5
Section 1 - Agency Profile and Program Information
Applicant Organization (full legal name):
Program Seeking Funding:
Funding Amount Requested: $
Agency Information
FEIN:
Street Address (main office):
Mailing Address (if different from above)
Does your organization have more than one location?
☐ Yes
☒ No
If yes, please list additional locations
In what month does your fiscal year begin:
In what month do you normally complete your annual audit/review:
In what month do you normally file your 990:
In what month do you renew your Solicitation Registration:
Website:
Phone Number:
Fax Number:
Name of Executive Director/President/CEO:
Name of Board Chair/President:
Year Organization was Established/Incorporated:
Mission Statement of Organization:
Program Information
Name of Primary Contact Person for Program:
Phone Number:
E-Mail Address:
Approximate number of people you expect to serve in one year:
Geographic area(s) that this request will cover:
Board and Administrative Information
Organizations should be able to produce supporting documentation for any “yes” responses, upon request.
Does your organization:
Maintain directors and officers insurance?
☒Yes
☐ No
Maintain written general board policies and procedures?
☐Yes
☐ No
Have written personnel policies and procedures?
☐Yes
☐ No
If “no” for any of these, please explain why.
Does your Board of Directors:
Maintain the responsibility for ensuring that sufficient funds are available for the organization to meet its objectives?
☐Yes
☐ No
Meet at least four times per year?
☐Yes
☐ No
Have an evaluation process for the Executive Director?
☐Yes
☐ No
Evaluate itself on an annual basis?
☐Yes
☐ No
If “no” for any of these, please explain why.
Section 2 - Items for Submission
Listed below are the items that need to be submitted with your funding request. Check the appropriate boxes to indicate you have these documents.
☐ 501 (c) 3 determination letter
If the box is not checked, please explain why not:
☐ Current bylaws
If the box is not checked, please explain why not:
☐ Solicitation Registration (current or letter of exemption)
If the box is not checked, please explain why not:
☐ Annual operating budget (for the entire organization)
If the box is not checked, please explain why not:
☐ Monthly organizational income and balance sheets for the past six months (in Excel format)
If the box is not checked, please explain why not:
☐ Audit
· Budget greater than $0 but less than $249,000 –
☐Financial review prepared by CPA
☐990 (990 EZ or 990 core)
-or-
· Budget $250,000 or greater –
☐CPA prepared independent audit
☐ Management letter
☐990 (990 EZ or 990 core)
If the boxes are not checked, please explain why not:
☐ Strategic plan
If the box is not checked, please explain why not:
☐ Marketing or public relations plan
If the box is not checked, please explain why not:
☐ Non-discrimination policy
If the box is not checked, please explain why not:
☐ Roster of current board members with the member’s city of residence and business or affiliation
If the box is not checked, please explain why not:
☐ Logic model
If the box is not checked, please explain why not:
☐ Accreditations
If the box is not checked, please explain why not:
Section 3 - Outcomes and Measurement/Evaluation
Indicate the outcome(s) that your program will measure. You may choose outcomes in more than one Target Area, and you may choose outcomes in more than one Impact Area.
*If there are additional outcomes that your program measures, that work toward the goals and target areas stated, please include those in the narrative in Section 4 of this document.
