Application for 2017-2018 Funding
*Definition of Terms:

Unduplicated Clients: This refers to the number of unique participants in the United Way funded program your agency runs. Participants should not be counted more than once.

Leverage: This refers to the amount of state or federal funding your agency will receive dependent upon each United Way dollar you are granted. For example: “For every $1 received from the United Way, my agency receives $5 from a federal grant.”

Match: This refers to the EQUAL amount of funding your agency will receive for a United Way grant. For example: “For a $3000 grant from United Way, my agency receives $3000 from a foundation grant.”

Agency Information

Organization Name
Mailing Address
Contact person for this grant
Work phone
Cell phone
All emails that should receive communications regarding this grant
What does your organization do? (Please be as brief as possible. 300 Word maximum.)
Physical addresses of all Monroe County locations and programs/services offered at each
(Please indicate preferred location for site visit; we will attempt to comply with your request but cannot guarantee visiting your preferred location.)
Does your organization provide services countywide if physical locations are not countywide?
Please explain briefly.

Clients Served by Your Agency

Clients Served by your entire agency in the 2016 Fiscal Year: / Unduplicated Clients to be served by the program for which you are requesting funding:
Total # of Unduplicated individuals served
# of Unduplicated individuals served in the Lower Keys
# of Unduplicated individuals served in the Middle Keys
# of Unduplicated individuals served in the Upper Keys
% Male
% Female
% Caucasian
% African American
% Hispanic or Latino
% Other

Program for which you are requesting Funding (July 2017 – June 2018)

Name of Program
Amount of funding requested
Discuss how your organization will effectively leverage funds to increase the impact of requested funding.
List anticipated match and leverage funding sources for the funds you are requesting from UWFK, including the source and amount.
Only list anticipated funding that is contingent on United Way or other local funding.
Please limit to 300 words or less.
How will you utilize volunteers and community resources to increase your impact?
How many paid staff will you need to run this program?
How many volunteers will you use to run this program?
Primary program focus (choose only one) / ______Access to nutritious food for people in critical need
______School aged, early childhood, and after care support with an educational or positive behavioral component
______Safety net services (Defined as: referral and short-term emergency response services)

Community Problem – Explain the critical need (problem) for this program in Monroe County, and why your project will help solve the problem. Please limit to 300 words or less.

Brief Summary of Program – Please limit to 500 words or less. Include the timeline for the program, and how it will be launched and sustained if United Way funding is not secured.

PROGRAM OBJECTIVES – Detail one (or at the most two) objectives that your program will achieve by June 2018. You will provide written numerical results showing your progress in January 2018 and results in June 2018.

Food Programs:
By June 2018, my agency will provide ______(number) of grocery bags to ______clients. AND/ OR

By June 2018, my agency will provide ______(number) of meals to ______clients.

Education Programs:
By June 2018, my agency will serve ______(number) of unduplicated clients for

______(length of service).

Safety Net Programs:
By June 2018, my agency will serve ______(number of clients), ______(number of

times). The services provided will be ______

______.

Program Objective / Specific Activities to
Reach That Objective / Activity Outputs / Expected Outcome
Measure
Program Objectives should be SMART: Specific, Measurable,
Attainable, Relevant, Time- framed / What you will do. How will you spend the money you receive from UWFK? / What data will you collect to prove your program’s success? / Participant benefits - results that support your goal and impact your clients. How does this program change people’s lives?
Example: Ensure that 10 senior citizens in Big Pine Key who live alone enjoy at least three healthy meals a week. / Example: Recruit a
restaurant partner to provide healthy prepared meals, manage hourly part-time person to pick up and deliver meals to seniors. / Example: Keep a delivery
log of 30 “Meals on Wheels” per week (3 meals to 10 seniors). Volunteer will interview participating seniors about their experience. / Example: 10 participating
senior citizens will have benefited from the service of healthy meals delivered to their homes.
SMART Objective #1 / Specific Activities / Data to be collected / Measurable Outcome

If applicable,

SMART Objective #2 / Specific Activities / Data to be collected / Measurable Outcome

OVERALL AGENCY OPERATING BUDGET FOR 2017 – 2018:

REVENUE / Last Year Actual Budget / This Year Budget Request
Special Events/Fundraisers
Program Service Fees
Investment Income
UWFK Funding Allocation
Funding from Parent
Organization
Other Non-Governmental
Funding
Local Government:
Monroe County HSAB
Sheriff’s Asset Forfeiture Fund
Other Local Government Sources
State & Federal Government:
State Funding
Federal Funding
Total Revenue
EXPENSES
Admin & Fundraising Salaries
and Benefits
Administrative Expenses
Fundraising Expenses
Program Services Salaries and
Benefits
Other Program Services
Expenses
All Other Expenses
Total Expenses
NET BALANCE

Program Budget for 2017 – 2018:

To reach your program objectives for this program stated above, how much funding will you need and do you have any other definite or other possible sources for the money besides United Way of the Florida Keys?

