United Way of Southwest Missouri, Inc

1

Program Funding Request Form

(Note: A separate Program Funding Request Form must be filled out for each program)

1. Program Funding History & Request Summary:

2. Number of unduplicated clients served by this program (actual from prior fiscal year):

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)

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.)

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.

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.

Budget Narrative: (Include in your budget narrative a list of all local corporate gifts to your agency over $1000.)