro-ect, please submit t!e names and contact information in a separate document as part of your application NVCAW 20 ! "undin# Application "$NA% & October !' 20 2

Department of Justice Canada

Ministre de la Justice Canada

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F' INGHIND CONTRI1UTION0

Cas 5o,r organi(ation sec,re* an5 inG"in* contri-,tions in s,))ort of 5o,r )ro<ect6 +es No *f you !ave indicated :yes,; please note details below, including t!e names of t!e organizations ( groups t!at will be providing t!e in-kind contributions, t!e nature of t!e contributions, and !ow you will be utilizing t!e contributions

I' PRO/ECT O1/ECTIVE0 AND INDICATOR0 OF 0UCCE00

)o =ualify for funding t!roug! t!e >ictims 3und, all N>CA? pro-ects must contribute to t!e ob-ective of increased knowledge and awareness of t!e impact of victimization, t!e needs of victims of crime, available services, assistance programs and legislation Co ill 5o,r )ro<ect meet t+e o-<ecti4e a-o4e6 (Maximum o$ 150 words) !+at are t+ree in*icators of s,ccess for 5o,r )ro<ect6 7I'e' Co . 2. !. ill 5o, ga,ge +et+er 5o,r )ro<ect +as -een s,ccessf,l or not6B

J' DIVER0IT2 > GENDER E9UALIT2

If 5o,r )ro<ect ta"es t+e nee*s of )eo)le +o come from *ifferent social an* c,lt,ral gro,)s? eK,it5 gro,)s an*>or *i4erse comm,nities into consi*eration? )lease e.)lain +o ' (Maximum 100 words)

1$' OFFICIAL LANGUAGE MINORIT2 COMMUNITIE0

If 5o,r )ro<ect *emonstrates sensiti4it5 to t+e nee*s of Official Lang,age Minorit5 Comm,nities 7i'e' Franco)+ones +o li4e o,tsi*e of 9,e-ec? or Anglo)+ones +o li4e in 9,e-ecB? )lease e.)lain +o ' (Maximum 100 words)

11' PRO/ECT DELIVERA1LE0

@pon t!e completion of your N>CA? 7954 pro-ect, you will be re=uired to submit an electronic version of a Pro-ect 2ummary 'eport, w!ic! will be available to download from t!e N>CA? 7954 website (www victimsweek gc ca" Along wit! t!is summary report, please send in any products, materials and media coverage (e g $ news clippings, blog entries, etc " t!at were produced as part of your pro-ect and p!otos of t!e event (if applicable" Please ens,re t+at 5o,r Pro<ect 0,mmar5 Re)ort? an5 )ro*,cts? materials an* me*ia co4erage )ro*,ce* as )art of 5o,r )ro<ect an* )+otos of t+e e4ent 7if a))lica-leB are s,-mitte* electronicall5 to t+e De)artment of /,stice no later t+an& Ma5 %1? #$1%

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Department of Justice Canada

Ministre de la Justice Canada

PROTECTED ONCE COMPLETED Page ;

1#' PRO/ECT !ORH PLAN

Please complete the (or) plan belo(. $f you need additional space' please attach a separate document to your email submission. Acti4it5 (What (ill happen*+ !+en (ill it happen* !+o is responsible* !+o (ill benefit from the acti,ity* !+at resources are needed*

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Department of Justice Canada

Ministre de la Justice Canada

PROTECTED ONCE COMPLETED Page =

1%' PRO/ECT 1UDGET

Please indicate t!e budget for your pro-ect by completing t!e c!art on t!e following page *f t!ere is not enoug! space on t!e budget attac!ed, please submit a separate budget wit! your application )!e Aepartment of <ustice Canada can provide up to a ma.im,m of L1$?$$$ )er organi(ation Partners!ips are encouraged, and could result in more t!an B59,999 being provided for a single pro-ect 3unding can only be provided for one )ro<ect )er organi(ation' &ultiple organizations partnering on a pro-ect m,st s,-mit onl5 one a))lication' Please include detailed information on all sources of revenue and all eCpenses

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Department of Justice Canada

Ministre de la Justice Canada

PROTECTED ONCE COMPLETED Page D

0OURCE0 OF REVENUE
Total Aepartment of <ustice Canada +our #rganization Ot+er& Total Re4en,e&

EMPENDITURE0
Total Total E.)en*it,res&

Please in*icate 5o,r organi(ationNs G0T>C0T re-ate 7)ercentageB from t+e Cana*a Re4en,e Agenc5D

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Department of Justice Canada

