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Variation Request Form: Council Details

This document is a template for a local government council to request a variation to an existing grant funding agreement. The template collects information about the council, main contact, project details, type of variation requested (timeframe, scope, funding), and justification. It acknowledges that any variation requires state approval and signature by both parties before taking effect.

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70 views

Variation Request Form: Council Details

This document is a template for a local government council to request a variation to an existing grant funding agreement. The template collects information about the council, main contact, project details, type of variation requested (timeframe, scope, funding), and justification. It acknowledges that any variation requires state approval and signature by both parties before taking effect.

Uploaded by

KB
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

Variation Request Form

Grants to Local Government Template


Note: Not all information in this template will be required for all local government grant programs

Council details
Council details

Council name Drop down box

Council address Free text

Contact
Principal contact person within Council
Title Free text Given name Free text

Surname Free text Position Free text

Phone Free text Email Free text

Project details
Project details
Name of Grant
Drop down box
Program

Project (title) Free text

Project reference
Free text
number
Estimated Project
Actual Project
Commencement Date Date
Commencement Date:
Date:
Estimated Project Percentage of Project
Date Free text
Completion Date: completed to date: (%)
Project Funding (ex
GST): ($)

Project components
Free text
completed to date:

Project components
Free text
yet to be completed:

Variation Request Form Page 1 of 4


Compliance with Project Funding Agreement
Are you currently in breach of the Project Funding
Agreement?
Note: Councils are responsible for ensuring Projects are
conducted in accordance with the requirements under the
relevant Project Funding Agreements. If a Council Free text
identifies that it may not be able to comply with a
requirement of the Project Funding Agreement, the
Council should seek a variation before it breaches the
agreement.

Type of variation
Variation type

Change to timeframes/milestones
Change of scope
Change of funding amount
Other

Change to timeframes
Request for a change to approved timeframes/milestones
Please outline the
timeframe or
milestone change
sought
Free text
E.g. extension to
completion date,
change to milestone
date, etc.
Proposed new date:
Where a number of
changes are sought, Date
please attach an
updated Project
Plan.
Please provide
supporting
Free text
justification for the
requested change.
What are the
consequences if this
Free text
variation is not
granted?

Change of scope
Request for change of scope
Note: A change of scope means a change to the Project Description (Item 6 of the Project Funding
Schedule) or the Approved Project Plan (Item 12 of the Project Funding Schedule) and includes changes
to features or functionality of a project, to deliver the outcomes originally approved. For example, a

Variation Request Form Page 2 of 4


design change to respond to engineering constraints. Changes to scope may also involve a change to
the timeframe or cost for the project.
Changes to include features beyond the outcomes originally approved will generally be considered new
projects.
Detail the proposed changes
Free text
to the approved scope
Provide justification for
Free text
proposed change of scope

Change of funding amount


Request for change of funding amount
Current Proposed
Breakdown of revised project costs (include all funding Amounts Varied Amounts
sources)
(ex GST) (ex GST)

Total Project Costs (Item 10 of the Project Funding Schedule) $ $


Third Party Contribution (Item 9 of the Third Party Contributor
$ $
Project Funding Schedule)
Third Party Contributor $ $
Ineligible costs (costs that are not Eligible Project Costs under the
$ $
Program Guidelines)
Total Eligible Project Costs $ $

Council’s contribution (Item 8 of Project Funding Schedule) $ $

Project Funding (Item 7 of the Project Funding Schedule) $ $

Financial year
expenditure will Free text
occur
Provide details why
the Total Project
Cost and the Total
Free text
Eligible Project Costs
have increased or
decreased

Other variation
Request for other variation
Note: Use this section to describe a proposed variation that is not a change of timeframes/milestones,
change of scope or change of funding amount
Detail the proposed variation Free text

Provide justification for


Free text
proposed variation

Supporting documentation
Revised Project Plan Free text

Variation Request Form Page 3 of 4


Evidence of delay, Free text
need for variation, as e.g. advice from service provider (e.g. Ergon Energy) advising of delayed
relevant timeframes
Other Free text

Previous variation details


Has a prior variation
been Yes
sought/approved for No
this project?
If yes, provide details Date sought, Date approved/not approved

If no, provide
Free text
reason/s why

Acknowledgements
In signing this request for variation application, the Council acknowledges that:

• the Project Funding Agreement (exclusive of the variations set out in this Variation
Request) remains on foot, and the Recipient is obliged to continue to carry out the
Project in accordance with that agreement until such time as a variation (if any) takes
effect;

• the State is not obliged to agree to all of any of the variations set out in this Variation
Request;

• any variation to a Project Funding Agreement does not take effect until the State issues
a signed variation letter and the Recipient signs and returns that letter.

Authorisation
On behalf of the Council, I certify that all details in this form (and any supporting documents) are
true and complete.

Name of Authorised Position


Person
Signature Date signed

Please email/submit this form to the [insert Administration Agency name] [insert details of how
report is to be lodged - link address if portal or email address]

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