INITIAL - Community Partners Grant Application - Due March 1, 2023 (Beginning of 3 year cycle)

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AGENCY INFORMATION

Agency Name

Physical Location in Allen County (Street Address):

City/Town:

State:

Zip:

Mailing Address (including town/zip) if different:

Agency Main Phone:

Agency Fax:

Website:

EIN Number:

Agency Fiscal Year:

Your 12 month accounting period.

First and Last Name Executive Director/CEO:

Email Address Executive Director/CEO:

Phone Number Executive Director/CEO:

First and Last Name Person Completing:

Title Person Completing:

Email Address Person Completing:

Phone Number Person Completing:

Agency Mission Statement:

Summary of Agency:

(50 words or less)

Days/Times of Operation:

Total Number of Volunteers at Agency:

Number of Years in Operation:

UNDUPLICATED TOTAL number of people served in Allen County by your agency:

Describe any significant Agency changes that occurred in the past 12 months (e.g. change in leadership, board, programs, revenues, funding sources, or expenditures) and any additional information you feel is pertinent.

(250 words or less)

AGENCY PARTICIPATION IN UWGL ACTIVITIES

Which of the following UWGL activities has your Agency participated in this past funding year? Please check all that apply:

End-of-Campaign BreakfastDay of CaringAgency Directors MeetingUnited Way Training (if offered)211 Information and Referral SiteMy agency has NOT participated in any UWGL activities.

Please explain why you have not participated. How can we help you get more involved next year?

(50 words or less)

INTERNAL CAMPAIGN

Did your agency run an internal United Way Campaign last year?

YesNo

Total Number of Employees:

How many of your staff participated in your internal campaign?

Percentage of your staff who participated in your internal campaign:

How much did your staff raise for the United Way Campaign last year? (Any amount is appreciated!)

Estimates are acceptable.

If not, can you explain why not? How can we help you get a campaign going next year?

(50 words or less)

Provide a brief description of the Agency's use of the UWGL partnership in marketing materials and the media:

(100 words or less)

FINANCIAL OVERVIEW OF AGENCY

UWGL encourages financial stability in our partner agencies. We encourage you to develop operating reserves and endowment funds as they indicate diversified and stable funding. You are not penalized for healthy balances in these funds. Reserves of 3-6 months of operating expenses are recommended. Provide information based upon your most recently completed fiscal year.

Balance of Undesignated Reserves at the end of the most recently completed fiscal year:

Number of months of operations that the Undesignated Reserves will cover:

What is the total annual Agency Revenue?

(From Line 12 of Form 990, or Line 9, Part I of Form 990-EZ)

What is the total annual Agency Expenses?

(From Part IX, Line 25(A) of Form 990, or Line 17, Part I of Form 990-EZ)

Net Operating Income/Loss (annual) for the Agency:

What is the total annual Agency Program Services Expenses?

(From Part IX, Line 25(B) of Form 990, or Line 32, Part III of Form 990-EZ)

What is the total annual Agency Management and General Expenses?

(From Part IX, Line 25(C) of Form 990, or if filing Form 990-EZ, from agency budget)

What is the total annual Agency Fundraising Expenses?

(From Part IX, Line 25(D) of Form 990, or if filing Form 990-EZ, from agency budget)

The annual Agency Administrative Cost (Management-General Expenses plus Fund Raising Expenses):

Percent of Expenses that go toward Agency Administrative:

Percent of Expenses that go toward Agency Program Services:

PROGRAM INFORMATION

Program Name:

First and Last Name Program Director:

Email Address Program Director:

Title Program Director:

Phone Number Program Director:

CURRENT REQUEST FOR GRANT FUNDING FOR THIS PROGRAM

Requested amount for this program:

Total Program Annual Budget:

Percent of Program budget being requested:

Did you receive UWGL funding for this program last year?

YesNo

If you received UWGL funding for your program last year, how much did you receive?

Do not include designations received; this number should reflect only the UWGL Award.

This equals an increase/decrease of:

PROGRAM OUTCOMES/IMPACT

Program Outcomes/Impact ANTICIPATED IN THE COMING FUNDING YEAR (July 1 through June 30)

HOW ARE PEOPLE'S LIVES IMPROVED BECAUSE OF YOUR PROGRAM SERVICES?