How will you spend the money from UWFK?

Be as specific as possible, recognizing that UWFK will be more favorable to funding services to clients rather than agency overhead. Please limit to 300 words or less.

PROGRAM BUDGET FOR 2017 – 2018:

REVENUE / Last Year Actual Budget / This Year Budget Request
Special Events/Fundraisers
Program Service Fees
Investment Income
UWFK Funding Allocation
Funding from Parent Org.
Other Non-Govt. Funding
Local Government:
Monroe County HSAB
Sheriff’s Asset Forfeiture Fund
Other Local Govt. Sources
State & Federal Government:
State Funding
Federal Funding
Total Revenue
EXPENSES
Admin/Fund. Salaries/Benefits
Program Serv. Salaries/ Benefits
Program Consultant Fees
Other Professional Fees
Office Space
Operating Capital Outlay
Equipment Lease/Rent
Vehicle Lease/Rent
Utilities
Office Supplies
Printing
Postage and Delivery
Maintenance
Insurance
Staff Travel
Conferences & Staff Training
Membership Fees
Advertising
Other Administrative Expenses
Client/Participant Assistance
Fundraising Expenses
All Other Expenses
Total Expenses
NET BALANCE

Applications and supporting documents can be mailed, emailed or hand-delivered, but all materials must be received by United Way no later than March 6, 2017 by 5 p.m. EST.

Email: If emailing, please scan all documents as PDF files, except for the Board of Directors roster which should be submitted in Excel. Email to: . You will receive confirmation that we have received your email within one business day. If you do not receive this confirmation, please contact our office at 305-735-1929.

Mail: You can mail your application packet to United Way of the Florida Keys, P.O. Box 2143, Key West, FL 33040. Please note that applications must be received, not postmarked, by March 6, 2017, so be sure to allow plenty of time for delivery.

Hand-Delivery: You can also drop off your application packet to our physical address, 6631 Maloney Avenue in Stock Island in Key West. We are co-located with the Habitat for Humanity office. If you choose hand-delivery, make sure to give your application packet to a United Way staff member only. Do not leave your packet in our on-site mailbox.

Signature and Certification

To the best of our knowledge and belief, the information contained in this application and attachments is true and correct. United Way of the Florida Keys (UWFK) is hereby authorized to verify all information contained herein, and we understand that any inaccuracies, omissions, or any other information found to be false may result in rejection of this application or elimination of funding after it is awarded. This certifies that this request for funding is consistent with our organization's Articles of Incorporation and Bylaws and has been approved by a majority of the Board of Directors.

We affirm that our Agency operates in accordance with a Non-discrimination Policy in writing that outlines how the organization does not discriminate in hiring, service delivery or volunteer services on the basis of race, religion, gender, sexual orientation, national origin, age, or disability.

We affirm that the Agency will use UWFK funds for the purposes as submitted in this Application for Funding. Any change will require written approval from UWFK. We understand that funding may cease at any time if adequate progress is not made toward the program for which we applied for funding.

We understand that the agency must meet the eligibility criteria to be considered for UWFK funding and that an incomplete application and/or omitting required attachments will disqualify the agency's application.

We further understand that meeting the eligibility criteria in no way ensure that the agency will receive funding from UWFK. Funding awards are determined by service needs of the community, availability of funds, and other factors.

In compliance with the USA PATRIOT Act and other counterterrorism laws, we hereby certify that all UWFK funds and donations will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes and executive orders.

Name of Agency Requesting Funding
Executive Director/CEOPrinted name
Signature
Date signed
Board President/ChairpersonPrinted name
Signature
Date signed

Thank you for taking the time to submit your program for potential funding in support of our mission of community caring for the Florida Keys.