United Way of Douglas & Pope Counties

Grant Application Cover Sheet


Name of organization & program requesting funding:
Legal name, if different:
Address:
City, State, Zip:
Employer Identification Number (EIN):
Name of top paid staff:
Title: / Phone: / E-mail:
Contact person regarding this application:
Title: / Phone: / E-mail:
Is your organization an IRS 501 © (3) not-for profit? / □ / Yes / □ / No
If No, is your organization a public agency/unit of government? / □ / Yes / □ / No
If No, check with funder for details on using fiscal agents, and list name and address of fiscal agent:
Fiscal agent’s EIN: / Website:
Dollar amount requested: / $
Total program budget: / $
Total annual organization budget: / $

PROPOSAL NARRATIVE

ORGANIZATION:

  1. Brief description of organization and organization’s history.
  1. Organization mission and vision.
  1. Your organization’s relationship with other organizations working with similar missions. What is your organization's role relative to these organizations?

PROGRAM:

  1. Brief description of program requesting funding.
  1. How long has the program been serving Douglas &/or Pope County?
  1. Why is the program needed in Douglas &/or Pope County?
  1. Overall goal(s) of the program.
  2. United Way identifies Education, Income, and Health as priority areas. Each is defined below, followed by specific outcomes for each priority area. Please select the one primary outcome that your program will deliver.

EDUCATION-Helping children and youth reach their potential.

Outcomes:

□ Increase children and youth’s access to enriched learning opportunities.

□ Ensure that children are fully prepared for kindergarten or age appropriate development.

□ Increase early grade literacy for students K-3.

*These outcomes are measured using the following indicators: school readiness scores, # of hours spent reading, reading test scores, and participation in enrichment programs.

INCOME- Promoting financial stability leading towards independence.

Outcomes:

□ Increased access to programs that help increase assets, achieve stabilization, and/or provide job training to improve employability.

□ Help individuals gain financial literacy skills.

□ Ensure the basic human service needs are met.

*These outcomes are measured using the following indicators: Longevity of housing stability, participation in skill training programs that increase opportunity, financial knowledge increased, and cash flow or savings increase as a result of training/education.

HEALTH- Improving people’s emotional, mental and physical well-being.

Outcomes:

□ Improve access to affordable and quality physical, mental and dental health care.

□ Reduce disparities in targeted populations by investing in programs that help older adults and those living with disabilities.

□ Increase access to programs that teach healthy behaviors and promote wellness to prevent future problems.

*These outcomes are measured using the following indicators: participation in programs that increase ability to maintain stability, change in behaviors regarding one’s health, and usage of available scholarships/services.

  1. Explain why you selected that priority area outcome.
  1. How does/will the program address the specific outcome selected?

PROGRAM EVALUATION:

  1. What impact do you expect to have over the next year? Over the next five years?
  2. What were the actual program outcomes achieved in the year most recently completed (benefits or changes for people during or after participation in program activities-should reflect new knowledge, attitudes and skills, leading towards long-term meaningful life changes)?
  1. Projected number of service units over the next year? Over next five years? (i.e. unduplicated persons served, meals, hours of counseling, workshops, educational materials distributed, etc.)
  1. What specific characteristics or behaviors are/will be measured to demonstrate how to program is achieving the selected outcomes? (See what UWDP is measuring related to your selected outcome). How will you measure this work (i.e. surveys, case notes, census data, etc.)?
  1. Long term strategies for sustaining this effort?
  1. Staff directly involved in program and qualifications.
  2. Are volunteers utilized in this program? If so, how?
  3. What are the criteria to qualify for the program?
  1. Is there a fee for services? If yes, please describe.
  2. How do you insure that individuals/and or families with low incomes can utilize your program?
  1. What % will United Way of Douglas & Pope Counties’ allocation be to the total program budget?

ATTACHMENT A

CLIENT DEMOGRAPHICS

Please complete the following grid concerning the composition of your clients (unduplicated) at the close of your most recent fiscal year.

Program Name:
Number of Unduplicated Individuals Served: / % of Total Number of Individuals Served: / Number of Unduplicated Individuals Served: / % of Total Number of Individuals Served:
By Race: / Douglas County:
African American / Alexandria
American Indian / Brandon
Asian/S.E. Asian / Carlos
European American / Evansville
Hispanic / Forada
TOTAL / Garfield
Holmes City
By Sex: / Millerville
Female / Miltona
Male / Nelson
TOTAL / Osakis
Other
By Age: / TOTAL (Douglas)
Infant-5
Age 6-12 / Pope County:
Age 13-18 / Cyrus
Age 19-30 / Glenwood
Age 31-50 / Lowry
Age 51-65 / Sedan
Age 65+ / Starbuck
TOTAL / Villard
TOTAL (Pope)
Number of Persons:
Below 200% of Federal Poverty Guidelines
With Disabilities

ATTACHMENT B

ORGANIZATION BUDGET

This budget sheet should reflect your total agency. / Agency’s fiscal year:
Past Year
2015 Actual / Current Year
2016 Actual / Next Year
2017 Proposed
INCOME
1. Allocations from United Way of Douglas &
Pope Counties
2. Contributions
3. Special Events
4. Contributed by Associated Organizations
5. Allocated from other United Ways
6. Fees & Grants from Government Agencies
7. Membership Dues
8. Program Service Fees/Net Incidental Income
9. Sale of Materials
10. Investment Income
11. In-Kind Income
11. Miscellaneous Revenue
TOTAL SUPPORT REVENUE
FROM ALL SOURCES
EXPENSES
12. Salaries
13. Employee Benefits
14. Payroll Taxes
15. Professional Fees
16. Supplies
17. Telephone
18. Postage and Shipping
19. Occupancy
20. Rental & Maintenance of Equipment
21. Printing and Publications
22. Travel, Conferences and Meetings
23. Specific Assistance to Individuals
24. Membership Dues
25. Insurance
26. In-Kind Expenses
27. Miscellaneous Expenses
28. Payments to Affiliated Organizations
TOTAL EXPENSES
Percentage (%) of management, general and
fundraising expenses total

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ATTACHMENT C

PROGRAM BUDGET

Past Year
13/14 Actual
2013 Actual / Current Year
14/15 Budget
2014 Actual / Next Year
15/16 Proposed
2015 Proposed
INCOME
Support
1. Government Grants
2. Foundations
3. Corporations
4. United Way or other Federated Campaigns
5. Individual Contributions
6. Fundraising Events and Products
7. Membership Income
8. In-kind Support
9. Investment Income
Revenue
10. Government Contracts
11. Earned Income
11. Other (specify)
TOTAL INCOME
EXPENSES
Item
1. Salaries
Subtotal
2. Insurance, Benefits and other Related Taxes
3. Consultant and Professional Fees
4. Travel
5. Equipment
6. Supplies
7. Printing and Copying
8. Telephone Fax
9. Postage and Delivery
10. Rent and Utilities
11. In-Kind Expenses
12. Depreciation
13. Other (Specify)
TOTAL EXPENSES
DIFFERENCE (Income less Expense)

Feel free to attach a budget narrative explaining your numbers if necessary.

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