This packet is to be completed by organizations requesting funding for the 2017calendar year.
Deadlines:
- Send an email with your agency intent to apply for funding by March 15, 2016.
- If you have a scheduling conflict for review week please let me know by March 15th.
- The completed funding request packets are due in the United Way office no later than April 15, 2016 at 5pm. Be sure to upload all additional documents in addition to the completed application form.
- Agency Reviews will be held the week of May 9-13, 2016. You must have an Agency Representative attend your designated date and time for the presentation to the Review Team for the allocation review.
- Agency Review Team meetings will last 30 minutes, 15 minutes presentation and 15 minute Q & A session. Please be prepared to answer financial questions.
Please note, this form is a common application developed by the United Way of Richland-Wilkin. The Agency Summary should describe your agency as a whole, and the Program Summary should be completed for each program for which you are requesting funding.
FINANCIAL INFORMATION
Please remit all financial information based on your fiscal year actual and budgets. Note the inclusion of an instruction sheet for the budgeting information.
If we do not have a copy of your agencies 501(c)3 certificate or letter from the IRS please include 1 copy for our file.
The United Way of Richland-Wilkin recognizes that the human needs of the counties are constantly changing. The United Way, as steward of community contributions, also recognizes the importance of establishing minimum standards for participation in the United Way. These standards assure that charitable funds are used efficiently and effectively to support health and human service needs in the counties. The goal of United Way is to be a leader in enriching our community by expanding the caring power of our people.
BASIC CONDITIONS FOR UNITED WAY OF RICHLAND-WILKIN (UWRW) FUNDING
1)Be a not for profit.
2)Abide by federal and state laws regarding non discrimination, charitable organizations and collective bargaining.
3)Offer health and human services programs to the areas of Richland and Wilkin Counties through a clearly defined mission statement.
4)Have active volunteer leadership that represents diverse elements of the community.
5)Have sound financial and program management.
6)Inform UWRW about major expansion or reduction in programming, services, facilities and staff. United Way shall be immediately informed in writing when United Way funded programs cease to function.
7)Support and cooperate with fundraising and marketing efforts of the UWRW
8)Conduct agency fundraising in such a manner to ensure that the UWRW giving base is not adversely affected.
9) It is the responsibility of the agency to advise United Way of the name of the person responsible or administering the funds.
10) The agency must show that services arenot primarily for the benefit of any church or synagogue, or for sectarian religious purposes.
11) Be able to show that services are not political in nature.
12) Demonstrate that services are available to all in the target population regardless of ability to pay.
13) The agency shall have the obligation to keep the public informed as to its services and objectives, and tomake known in every practical manner that it is the recipient of United Way support.
14) To cooperate with other agencies, both public and private, and with the United Way with the objective of preventing duplication of effort and services to a similar population.
Please complete & Return
ANTI-TERRORISM COMPLIANCE MEASURES
In compliance with the USA PATRIOT Act and other counterterrorism laws, the United Way ofRichland-Wilkinrequires that each agency certify the following:
“I hereby certify on behalf of (agency name) ______that all United Way funds and donations will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes and executive orders.”
Print Name: ______Title:______
Signature: ______Date: ______
AGENCY PROFILE
Agency Name: EIN#
Mailing Address:
Email Address:
Website Address:
Contact Person:
Presenter for Allocation Review if different from Contact Person:
Phone Number:
In one page provide information about your organization that will put the program into organizational framework. Please address the following:
1)Organization’s Mission and Goals. Please show evidence that the program is a core offering of the agency and is vital to your agency’s mission. Explain how the mission of your organization fits with the vision of the United Way of Richland-Wilkin,( To be recognized as a leader for enriching our community by expanding the caring power of our people)
Mission/Vision Statement:
2)Communities and populations the organization provides services to, specifically within Richland and Wilkin counties. Describe any circumstances where clients would be refused services? Who are the people you serve?
3)A brief description of the programs and services the organization provides.
4)Please attach an organizational chart showing your volunteer board and committee structure. List the names of your Board of Directors.
PROGRAM SPECIFIC INFORMATION
What is the community need that you are focusing on solving? How did you determine that need? What data was used to determine the need?
1)What is the dollar amount for funding requested? Is this amount different than last year’s request? Why? (Please share analogy for increasing /decreasing your request)
Amount Requested? ______
2)What specific program or services are the dollars targeted for? Provide a succinct summary of the program basics. Who (target audience), what, when where?
3)What specific goals and objectives does your program have in making a lasting impacat on the community issue you are trying to resolve.?Include a description ofthe social problem and explain why this program will address the problem.