Ministre de la Justice Canada

PROTECTED ONCE COMPLETED Page F Con*itions Aepartmental funding may be used only for t!e purposes specified in t!is application #nce t!e Aepartment !as agreed to provide financial assistance, no substantial c!ange to t!e pro-ect s!all be made wit!out t!e consent of t!e Aepartment, and it s!all be at t!e discretion of t!e Aepartment to determine w!at constitutes substantial c!ange in eac! case Any funding not used for t!ese purposes must be returned to t!e Aepartment )!e organization is w!olly responsible for its own debts )!e Aepartment will not consider any application to pay debts *f any part of t!is funding is used to pay salaries, federal and provincial laws concerning salaries and source deductions must be applied (e g deductions for income taC, employment insurance, etc " P,-lic ac"no le*gement of f,n*ing )ro4i*e* -5 t+e De)artment is reK,ire*' T+e De)artmentOs financial assistance m,st -e clearl5 ac"no le*ge* in an5 ),-lications? ritten or )rint material )ro*,ce* as )art of t+e )ro<ect an*>or *,ring an5 ),-lic )resentations (E % We wis! to ac&nowled%e t!e $undin% t!at was "ro'ided (# t!e )e"artment o$ *ustice +anada Victims ,und) T+e De)artment of /,stice Cana*a logo is a4aila-le for 5o,r ,se? as ell as t+e NVCA! #$1% logo' )!e organization agrees to respect and apply t!e spirit and, if applicable, t!e letter of t!e Canadian .uman Ri#hts Act and of t!e Official %an#ua#es Act *n t!e event of an access to information re=uest regarding t!e present funding application or any ot!er information about t!e organization in t!e AepartmentEs possession, t!e organization will be consulted before any confidential information is disclosed @nder t!e Access to $nformation Act, t!ere is provision for eCemption from disclosure of personal information sub-ect to t!e Pri,acy Act, and of confidential financial or business information )!e designation P'#)EC)EA (once t!is application form is completed" ensures t!at t!is information receives en!anced protection ?!en funding is approved, t!e amount of funding, t!e purpose for w!ic! t!e funds were granted and t!e name of t!e organization receiving t!e funding are considered public information I' t+e ,n*ersigne*? *eclare t+at& t!e information in t!is application is accurate and completeF t!e application is made on be!alf of t!e organization named on page one (5" wit! its full knowledge and consentF if financial assistance is provided, t!e organization will submit financial statements and activity reports as re=uired by t!e Aepartment of <ustice CanadaF if financial assistance is provided, t!e organization will submit to an evaluation of t!e pro-ect funded, as re=uired by t!e Aepartment of <ustice Canada

Name of organization$ Name of person wit! signing aut!ority$ Position()itle$ Aate$

Please Note& T+e De)artment of /,stice DOE0 NOT nee* a signe* )a)er co)5 of t+is a))lication' T+e s,-mission of t+is a))lication electronicall5 to t+e De)artment is ,n*erstoo* to -e consent for t+e De)artment to re4ie t+e a))lication an* to enter into a f,n*ing agreement it+ t+e organi(ation? if f,n*ing is a))ro4e*'

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Department of Justice Canada

Ministre de la Justice Canada

PROTECTED ONCE COMPLETED Page I

Anne. A& NVCA! #$1% F,n*ing A))lication C+ec"list

Applicants must ensure that the follo(in# points ha,e been addressed in their application' and that the applicable documents ha,e been included as attachments in the email submission.

2election Criteria$ &y application !as been completed in full &y completed application, along wit! any re=uired supporting documentation !as been emailed to victimsweek-semainedesvictimesG-ustice gc ca at t!e Aepartment of <ustice Canada by November 57, 7957 All of t!e eCpenses t!at * !ave listed in my budget are eligible for funding, and * !ave consulted : Co to A))l5 for F,n*ing P A G,i*e to Pre)aring a Pro)osal; and t!e :3A.; document included in t!e N>CA? 7954 funding package to confirm' * believe t!at all of t!e eCpenses listed in my budget are reasonable and customary, and demonstrate a good value for Canadians )!e t!eme for N>CA? 7954 (We All Ha'e a Role" is reflected in my proposed pro-ect &y proposed pro-ect supports t!e >ictims 3und ob-ective of raising awareness and knowledge about t!e impact of victimization, t!e needs of victims of crime, available services, assistance and legislation * !ave attempted to work wit! partners in my community, and to make t!is pro-ect as collaborative as possible Additional Aocuments$ *f my organization is incorporated, * !ave attac!ed a copy of t!e certificate and t!e articles of incorporation #' t!e letters patent to my email submission *f my organization is located in .u/bec, and * answered :yes; to any of t!e =uestions in 2ection H, * !ave attac!ed t!e #rder in Council allowing my organization to negotiate and enter into an agreement wit! t!e Aepartment of <ustice Canada to my email submission *f * am submitting t!is application on be!alf of a formal partners!ip (for t!e purpose of t!is pro-ect", * !ave included signed letters of confirmation from eac! of t!e partner organizations in my email submission *f * !ave more t!an 4 partner organizations, * !ave included t!e organization names and t!e contact person from eac! organization in a separate document included in my email submission *f * completed my pro-ect work plan in a separate document, * !ave included it in my email submission *f * completed my budget in a separate document, * !ave included it in my email submission

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