Measuring the success of your agency initiatives is an important part of effectively managing a program. UWGL must be able to show our donors that their contributions are truly making a positive difference in our community. Therefore, part of applying for funding is to offer evidence that what you are doing is effective.

Below we ask you to share your desired outcomes for this program in the coming year. Tell us how you hope to impact lives through the services you provide. We require a minimum of two (2) outcomes, and a maximum of four (4).

In March and September, we will ask you to report on your success at reaching your program goals when you complete the IMPACT REPORTS.

	Outcome Desired	Data/Tools Used to Track Progress	Target # of Clients Receiving Service	Target # Achieving Desired Outcome	Target % Achieving Desired Outcome
Outcome #1
Outcome #2
Outcome #3
Outcome #4

Comments on future outcomes anticipated in the coming funding year:

Optional (50 words or less)

COMMUNITY IMPACT OF YOUR PROGRAM

What would $1 per pay period ($26/yr) fund or support?

(50 words or less)

What would $4 per pay period ($104/yr) fund or support?

(50 words or less)

What would $10 per pay period ($260/yr) fund or support?

(50 words or less)

What would $20 per pay period ($520/yr) fund or support?

(50 words or less)

REQUIRED DOCUMENTATION

United Way standards require specific documentation from its' partners. Please upload the MOST RECENT version of all the following documentation. In addition, please follow these instructions for uploading successfully.

All attachments in pdf format should have portrait orientation and be sized to 8 1/2 x 11 only.
The file size should not exceed 35 MB.
If a document consists of multiple pages, it needs to be uploaded in one file. Do not attempt to upload one page at a time on any question requiring upload.
The file extensions accepted by the system are pdf, doc, docx, xls, xlsx, ppt., pptx. (PDF is PREFERRED.)

Success Stories

One of the most powerful tools UWGL can use to raise funds in support of our community partners is the success/impact stories. Donors who hear specifics of how an individual or family has been helped are much more likely to give than those not exposed to stories. Stories should give anecdotal evidence of the effectiveness of your program's services, describing how the client's life was changed. This information will be used by UWGL's communication and marketing efforts.

Download Forms Needed to Complete Application

Please visit www.unitedwaylima.org/agency-resources to download the following forms for submission. BECAUSE THESE FORMS ARE PERIODICALLY UPDATED, PLEASE DOWNLOAD THE LATEST VERSION FROM THE WEBSITE RATHER THAN RELYING ON THE FORM YOU USED LAST YEAR.

1. Success Story Release
2. USA Patriot Act Statement of Compliance
3. Program Budget Form (Required)
4. Optional Worksheet for Completing Program Outcomes

Upload Agency Information

501(c)3 IRS Determination Letter

Board of Directors List (including position held, number of years served, and contact information)

USA Patriot Act Statement of Compliance

Annual Audit or Financial Review

IRS Form 990 (complete document) or 990EZ (Part I - Part X only)

Agency Balance Sheet

Agency Profit and Loss

Any other supporting documentation

You may include any documents you were unable to upload above, as well as anything else you feel is pertinent to your program.

Upload Program Information

Board Approved Program Budget

Please complete the Program Budget Form (found at the link listed above) with the simplified financial budget of only the program for which you are requesting funding.

ONE Success Story and Release

Please be sure to include one NEW success story from the past year.

Additional Comments Regarding Submitted Documents?

OPTIONAL (50 words or less)

ENVISION THE FUTURE WITH US!

The hope of UWGL is to inspire the community to give every campaign year. We want to move our county from a mindset of “desperation” (just hoping to hit a campaign goal) towards one of “inspiration” (considering what might be possible if more people participated in the campaign). Sometimes the stories of what you are unable to do because of lack of funds is just as motivational as stories of what has been accomplished. To move towards inspirational thinking we need you to dream with us. What would be possible if we were able to double your United Way Grant? We will use this information to inspire more people to give more money in next year’s campaign. Thank you!

Dream a Little!

(250 words or less)

AUTHORIZATION

I verify that I have reviewed the information provided and it is accurate and correct to the best of my knowledge. I also verify that I have reviewed it with my Program Director and have received Board support/approval.

Agency Executive Director/CEO - First and Last Name:

Date Completed:

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