EDUCATION
Target Area #1 – School Readiness and Academic Success
☐Individuals that show maintenance or improvement in communication skills
☐Individuals that show maintenance or improvement in gross motor skills
☐Individuals that show maintenance or improvement in fine motor skills
☐Individuals that show maintenance or improvement in problem solving skills
☐Individuals that show maintenance or improvement in personal-social skills
☐Individuals that pass a kindergarten readiness evaluation
☐Individuals that show improvement in reading level
☐Individuals that progress to the next grade
☐Individuals that graduate from high school
☐Individuals that increase school attendance
☐Individuals that show improvement in grade point average
☐Individuals that pass a college readiness test
☐Individuals that earn a post-secondary credential
☐Individuals that show improvement in areas of concern or delay
Target Area #2 – Social Support and Character Development
☐ Individuals that show reduced detentions, suspensions, or other school-based behavioral interventions
☐ Individuals that report having a youth-centered relationship with a mentor
☐ Individuals that report feeling emotionally engaged with a mentor
☐ Individuals that report feeling satisfied with the relationship they have with a mentor
☐ Individuals that show an increase in support assets
☐ Individuals that show an increase in empowerment assets
☐ Individuals that show an increase in boundaries and expectations assets
☐ Individuals that show an increase in constructive use of time assets
☐ Individuals that show an increase in commitment to learning assets
☐ Individuals that show an increase in positive values assets
☐ Individuals that show an increase in social competencies assets
☐ Individuals that show an increase in positive identity assets
☐ Individuals that maintain applicable changes at 6 months and 12 months after program completion
Target Area #3 – Strong Families
☐ Individuals that report a decrease in parenting stress
☐ Individuals that increase knowledge of children’s social development
☐ Individuals that increase knowledge of children’s emotional development
☐ Individuals that increase knowledge of children’s cognitive development
☐ Individuals that increase knowledge of children’s physical development
☐ Individuals that increase ability to establish nurturing relationships
☐ Individuals that increase ability to establish routines
☐ Individuals that increase ability to maintain expectations
☐ Individuals that increase ability to adapt to challenges
☐ Individuals that increase ability to connect to community
☐ Individuals that report an increase in their parenting skills
☐ Individuals that report an increase in their level of communication with their child’s school
☐ Individuals that report an increase in volunteering at their child’s school
☐ Individuals that report an increase in engaging in learning activities at home with their child
☐ Individuals that report participating in decision making activities at their child’s school
☐ Individuals that report feeling an increased sense of collaboration with their child’s school and community
☐ Individuals that maintain applicable changes at 6 months and 12 months after program completion
INCOME
Target Area #1 – Family-Sustaining Employment
☐ Individuals who complete work skills training programs
☐ Individuals who receive a degree, certification, or credential
☐ Individuals who increase work skills
☐ Individuals who increase educational skills/levels
☐ Individuals who become employed
☐ Individuals who remain employed for 6 months and 12 months post program completion
☐ Individuals who improve employment situation at 6 months and 12 months post program completion
Target Area #2 – Income Supports
☐ Individuals who applied for benefits
☐ Individuals who accessed benefits, including types utilized (EITC, child care, food assistance, cash assistance, Medicaid)
Target Area #3 – Manageable Expenses
☐ Individuals who demonstrate an increased knowledge of financial literacy
☐ Individuals who start, maintain, or increase savings at 6 months and 12 months post program completion
☐ Individuals who improve debt-income ratio at 6 months and 12 months post program completion
☐ Individuals who increase credit score at 6 months and 12 months post program completion
☐ Individuals who either maintain or responsibly alter their household budget at 6 months and 12 months post program completion
☐ Individuals who use financial institution for savings or investment since program enrollment
☐ Individuals who identify short term financial goals
☐ Individuals who reach short-term financial goals by program completion, and at 6 months and 12 months post program completion
HEALTH
Target Area #1 – Healthy Beginnings
☐ Babies who are born full-term without medical complications
☐ Babies who are born at a normal birth weight
☐ Children who maintain recommended immunization schedule
☐ Families that prepare a safe, nurturing environment for their infant
Target Area #2 - Healthy Eating and Physical Activity
☐ Individuals who participate in nutrition program
☐ Individuals who complete nutrition program
☐ Individuals who increase consumption of nutritious food
☐ Individuals who participate in physical activity program
☐ Individuals who complete physical activity program
☐ Individuals who increase frequency of physical activity
☐ Individuals who maintain a healthy Body Mass Index
☐ Individuals who reduce Body Mass Index
☐ Individuals who maintain applicable changes at 6 months and 12 months after program completion
Target Area #3 - Healthy and Independent Aging
☐ Individuals who maintain ability to live at home
☐ Individuals who maintain or increase ability to live an active lifestyle
☐ Individuals whose caregivers receive respite
Target Area #4 – Supporting Healthy Choices
☐ Individuals that report an increase in their knowledge of how to manage their disease
☐ Individuals that report an increase in their ability to manage their disease
☐ Individuals that report a reduction in anxiety
☐ Individuals that report an increase in ability to cope
☐ Individuals that report a decrease in the amount of time that poor physical health kept them from doing their usual activities
☐ Individuals that report an increase in overall life satisfaction
☐ Individuals that report an improvement in their physical health
☐ Individuals that report an improvement in their social/emotional health
☐ Individuals that report getting the social/emotional support they need
☐ Individuals that report a decrease in the amount of time that emotional problems have interfered with work and/or daily activities
BASIC NEEDS
Target Area #1 – Food
☐ Number of individuals served
☐ Number of meals provided
Target Area #2 – Shelter
☐ Number of individuals served
☐ Number of nights that shelter was provided
☐ Average number of nights per person
☐ Specific types of disaster services provided (clothing, shelter, food, etc.)
