Use this form if your TOTAL AGENCY REQUEST equals $5,000 or less.

AGENCY: ______

Checklist: One checklist per agency, one page form provided with this application
Cover : Agency Cover Sheet (form provided with this application, please
complete one per agency)
Part I: Program Budget (form provided with this application; Excel version is
available upon request by calling 803-324-2735)
Part II: Program Summary (form provided with this application)
Part III: Program Service Data: (form provided with this application)
Part IV: How can we help to promote your program? (Form provided with
this application)
NOTE: These may be used in our 2015-16 Campaign Materials

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United Way of York County, SC Short Form Application 2015-16

Use this form if your TOTAL AGENCY REQUEST equals $5,000 or less.

Agency: EIN Number:
DUNS Number:
Program:
CEO/Executive Director:
Board Chairman:
Agency Address:
City/State/Zip:
Phone: Fax:
Email:
Agency’s Mission Statement:
This agency is: qNew to United Way of York County, SC q Previously Funded Agency ______# years
Agency Fiscal Year: q Calendar Year q (Month) ______to ______
Total agency budget this year = $______Total agency budget NEXT year = $______
Community Impact Goal: Choose one of the three impact goals that best fits the intent of your program
q Goal 1: EDUCATION: All York County children and residents will be prepared to be life-long learners and productive citizens
q Goal 2: FINANCIAL STABILITLY: All York County residents will meet their basic needs and be economically self-reliant
q Goal 3: HEALTH: All York County residents will be mentally and physically healthy
This Program: q Charges participants a fee (attach fee schedule) q Does not charge participants a fee
This program is: q New, never offered before q Existing Program, not funded by UWYC in 2014-15
q Continuing, previously funded by UWYC...... 2014-15 UWYC Allocation Award = $______
2015-16 Funding Request UWYC = $______
Brief Program Description (limit to space provided):

CERTIFICATION & AUTHORIZATION: By our signatures we certify that the governing board of the applicant agency reviewed the scope of this application and took official action authorizing the submission of this request.
I affirm that the information provided in this application is truthful and accurate:


SIGNATURES: Executive Director ______Date:______

Board Chairman______Date:______

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United Way of York County, SC Short Form Application 2015-16


Agency: ______Program Name:______

Item

/

Last Year Actual

/ Current Year Approved & Operating: /

Next Year Projection

Balance carried over from previous Year
Income
Contributions, Bequests / $ / $ / $
Special Events / $ / $ / $
Grants–Government / $ / $ / $
Grants–Foundation / $ / $ / $
Program Fees / $ / $ / $
Investment Income / $ / $ / $
Program Sales / $ / $ / $
UW York County SC / $ / $ / $
UW Designations / $ / $ / $
Other UW’s / $ / $ / $
Other Revenue / $ / $ / $
TOTAL INCOME / $ / $ / $
Expenditures
Salaries, Taxes & Benefits / $ / $ / $
Professional Fees / $ / $ / $
Supplies / $ / $ / $
Operating Expense / $ / $ / $
Equipment / $ / $ / $
Other Expense: list / $ / $ / $
$ / $ / $
$ / $ / $
TOTAL EXPENDITURES / $ / $ / $

ENDING BALANCE

/ $ / $ / $

You may attach one additional page if needed to answer the following questions:

1.  Do any revenue sources need additional explanation (ex: one time grant, etc.)?

2.  Do any expenditures need additional explanation (ex: replace HVAC)?

3.  Are there significant changes in funding anticipated for FY 2015-16? If yes, please provide detail:

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United Way of York County, SC Short Form Application 2015-16

Agency: ______Program: ______

Program Narrative - Please include the following: (This document must be created for each program funding request; total two (2) pages maximum per program)
A.  Outline the project or program for which funding is requested.
B.  Summarize your organization’s history; include evidence of strong leadership and its track record as a viable community organization.
C.  Summarize evidence of sound administrative and financial practices.
D.  State program’s previous successes and goals for the upcoming year.

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United Way of York County, SC Short Form Application 2015-16

Agency: ______Program: ______

1.  Use this chart to provide program service data for three funding years – Previous year ACTUAL; Current year ESTIMATED; Next year TARGET. Please list the units of service you routinely count for this program (outputs); there may be several outputs per program (e.g. counseling sessions, hotline calls, youth membership, classes taught, individuals or families served, referrals to other agencies - You may attach one additional page for program service data, if needed to fully explain the reach of your program)

Unit of Service:
(Please describe) / Previous
Funding Year
2013-14
ACTUAL / Current
Funding Year 2014-15 Year to Date / Proposed
Next Funding Year 2015-16
TARGET
Example: clients served, counseling sessions, referrals, classes, lbs. of food / 225 clients
150 classes / 240 clients
175 classes / 275 Clients
200 classes

2.  Please report the number of unduplicated* adults, children and households this program served as primary clients/customers. *Please provide estimate of non-repeating clients:

Actual Total Served Previous Funding Year 2013-14 / % NEW
People
served / Current Funding Year YTD
July – Dec 2014 / % NEW
People served YTD
July - Dec
2014 / Proposed
Next Funding Year 2015-16
TARGET # Clients
Adults
Children
Total Individuals
Total Households

3.  Please report data of unduplicated individuals on the home ZIP code:

_____ 29704 Catawba _____ 29726 McConnells

_____ 29710 Clover/Lake Wylie _____ 29742; 29743 Sharon/Smyrna

_____ 29708; 29715; 29716 Fort Mill/Tega Cay _____ 29745 York

_____ 29717 Hickory Grove _____ ZIP code outside York County please

_____ 29730; 29731; 29732; 29733 Rock Hill list:______

= 100% TOTAL

4.  Does your program serve only low income clients? ____ No ____ Yes*

*Please report number of clients served in the following categories:

____ 100% Federal Poverty Guidelines: <$11,670 - Individual or < $23,850 - Family of four

____ 135% and below (Free Lunch): ≤$15,754 - Individual or < $32,197 - Family of four

____ 136% - 185% (Reduced Lunch): <$21,589 - Individual or < $44,122 - Family of four ____ 186% and above: >$21,590 - Individual or ≥ $44,123 - Family of four

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United Way of York County, SC Short Form Application 2015-16

1.  Please give examples of how United Way funding can impact at least two of the following dollar amounts for your program:

$52 ($1/week):

$104 ($2/week):

$156 ($3/week):

$208 ($4/week):

$260 ($5/week):

$600 per year - Palmetto Leadership Society Level:

2.  Success story of United Way program participant.

3.  How has your program changed conditions and lives in York County?

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United Way of York County, SC Short Form Application 2015-16