4)Describe how the program actually works and the expected level of service (ie number of participants, people served) during the proposed grant year.
5)Please explain what outcomes will be or are reached with this program? How have they changed from last year?An example to explain this would be the program logic model which clearly illustrates the specific outcomes the program hopes to achieve and demonstrates a clear relationship between the inputs, and activities and the outputs and the outcomes.
6)How will or do you measure the success and impact of this program? Please give examples?
**A copy of your evaluation tool is required please upload.
7)Describe the relationship you have with other organizations to avoid duplication of services. Include a description of any partnerships or collaborations that make this program possible, describe what is eachentity providing for the partnership.
8)How are volunteers utilized in this organization? If not, why are they not utilized? Do you have a volunteer training program?
9)What is the sustainability plan for this program andexplain why the UWRW investment in this program is needed.
INSTRUCTIONS FOR COMPLETING PAGE 7 BUDGET INFORMATION.
Income
UWRW funds -- the funds that you are currently receiving(2015 Allocation) 2016 Proposed requested dollars
Government funds – State and Federal grants, reimbursement or funding from any governmental entity, Medicaid reimbursement
Non-Government grants/Foundations – private grants, please include a timeline of the grant and the spend down
Earned Income – Fees for service, fundraisers, public sales
Contributions – Memorials, individual donations
All other income – other United Ways funding, interest income, any income not included in the other categories
Expenses
Personnel & Related – Salaries, benefits, travel, payroll taxes, retirement
Operating Expenses – Rent, utilities, maintenance, supplies, postage, telephone/internet
Program Expenses – Marketing, Printing, conferences/trainings
Specific Assistance to Individuals – assistance to provided directly to individual clients of the program
All other Expenses -- liability insurance, membership dues, any expense not included in other categories
Agency Name: Program Name:
Number of Full Time Equivalent’s Staff in the program:
Number of Part Time Staff in the program:
Do not include Volunteer or In Kind Services.
Past Year Current Year Next Year
Actual 2015Program
Balance Sheet / Current 12 month budget-2016 / 2017 Proposed Budget
INCOME
UWRW funds
Government Funds
Non Government /Foundation Grants
Earned Income
Contributions
All Other Income(Please list sources of other income)
Total Income
EXPENSES
Personnel & Related
Operating Expenses
Program Expenses
Specific Assistance to Individuals
All Other Expenses
Total Expenses
*If you have a balance sheet please upload a copy.
Program Request of previous United Way funding
2013 / 2014Allocation Dollars received
Total UW $ used for projects/programs
Remaining Carryover dollars
Does your agency have an operating reserve? ______yes ______no
If yes, balance at the end of most recently completed fiscal year $______
How many months does the reserve cover? ______months
Does your agency have an endowment fund? ______yes ______no
If yes, balance at the end of most recently completed fiscal year? $______
Do you reinvest the interest earned or use the interest? Please explain.
PROGRAM BUDGET OVERVIEW & NARRATIVE
1)Briefly describe other financial resources that your organization is seeking or has secured to address the outcomes and conduct the program described in this proposal. If the funds are time limited, program restricted to a certain group of clients, please explain.
2)If this is a currently funded United Way program and there is an increase in request for funding, describe how the increase will be used.
3)If the program is not currently funded by United Way describe why the program is seeking funding at this time?
4)Please explain how funds received from the 2015 Allocation are beingexpended in 2016, if not what are the plans for those funds.
5)What is your agencies overall total budget, what percentage is this program to the overall Agency Budget?
**Please feel free to upload another sheet to provide additional information for your request for funding.
Client Demographics Report for the Year 2015/ Part I
Agency:
Program:
We are tracking the below items to help us determine the scope of your program. If your program does not track the information below, please explain why. Please do not change the categories to fit your data. **Please be specific to Richland and Wilkin Counties.
1. Client Age (Indicate number of clients in each age category)
0-5 6-18 19-35 36-65 Over 65 Total
=2. Client Income (Indicate number of clients in each category)
$0-$15,000-$30,000- $50,000- $75,000
$14,999$29,999$49,999 $74,999 & over Total
=3. Client Residence (Indicate number of clients who reside in each location)
Wahpeton Rural Richland Richland County Total
=Total
Breckenridge Rural Wilkin Wilkin County Total Richland + Wilkin + Other
=Other (Please List) Unknown Other Unknown Total
=4. Client Gender(Indicate number of clients in each category)
Female Male Total
=5. Client Race/Ethnicity(Indicate number of clients in each category)
African Native Asian/Pacific Immigrant/
Caucasian American Hispanic American Islander Refugee* Other* Total
=* Please specify which refugee/immigrant and other populations your agency tracks below.