☐ Value of specific types of disaster services provided (clothing, shelter, food, etc.)
Target Area #3 – Emergency Assistance
☐ Number of individuals served
☐ Number of bills paid for housing (rent, mortgage)
☐ Value of bills paid for housing (rent, mortgage)
☐ Number of bills paid for utilities (gas, electric, etc.)
☐ Value of bills paid for utilities (gas, electric, etc.)
☐ Number of bills paid for medical expenses
☐ Value of bills paid for medical expenses
☐ Number of bills paid for other needs
☐ Value of bills paid for other needs
Target Area #4 – Safe Environment
☐ Number of individuals served
☐ Number of days that a safe environment was provided
☐ Average number of days per person
Section 4 - Program Narrative
Please tell us about your program. Remember that this is your opportunity to help us understand how your program fits into United Way's Agenda for Change. When writing the narrative, you should address the following things:
· How does your program align with the goals and target areas listed in the Community Impact Agenda for Change?
· How does your program align with the community-level data provided in the Community Impact Agenda for Change? What need is being addressed?
· How is your program delivered?
· Does your organization utilize evidence-based or best-practice strategies for program design and execution?
· Where is it delivered?
· When is it delivered?
· Who is the target audience for your program (if possible, include age, gender, ethnicity, ZIP code/school district)? Approximately how many people will you serve in one year?
· Does your program measure additional outcomes, that support the goals and target areas stated, that were not listed in Section 3 of this document?
· How will you measure the outcomes that you’ve indicated in this request? What tool will you use, and how will you use it? How often will you implement the tool?
· How many full-time staff members, part-time staff members, and volunteers are involved in delivering this program?
· What is the cost per unit to deliver your program?
· What other organization offers a similar service?
· What elements of your organization qualify you to contribute to the United Way Community Impact Agenda for Change (management practices, volunteer management, diversification of funds, governance, etc.)?
· What collaborative efforts are you involved in (list the organizations that you collaborate with, and describe the nature of the collaboration)?
· Is there anything else that we should know about your program?
Type narrative in box below. Maximum length is 4 pages, double spaced.
Section 5 - Proposed Budget
Item / Amount / SideFederal** / Click here to enter text. / Income
State** / Click here to enter text. / Income
Local Government** / Click here to enter text. / Income
Foundations** / Click here to enter text. / Income
Fund Raising / Click here to enter text. / Income
Individual Contribution / Click here to enter text. / Income
United Way Donor Designation / Click here to enter text. / Income
United Way Allocation / Click here to enter text. / Income
Allocations from Other United Ways / Click here to enter text. / Income
Program Service Fees / Click here to enter text. / Income
Investment Income / Click here to enter text. / Income
Other Revenue** / Click here to enter text. / Income
Direct Program Costs / Click here to enter text. / Expense
Salaries, Payroll Taxes & Benefits / Click here to enter text. / Expense
Professional, Consultant Fees & Legal / Click here to enter text. / Expense
Occupancy / Click here to enter text. / Expense
Travel, Transportation & Meals / Click here to enter text. / Expense
Conference & Staff Development / Click here to enter text. / Expense
Supplies / Click here to enter text. / Expense
Phone / Click here to enter text. / Expense
Postage / Click here to enter text. / Expense
Equipment / Click here to enter text. / Expense
Marketing, Public Relations / Click here to enter text. / Expense
Membership Fees & Dues / Click here to enter text. / Expense
Miscellaneous Expenses** / Click here to enter text. / Expense
Total Income / Click here to enter text.
Total Expense / Click here to enter text.
Total Surplus/Deficit / Click here to enter text.
For items marked with **, include specific source.