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2016-17 AGED CARE APPROVALS ROUND
PART C - CAPITAL GRANT
Organisation name:(if approved provider, insert approved provider name)
Service name:
Please select the state/territory in which the capital grant is sought
Select State/Territory
Form InstructionsIf you are applying for a capital grant only you must complete:
Part A – Aged Care Application form once for your organisation Part C – Capital Grant Application form for each service.
If you are seeking an allocation of residential aged care places for this service in addition to a capital grant, you must complete a Part B – Residential Aged Care Places application form.
Only attachments specifically requested should be included with your application. Additional attachments provided will not be considered during the assessment process.
Detailed information about completing this application form is included in 2016-17 ACAR Essential Guide.
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
Submit your electronic application to the Department of Health at [email protected] on or before 11:59pm (AEST) 28 October 2016.
Details on how you can submit your electronic application can be found at Chapter 1 of the 2016-17 ACAR Essential Guide.
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PART C – Capital GrantSection 1 - Service Details
1.1 Service Information
Is this an existing aged care service? Select one
Approved Provider ID
RAC Service ID (existing service only)
1.2 Service AddressStreet number
Street name
Street type
Suburb/town
State/territory Select a state
Postcode
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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PART C – Capital GrantSection 2 – Capital Works
INSTRUCTIONSBefore completing this section, you must refer to Chapter 4 of the 2016-17 ACAR Essential Guide.
Enter the total project cost for the capital works.
2.1 Total Project Cost*
*This figure must equal the ‘Total Project Cost’ figure in 2.22 Cost Certificate and the ‘Total Funds’ in 3.5 Sources of Funds for the Capital Works.
Applicant contribution
Grant amount sought
2.2 Capital grant project details – provide a description of the proposed capital works.
Word limit 500
2.3 Describe the issues the proposed capital works will address.
Word limit 300
2.4 If the proposed capital works are regarded as urgent, explain the reasons for this urgency.
Word limit 300
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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2.5 Describe why you are unable to fund the proposed capital works project.
Word limit 300
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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2.6 Provide the configuration of your service, both BEFORE and AFTER the proposal for this service is implemented.
BEFOREthis proposal is implemented
New construction
Upgrading of existing rooms
Unchanged rooms after this
proposal is implemented
AFTERthis proposal is implemented
E=B+C+DA B C D E
Single rooms -en-suites
Number of rooms
Total m2
Number of residents
Single rooms -shared bathrooms
Number of rooms
Total m2
Number of residents
Single rooms -common ablutions
Number of rooms
Total m2
Number of residents
Double rooms –en-suites
Number of rooms
Total m2
Number of residents
Double rooms -shared bathrooms
Number of rooms
Total m2
Number of residents
Double rooms -common ablutions
Number of rooms
Total m2
Number of residents
Multi-bed wards
Number of rooms
Total m2
Number of residents
Common ablution areas
Number of showers /baths
Number of toilets
Additional toilets off common areas
Other areasNo m2 No m2 No m2 No m2 No m2
Laundry
Kitchen
Lounge /Dining
Other recreational areas
Administration areas
2.7 Provide details of any temporary accommodation and/or care arrangements you will need to put in place during the construction or redevelopment work. This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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Word limit 300
Milestones
2.8 Provide the key milestones in the development of the proposed capital works project.
Key Milestone Date achieved(dd/mm/yyyy)
Date to be achieved(dd/mm/yyyy)
Evidence attached?
Acquisition of land (if applicable) Select one
Approval of finance Select one
Development Application approved Select one
Building Application approved Select one
Arrangements for existing residents Select one
Commencement of building work Select one
Completion of building work Select one
Approval from appropriate state/territory and/or local government authorities
Select one
Admission of residents (must align with response at Question B2.2)
Select one
2.9 Identify any known risks that may affect your ability to meet the above key milestones.
A. Identified risks
B. How are you going to manage identified risks?
Word limit 500
2.10 Concessional, supported, assisted and low means care recipients.
Concessional, supported, assisted& low-means care recipients
Current number(as at 31 July 2015)
Expected number(upon completion of works)
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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2.11 If you have identified as part of your overall proposal a significant increase in the number of concessional, supported, assisted or low means care recipients, describe the steps you will take to achieve this outcome.
Word limit 300
2.12 Is the primary purpose of this capital works project to facilitate the provision of care to people from one or more of the special needs groups?
Select one
2.13 Specify the special needs group(s).The special needs groups are defined in the Aged Care Act 1997, a list may be viewed in Chapter 4 of the 2016-17 ACAR Essential Guide.
1.
2.
3.
You may identify more than one special needs group as the primary purpose. While it is recognised that a care recipient may be a member of more than one special needs group, for the purposes of Questions 2.14 - 2.19 a care recipient should only be included in one special needs group.
If the primary purpose of the capital works project is the provision of care to people from one or more identified special needs group, this may be reflected in the conditions of any grant.
NOTE: Complete one set of Questions 2.14 - 2.19 for EACH special needs group for which the capital works are primarily focused.
2.14 Outline the evidence that demonstrates that there is a need in the area for residential aged care, providing specific details concerning each special needs group(s) identified at Q2.13.
Word limit 1,000
2.15 How many people from this group do you provide care to at the service now?
2.16 How many people from this group will you provide care to at this service at the conclusion of this project?
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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2.17 If you have forecast a significant increase in the numbers of people from the special needs group, describe the steps you will take to achieve this outcome.
