INITIAL - Small Opportunity Grant Application

INITIAL - Small Opportunity Grant Application - Due March 1, 2024

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FISCAL AGENT/FISCAL SPONSOR

Does your Program operate under the oversight of a Fiscal Agent/Fiscal Sponsor?

YesNo

FISCAL AGENT/FISCAL SPONSOR INFORMATION

Fiscal Agent/ Fiscal Sponsor Important Information

If utilizing a Fiscal Agent/Fiscal Sponsor United Way of Greater Lima will need to collect additional information as seen in the required documents section at the end of the form. These additional documents will replace some of the other documents previously required. United Way of Greater Lima will require all Agencies utilizing a Fiscal Agent/Fiscal Sponsor to provide a written agreement confirming the Fiscal Agent/ Fiscal Sponsor relationship. This agreement must include a statement regarding the Fiscal Agent's/Fiscal Sponsor's ability to retain discretion and control over the donated funds. In addition to the agreement United Way of Greater Lima will also require an annual accounting for all funds received from UWGL. This document will replace the previously asked for 990 and should show how and where the funds were used for the designated program.

A Fiscal Agent/Fiscal Sponsor must be a 501(c)3 nonprofit organization. Since Churches are granted automatic tax exempt status, they meet United Way of Greater Lima's requirements needed to serve as a Fiscal Sponsor.

Fiscal Agent/Fiscal Sponsor Name

Street Address:

City/Town:

State:

Zip:

If Mailing Address is different Please Check Here -->

MAILING ADDRESS

Street Address:

City/Town:

State:

Zip:

Fiscal Agent/Fiscal Sponsor Main Phone:

First and Last Name Executive Director/CEO:

Email Address Executive Director/CEO:

Phone Number Executive Director/CEO:

Fiscal Agent/Fiscal Sponsor Agency Mission Statement:

AGENCY INFORMATION

Agency Name

Physical Location in Allen County (Street Address):

City/Town:

State:

Zip:

If Mailing Address is different Please Check Here -->

MAILING ADDRESS

Street Address:

City/Town:

State:

Zip:

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:

(250 words or less)

Days/Times of Operation:

Total Number of Volunteers at Agency:

Number of Years in Operation:

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)

Has your agency previously applied for and/or received UWGL Small Opportunity Grant funding?

YesNo

Is your agency a current UWGL Community Partner Agency?

YesNo

The Small Opportunity Grants are for agencies that are NEW to The United Way of Greater Lima. If you are currently a Community Partner please discontinue filling out this application and return to https://www.unitedwaylima.org/agency-resources and locate our Community Partner Grant Application. If you are a current Community Partner and you are looking to apply for funding for a new and Innovative program, please return to https://www.unitedwaylima.org/agency-resources and locate the Innovation Grant Application. If you are unsure of which application you need to complete, please contact the United Way of Greater Lima's office at 419-227-6341 and someone will be able to assist you.

If you are a NEW agency that has not received either our Community Partner Grant or Innovation Grant funding before, please select "no" on the question above and continue filling out the application.

Thank you!

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?

(250 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?

(250 words or less)

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

(250 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:

Title Program Director:

Email Address 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:

How does your program plan to use the UWGL funding?

(250 words or less)

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 (250 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.)

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

Upload Agency Information

Resolution or Written Agreement between Fiscal Agent/Fiscal Sponsor and Program Agency (must contain who has control over the United Way Funds)

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)

Annual Accounting

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.

Additional Comments Regarding Submitted Documents?

OPTIONAL (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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