Community Investment Fund Application Form

Overview of the Organization

Contact Information

Organization Name:

Mailing Address:

Local Office Address
(if different than above):

Website

Facebook

Twitter

Instagram

Other Social Media

Is the organization a registered Non-Profit in the Province of Ontario?

YesNo

Is the organization a Registered Charity with Canada Revenue Agency?

YesNo

If you are unsure of the difference between these two, please consult this website.

CRA Charitable Registration #:
(if you are not a registered charity, please include your non-profit registered business number)

Name of Executive Director

Contact Person

Position

Telephone

Email

Information Regarding Board of Directors

Please upload a chart for all members of your Board of Directors (preference Excel) with Full Name, Position on Board, # Years on Board, Occupation

AGM Information

Date of last Annual General Meeting

Did you invite UWC SDG to attend your last AGM?

YesNo

Date of upcoming Annual General Meeting
(at least indicate the month in which you intend for it to take place)

Organizational Information

Mission Statement:

Brief overview of services/activities that you offer to meet this mission:

Insurance

Does the organization hold insurance?

We have general liability insurance of at least $2 million.

We do not but we will obtain it if approved for funding.

We have Employee Accident Insurance or WSIB.

Language

Does the organization offer services in both official languages?

Location

**only for organizations with no physical location within SDGC&A**

If your organization is located outside of SDGC&A, do you have a dedicated individual providing services in this region?

Number of hours dedicated to our region:

Part-TimeFull-Time

Name of that individual:

PROGRAM / PROJECT NAME:

EXPECTED START and END DATE:
(Note: Dates cannot begin prior to April 1, 2023 and must end by March 31, 2024)

Most Recent Annual Report (file size must not exceed 20mb)

Most Recent Audited Financial Statement or Externally Reviewed Financial Statements
(Internally reviewed financial statements will not be accepted)

We have provided our Board of Directors the opportunity to review this submission and they are aware of this application. Download, sign this form, and upload below.

Program/Project Description

Please keep your descriptions for the progam you are applying for simple and brief.

Under which pillar will you be applying? Choose only ONE.
Please refer to our website for more information regarding the pillars.

All That Kids Can BeHealthy People Strong CommunitiesPoverty to Possibilities

Please clearly describe how this program/project is related to the UW pillar under which you have applied.

Provide a brief description of the specific program/project for which you are seeking funding.

Provide a summary of any research that supports the need for this project/program or which may otherwise support the success of your proposal.

Are there individuals waiting to be served by this program/project?

YesNo

If yes, what factors prevent service to these individuals?

Do you refer waitlisted or other individuals to any other community program or organization?

YesNo

If yes, please specify. If no, please explain why.

Partnerships

Does this program/project work in partnership with any other organization(s)?

YesNo

If yes, please explain the role and benefit related to program delivery.

Theory of Change & Project Outcomes

A Theory of Change links program outcomes and activities to explain HOW and WHY a desired change is expected to come about. It identifies what you are trying to achieve, what changes in people you expect to see, and how these changes will occur.

NEED
Briefly describe the local need/problem that you want to address with this program. What do you see as the underlying cause(s) of the issue or problem?

How will the program/project address this issue/problem?

IMPACT
Provide one sentence that clearly states the outcome the program is expected to achieve (elevator pitch).

EVALUATION
How will you know that this project/program is a success? (Milestones, Benchmarks). Please be as specific as possible, providing both quantitative and qualitative measures for this project only.

Please upload any reference research documents that support this summary if available.

Reporting

A mid-year and final report will be required. The mid-term report will collect information on budget spent to-date, progress made towards achieving stated outcomes and number of participants in your program/impacted by your program. The final report should demonstrate your organization's analysis and interpretation of data collected including noting any unusual findings and future plans to build on/address the findings.

Briefly describe how this program/project will be evaluated, including the tools that will be used.

Program/Project Inputs & Resources

How many Full Time Equivalent employees (FTEs) will be used to deliver this program/project?

How many Part Time Equivalent employees (PTEs) will be used to deliver this program/project?

Please identify any other key resources necessary to run this program/project including the number of volunteers required for this specific project:

Does your agency actively recruit volunteers for this program?

Budget

Total Cost for the specific project for which you are applying. This number MUST match the detailed budget sheet below.

Total UW Funding Requested

Total Contribution from Other Sources

Have you applied to any other funding for this project?

YesNo

If yes, please upload supporting documentation.

Detailed Budget Sheet

**THIS SECTION IS REQUIRED**

A) Program/Project Management Costs and Financial Details regarding THIS project

	Total Cost	UW Request	Other Contribution
Administrative Wages	$	$	$
Benefits	$	$	$
TOTALS - A	$	$	$

B) Other Administrative Costs regarding THIS project

	Total Cost	UW Request	Other Contribution
Professional Fees	$	$	$
Rent	$	$	$
Utilities	$	$	$
TOTALS - B	$	$	$

C) Capital/Assets regarding THIS project

Description	Total Cost	UW Request	Other Contribution
	$	$	$
	$	$	$
	$	$	$
TOTALS - C	$	$	$

D) Direct Program Delivery regarding THIS project

	Total Cost	UW Request	Other Contribution
Staff Wages	$	$	$
Benefits	$	$	$
Materials/Supplies (briefly list on an additional page)	$	$	$
Travel	$	$	$
Other (briefly list on an additional page)	$	$	$
TOTALS - D	$	$	$

Total Budget (Please Calculate)

Total Cost ( A + B + C + D)	UW Request ( A + B + C + D)	Total Other Contribution (A + B + C + D)
$	$	$

Has this program/project previously received funding from the United Way of SD&G?

YesNo

If yes, please specify the amount of funding and time period in which the funds were received.

If yes, please indicate and explain if there was a surplus or deficit for this program/project in 2022-2023.

If you are requesting an increase in 2023-2023, what are the main factors that influence this increase?

Please indicate planned project fundraising activities below including: timing and the revenue expected to be generated through the fundraising project.

Activity and brief description	Timelines	Expected Revenue

(Insert additional information on a separate document if required)

Total Expected Revenue

$

Are there Reserve Dollars or Large Assets indicated in your Audited Financial Statements?

YesNo

If yes, please detail.

Does the organization have the ability to maintain services during any potential service disruptions (i.e. mandatory lock-downs)?

YesNo

Should your organization experience prolonged service disruptions caused by external events, would you be able to offer services as outlines in this application or would you need to make modifications? Please describe any modifications you envision.

Signatures and Authorizations

I have read the detailed Application Information document and this Application, and to the best of my knowledge, the information provided on the organization and the project is correct and complete.

Name of Applicant

Title

Date

The information collected in this application will only be used to determine Community Investment Fun allocations for 2023-2024 through the United Way/Centraide Stormont, Dundas and Glengarry.

For information regarding our Mission, Vision, pillars of work, please refer to:
https://unitedwaysdg.com

If you have questions or would like clarification about the information contained in this package, please contact the United Way office: 613-932-2051 or email: jan@unitedwaysdg.com

Submission Deadline
Thursday, March 30, 2023
1PM EST