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SMALL/SPECIAL PROJECTS Grant Application - Requests Considered Monthly

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:

Agency Fiscal Year:

Your 12 month accounting period.

First and Last Name Contact Person:

Title - Contact Person:

Email Address - Contact Person:

Phone Number - Contact Person:

Agency Mission Statement:

Has your agency previously applied for and/or received United Way Greater Lima Funding?

YesNo

If yes, Program Name and Year:

Is your agency governed by a Board of Directors?

YesNo

PROGRAM INFORMATION

Program Name:

Please select the area of impact of your program:

EDUCATION. Children and youth are equipped to learn at every grade and are prepared for success after high school graduation.HEALTH. Individuals and families have access to healthcare, improve their health, or maintain their health.FINANCIAL STABILITY. Individuals and families improve their socio-economic status.

Summary of program. Describe the Allen County need this program addresses and how you will implement the program in the community.

(250 words or less)

Describe your target population, how many people (unduplicated) you expect to serve, and how this program serves minorities and underserved populations.

(200 words or less)

CURRENT REQUEST FOR GRANT FUNDING

Requested amount for this Program:

Total Program Budget:

This equates to this percent of your Program Budget:

How does your program plan to use the UWGL funding?

(100 words or less)

PROGRAM OUTCOMES/IMPACT

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, please share your desired outcomes for this program in the coming year. We require a minimum of one (1) outcomes and a maximum of four (4).

Program Outcomes/Impact ANTICIPATED IN THE COMING YEAR

	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 your anticipated outcomes in the coming funding year:

OPTIONAL (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.)

Download Forms Needed to Complete Application

Please visit www.unitedwaylima.org/agency-portal to download the following forms for submission:

1. USA Patriot Act Statement of Compliance
2. Program Budget Form (Required)
3. 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)

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

USA Patriot Act Statement of Compliance

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.

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.

First and Last Name - Agency Executive Director/CEO:

Email Address - Agency Executive Director/CEO

Date Completed:

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