1
Program Funding Request Form
(Note: A separate Program Funding Request Form must be filled out for each program)
Agency Name:Program Name:
Program Physical Address:
Program Contact Person:
1. Program Funding History & Request Summary:
Dollar Amount Received(from UWSWMOSEK) in 2015 / Dollar Amount Requested
(from UWSWMOSEK) for 2016 / $$ Difference from 2015 Allocation Received and 2016 Requested
Total Program Expenses
for 2015 / Total Program Expenses
Budgeted for 2016
2015 UWSWMOSEK Allocation Received
% of Overall Program Expenses
(Amount Received divided
by Total Expenses) / 2016 UWSWMOSEK
Requested
% of Overall Program Expenses
(Amount Requested divided
by Total Expense Budgeted)
2. Number of unduplicated clients served by this program (actual from prior fiscal year):
Infants/Toddlers (Birth-3 Years)Children (4-12 Years)
Teens (13-17 years)
Young Adults (18-22)
Adults
Seniors (65+)
Total Clients Served:
3. Provide a brief description of the program.
2
4. What are the days and hours of program operations?
5. What United Way Community Impact Area does the program align with? (Include Percentage)
¨ Education Helping children and youth achieve their potential by succeeding in school, graduating,
______% finding work and becoming productive adults.
¨ Income Supporting financial independence through employment, job training, money management,
______% owning or renting a home and saving for the future.
¨ Health Promoting healthy choices and behaviors that improve well being.
______%
6. What Community Level Outcome(s) are you addressing with the program?
(Circle or highlight applicable outcomes; logic model and measurement system must reflect outcome(s) chosen)
Education / Income / HealthChildren and youth are ready for school, starting with the skills they need to succeed. / Families sustain employment. / Infants have healthy beginnings.
Children’s reading skills are on track by fourth grade / Families build savings and assets. / Community members choose healthy eating.
Youth transition successfully to and from middle school. / Living wage employment opportunities are available. / Community members choose physical activity.
Youth graduate high school on time. / Families have manageable expenses. / The community supports healthy choices.
Youth are working or in advanced education by age 21. / Families have access to affordable housing. / The community has access to healthcare.
3
7. Briefly describe your target population.
8. Describe the need that exists in the community for your program’s services. Please cite your data sources. (Some recommended sources include The County Rankings Report, Kids Count, US Census)
9. Which counties are served by this program? (Check all that apply)
¨Jasper ¨Newton ¨Crawford ¨Cherokee ¨Barton ¨ Other Counties
10. What are the client eligibility requirements?
11. Are clients charged fees for program services? ¨YES ¨NO
If no, please skip to question 14.
12. What is the percentage of clients paying fees?
13. Do you have a sliding fee scale? ¨YES ¨NO
If yes, please attach a copy of your sliding fee schedule to this form.
4
14. Is there a waiting list for services? ¨YES ¨NO
Average number of clients on the waiting list:
Average wait time per client:
15. Who serves as a referral source for the program?
16. Do volunteers work directly with the program? ¨YES ¨NO
If YES, thinking only about UNPAID volunteers working directly with the
program (Jan 1 2015-Current Date):
(Do not include board members attending board and/or committee meetings.)
Number of Volunteers: / Number of Volunteer Hours:17. What changes if any will occur within your program if your funding request is not met?
5
Geographic Service Area: Please indicate the total number of unduplicated clients served by this program
who reside in each of the following locations.
Missouri / Kansas / OklahomaBarton County / Lawrence County / Bourbon County / Craig County
Lamar / Aurora / Fort Scott / Vinita
Liberal / Freistatt / Cherokee County / Delaware County
Barry County / Halltown / Baxter Springs / Afton
Butterfield / Marionville / Columbus / Grove
Cassville / Miller / Galena / Jay
Exeter / Mount Vernon / Riverton / Ottawa County
Monett / Stotts City / Crawford County / Commerce
Purdy / Newton County / Arma / Miami
Wheaton / Diamond / Girard / Picher
Butterfield / Granby / Cherokee / Quapaw
Cassville / Joplin (64804 / Frontenac / Other OK Counties
Dade County / Neosho / Mulberry
Arcola / Seneca / Pittsburg
Everton / Vernon County / Labette County
Dadeville / Brounaugh / Chetopa
Greenfield / Nevada / Oswego
Lockwood / Sheldon / Parsons
Arcola / Walker / Montgomery County
Everton / Other MO Counties / Coffeyville
Dadeville / Independence
Greenfield / Neosho County
Lockwood / Chanute
Greene County / Erie
Republic / Thayer
Springfield / Other KS Counties
Strafford
Walnut Grove
Willard
Republic
Jasper County
Carl Junction
Carthage
Carterville
Duenweg
Duquesne
Jasper
Joplin 64801
Joplin (64804)
Sarcoxie
Webb City
McDonald County
Anderson
Goodman
Noel
Pineville
Inputs / Activities / Outputs / Outcomes
*Outcomes must be quantified by including numerical targets for change. Example: 90% of youth will graduate on time. / Measurement Systems
What are the resources needed to operate your program? / What does the program do with the inputs? / How many times did you do the activities and for whom? (This year – what will you track in this area?) / Initial Outcome / Intermediate Outcome / Long Term Outcome / How will you measure your outcomes?
6
7
PROGRAM BUDGET FORM
(Total Budget for Program)
Name of Program:
Budget figures should coincide with fiscal calendar year (calendar or July-June). Be sure to describe any budget items that many need clarification in the Budget Narrative Section below.
REVENUE / 2015 Budget / 2016 Proposed BudgetRequested from United Way SWMO & SEK
Contributions Unrestricted
Contributions Restricted
Fund Raising (Gross)
Contributed by Associated Organization
Government Income
Program Generated Support
Grants
Other Earned Income
Total Revenue
EXPENSES / 2015 Budget / 2016 Proposed Budget
Salaries
Payroll Taxes
Employee Benefits
Supplies/Equipment
Telephone/Telecommunications
Postage & Shipping
Equipment Rental & Maintenance
Printing/Publications
Travel
Certifications/License Fees
Training/Conferences/Meetings
Program Related Insurance
Occupancy/Utilities
Specific Assistance for Individuals
Depreciation
Fundraising Expense
Payments to Affiliated Organization
Other Expenses
Total Expense
Revenue minus Expense
Budget Narrative: (Include in your budget narrative a list of all local corporate gifts to your agency over $1000.)