UNITED WAY OFFARIBAULT

2017Request for Program Funding

Cover Sheet

Date ______

Organization Information

Name of organization

/

Years as a UWF member agency

Address

/

City, State, Zip

/

Employer Identification Number (EIN)

Phone

/ Fax / Website

Name of Executive Director

/

Phone

/

E-mail

Name of Contact for this application

/

Phone

/

E-mail

2017Proposal Information

Please give a short summary of your 2017 program(s) request:
Population served by program(s): ______
Geographic area to be servedbyprogram(s)in 2017: FaribaultNerstrandMorristownWarsaw
 Other (list) ______

Estimated number of people to be servedbyprogram(s)in 2017:

___Faribault + ___ Nerstrand + ___ Morristown + ___ Warsaw + ___ Non-Residents served in southern Rice County = ____ Total number of people to be served in 2017

Is your organization an IRS 501(c)(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:

SUPPORTREQUESTED:

2015 Request
(if applicable) / 2015 Faribault United Way grant
(if applicable) / 2016 Request
General Organization Funding
Program-Specific Funding:
Program Name(s)
1)
2)
3)
4)
Total

Budget

Total annual organization budget: / $
Total annual project budget (for support other than general operating): / $

Proposal Narrative

I. Organization Information

  1. Please state your organization’s mission and vision statements.
  1. Describe your organization’s current programs or activities, including any service statistics and strengths or accomplishments. Please highlight new or different activities, if any, for your organization.
  1. Describe your organization’s relationship with other organizations working with similar missions. Do you collaborate with them? If so, how?

II. Purpose of Grant

Please select the designated area(s) your program will cover

Education

Health

Basic Needs / Income Stability

General Operating Proposal

General operating proposals: Complete Section A below and move to Part III - Evaluation.

All other proposal types: Complete Section B below and move to Part III - Evaluation.

A.General Operating Proposals

1.What are the challenges, issues or need currently facing your organization?

2.What is the overall goal(s) of your organization for the funding period.

3.What are the objectives or ways in which you will meet the goal(s)?

4.Name specific activities and who will carry out these activities.

5.In what time frame will these take place?

6.What are your long-term funding strategies for sustainability?

B.Program Proposals

1. Situation

  1. Describe the opportunity, challenges, issues or need that your 2017 proposal addresses.
  2. How was that focus determined and who was involved in that decision-making process?

2. Activities

  1. What is your goal regarding the situation described above?
  2. What are your objectives and ways in which you will meet the goal(s)?
  3. Please bullet point specific activities for which you seek funding. Under each, answer the following:
  4. Who will carry out those activities?
  5. In what time frame will they take place?
  6. How will the proposed activities benefit the Faribault area and what is the impact you expect to have?
  7. Describe long-term funding strategies (if applicable) for sustaining this effort.

Part III. Evaluation

Please describe your criteria for success. What do you want to happen as a result of your activities? You may find it helpful to describe both immediate and long-term effects.

  1. How will you measure these changes?
  2. Who will be involved in evaluating this work (staff, board, constituents, community, consultants)?
  3. What will you do with your evaluation results?

Part IV. Management and Financial Oversight

  1. How often does your organization’s Board of Directors meet?
  1. How often are financial statements presented to the Board?
  1. Are members of the organization’s management and/or Board financial professionals, or have financial training?
  1. Does your organization have outside assistance with financial record-keeping? If so, is it volunteer, or paid?
  1. How often are financial records/books updated? How often are your accounts reconciled with the bank?

Attachments

The following attachments are required:

  1. Finances
  1. Most recent financial statement from most recently completed year. Provide draft financial statements and mark as such if statements aren’t final or audit is not complete.
  2. This information should include:

-Balance sheet

-Statement of activities (or statement of income and expenses) and functional expenses.

-Form 990 tax return (if you are required to file).

-Audit if revenues of $500,000 or up.

  1. Organization budget for current year, including income and expenses. (Form separate.)
  2. Project Budget, including income and expenses, if applicable. (Form separate).
  1. List of board members and their affiliations.
  2. List key staff, describing qualifications relevant to your specific request.
  3. Current non-profit registration confirmation from the Minnesota Attorney General
  4. Anti Terrorism Compliance Form

New Applicants Only:

1.A copy of your current IRS determination letter (or your fiscal agent’s) indicating tax-exempt 501(c)(3) status.

2.A copy of your organization’s board-approved diversity policy.

2016 COMMUNITY OUTREACH INFORMATION

Agency: Program:

Please give a brief description of your agency (approximately 15 – 25 words) and description of your program (approximately 15 – 25 words). This information may be used in United Way of Faribault promotional materials and referral resources.

Photographs: Please submit five photos of your agency work in the Faribault area on a DVD/Disk format or flash drive to be used in promotional materials. High resolution pictures are preferred.

Final Proposal Checklist:

Cover Sheet

Proposal narrative.

Organization budget.

Project budget (if not general operating grant).

Financial statements showing actual expenses including:

-Balance sheet.

-Statement of activities (income and expenses).

-Statement of functional expenses.

-Audit, if revenues are $500,000 or higher.

-990, if you file.

(Provide draft financial statements and mark as such if statements aren’t final or audit not complete.)

List of board members and their affiliations.

Brief description of key staff.

IRS determination letter (if new applicant).

Diversity statement (if new applicant).

Confirmation letter of fiscal agent (if required).

Photos for publicity (on disk or jump drive).

Current non-profit registration confirmation from the Minnesota Attorney General.

Anti Terrorism Compliance Form

THE INDIVIDUAL COMPLETING THIS FORM CERTIFIES THAT:

  1. This agency is a governmental agency or an agency which is recognized by the IRS as tax exempt 501 (c) (3).
  2. This agency is organized under the laws of the State of Minnesota.
  3. This agency files an IRS 990 (if required).
  1. This agency is directed by an active and responsible governing body whose members have no material conflict of interest and a majority of which serve without compensation.
  2. The organization’s administrative and fundraising expenses are _____ percent of total budget.

Name & title of individual completing this form (Please print):

Name:______Title:______

Signature: ______Date: ______

Phone number: ______Email:______

Thank you for submitting your proposal!