Word limit 300
2.18 Describe your organisation’s experience and/or expertise in the provision of appropriate care to the identified special needs group, or how your organisation intends to develop such expertise and any other approaches you plan to take to meet the particular care needs of the identified special needs group.
Word limit 300
2.19 Describe how the building design and external environment will meet the particular care needs of the identified special needs group.
Word limit 300
2.20 Is a significant purpose of the capital grant to address the particular care needs of people with dementia?
Select one
2.21 Identify how the building design and external environment will meet the particular care needs of people with dementia.
Word limit 300
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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2.22 Cost Certificate.
$DO NOT INCLUDE GST
A. Land costs
(a) Site acquisition (only include costs if land is not already acquired)
(b) Site preparation
(c) Fencing and road-works
(d) Demolition
(e) Connecting mains to property boundary (water, sewerage and/or electricity)
(f) Landscaping
(g) Survey fees re: sub-division costs
B. Estimated capital works (building) cost for the project
C. Costs of furniture, furnishings and fittings
D. Other cost of works NOT included in the above estimate
(h)
(i)
(j)
E. Fees
(k) Architect fees @ ……. % on $ ………..
(l) Other professional consultants’ fees
(m) Describe any other fees
(n) Contingency sum(s)
TOTAL PROJECT COST
I declare this is my best estimate of the total project costs of the capital works described in Question 2.2 and is based on the configuration of the service as described in Question 2.6
Name of company
Name of Architect or Design or Construction professional
Signature Qualification Date
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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Part C – Capital Grant Section 3 – Financial Information
3.1 Service Overview.A B C D
* If your organisation’s financial year ends on a date other than 30 June, complete in accordance with your financial year end and insert the financial year end date.
Actual position
As at 30 June 2016*
Date
Forecast situation
immediately BEFORE the
commencement of capital works
for places applied for in this ACAR in
relation to this service
Date
Forecast situation
immediately AFTER the
completion of capital works
for places applied for in this ACAR in
relation to this service
Date
Forecast situation at the financial year
end when maximum
occupancy is achieved for places applied for in this ACAR in relation to
this service
Date
$’000 $’000 $’000 $’000Service incomeGovernment subsidies
Resident fees (including Daily Accommodation Payments)
Interest and other income
(A) Total service income
Operating expensesSalaries and wages (including on-costs)
Supplies, utilities and administration costs
Depreciation (property, plant and equipment)
Principal loan repayments (parent/related organisations)
Principal loan repayments (Zero Real Interest Loan)
Other principal loan repayments
Interest, tax and other expenses
(B) Total service expenses
Net operating surplus/(deficit) (A-B)
Number of operational places
Occupancy rate % (no. residents/no. operational places*100)
% % % %
Number of residents paying Refundable Accommodation Deposits/Accommodation Bonds
Total liability for Refundable Accommodation Deposits/Accommodation Bonds
Number of residents paying Daily Accommodation Payments
Average Daily Accommodation Payment
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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3.2 Outline how your organisation will address any operating deficit.
Word limit 150
3.3 Describe the assumptions underlying the projections.Eg: assumptions made about changes in occupancy, income, expenses, growth/decrease in number of residents paying RADs/DAPs and the average RAD/DAP paid.
Word limit 150
3.4 Capital works costs associated with this application.
Project element
Existing places(Operational or offline)
Provisionally allocated or newplaces
New Construction
$’000
Upgrading$’000
New Construction$’000
Upgrading$’000
Do not include GST Do not include GST Do not include GST Do not include
GSTAcquisition of land (include costs only if land has not already been acquired)
Construction of new building
Fit out of new building
Upgrading of existing premises Refurbishment/fit out of upgraded existing premises
Landscaping and road works
Other (provide detail at ‘Other Capital Works Costs’)
Total capital works cost
Number of existing operational places to be accommodated
Number of existing offline places Number of places sought in this ACAR
Number of provisionally allocated places from previous ACARs to be accommodated
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
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Other capital works costs.
Word limit 150
3.5 Sources of funds for the capital works.
Internal sources $’000Cash and investments Loans from parent/related party Sale of assetsDescribe:
Fundraising activities
Resident sourcesRefundable Accommodation Deposits/Accommodation Bonds from existing places (do not include provisionally allocated places)
Refundable Accommodation Deposits from places sought through this ACAR (complete 3.6 Bridging Finance)
Refundable Accommodation Deposits from provisionally allocated places brought online prior to the places sought in this ACAR
Refundable Accommodation Deposits from provisionally allocated places to be constructed at the same time as places sought in this ACAR (complete 3.6 Bridging Finance)
External sourcesLoans from external organisations including financial institutions Other external sources of funding Additional sources of fundingCapital funding from state/territory government Capital grant(s) allocated in previous ACAR(s) Zero Real Interest Loans allocated in previous ACAR(s) Capital grant sought in this ACAR Total funds
3.6 Bridging finance to be used for the capital works identified in this application.
If the receipt of Refundable Accommodation Deposits from places sought through this ACAR, or for provisionally allocated places to be constructed at the same time is a source of funds for the capital works, include details of the bridging finance that will be used to finance the project prior to maximum occupancy being achieved.
2016-17$’000
2017-18$’000
2018-19$’000
2019-20$’000
2020-21$’000
Amount borrowed Principal repayments Interest repayments Date bridging finance is to be repaid in full / /
How many hours did your organisation take to complete this ACAR Capital Grant application?
This form is approved under paragraph 13-1(c) of the Aged Care Act 1997