United Way of Richland-Wilkin
Client Demographics Report for the Year 2015 / Part II
Agency:
Program:
Please provide data for categories below that are applicable to the program being reviewed.
Numbers must be tracked and quantified. Estimates are not needed. Do not provide information for which you do not record and keep data. Please provide data from Richland and Wilkin Counties only.
______Number of served meals provided ______Number of food baskets provided
______Number of basic needs “kits” provided
______Number of referrals made to other services
______Number of hours of case management provided
______Number of hours of counseling provided
______Number of hours of before/after school care provided
______Number of activities/classes provided for youth (0-18).
Please provide breakdown by category:
____ sports/recreation____ theater/drama ____ art ____ academic enrichment ____ skill development ____ other activities
______Number of activities/classes provided to adults (19-54)
Type of activity/class ______
______Number of activities/classes provided to senior citizens (55+)
Type of activity/class ______
______Number of volunteers ______Number of volunteer hours
______Number of scholarships provided for participation in program.
Please provide breakdown by category:
______Children (0-18) _____ Adults (19-54) _____ Senior Citizens (55)
We would like you to share in a short narrative any “dreams” that your organization may have regarding impacting our community. Please give an explanation to the following question:
Has your organization identified a need in our community that you could address if the resources (financial and human) were available to do so? Does your agency have a strategy for increasing or expanding services in an existing program or plan for a new programs? Please give a detailed explanation and determine what the community impact will be.
If you were to categorize your requested program in a Community Impact area which one and why?
Primary United Way Funding Priority Area and Outcome your program meets: (Choose ONE only)
EDUCATION – Helping children and youth achieve their potential.
INCOME – Helping families become financial stable and independent, while ensuring that basic needs are met.
HEALTH – Improving people’s health.
Need
Explain how your program is consistent with the priority area chosen above. Why do you think this program is needed in our community? EXAMPLES: Cite existing agency data, waiting lists, census, Kids Count, or other dependable research, etc.
Year-End Report
This report is for the allocation received in 2015 based on your 2014 funding request. Complete a Year End Report for each program funded by United Way of Richland-Wilkin. We understand that each agency might use different financial and program reporting periods. However, please do your best to provide data that reflects the funding period of January – December 2015.
Agency Name:
Program Name:
Staff Contact:
E-Mail Address:
Reporting Period: January 1, 2015 through December 31, 2015
List your 2014 funding distribution PER PROGRAM.
Please note if your fiscal year is different from calendar year.
PROGRAM / TOTAL GRANT AWARD FOR 2014 / TOTAL FUNDING SPENT JAN-DEC / TOTAL BUDGET FOR 2015 PROGRAM1. / $ / $ / $
2. / $ / $ / $
3. / $ / $ / $
4. / $ / $ / $
5. / $ / $ / $
TOTAL SPENDING: / $ / $ / $
For each program listed above, explain the full year’s results. Show what kind of impact these programs had on Richland and Wilkin Counties or specific populations. This information will be reviewed in addition to your application to compare what the program has accomplished in 2015 and what it will attempt to accomplish in 2017, by your funding application.
1) Outputs: (This is the quantity of services that you proposed to provide) Be specific.
- Please report numbers/percentages of services provided by the end of 2015.
- Did you meet your objectives by the end of this funding cycle? If not, please explain.
2) Outcomes: (These are the results that you proposed to accomplish)
- Report the results of evaluation data to date.
- Have you encountered any barriers to the success of this program or observed any unintended outcomes so far this year?Detail unintended outcomes that affect your service delivery. Are there implications for other agencies in our community? What changes do you propose for the program, if any?
3) Measurement tools: (This is the description of your evaluation tools/process.)
- Are these tools proving to be an effective means for gathering the data necessary to evaluate your program? (If not, please discuss your alternate methods of data collection.)
- Include a sample of your measurement tools, if applicable.
4) Other Notable Statistics: (provide any further outcomes measured by your program)
5) If conditions or restrictions were attached to your funding, please report on what you have done this reporting period to respond to these.
Outcome Success Story
Please provide a success story that best illustrates your program outcomes. State this outcome below as you want it communicated to United Way Board members, volunteers, donors, and the community at large.
Outcome:
The story should illustrate your program’s effect on a single individual or family. Limit your response to one page. If you are including a photo, you must have permission to use the photo in this manner.
Can United Way help you promote any upcoming programs or services that you are providing the community? Email information to .
Person Completing Report:
Title:
Phone #: (___) ______Email ______
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