INNOVATION 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 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:

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 Person Completing:

Phone Number Person Completing:

Agency Mission Statement:

Has your agency previously applied for and/or received Innovation Grant Funding?

YesNo

If yes, Program Name and Year:

Is your agency a current UWGL Community Partner Agency?

YesNo

Is your agency governed by a Board of Directors?

YesNo

PROGRAM CONTACT 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

Requested amount for this Program:

Total Program Budget:

Percent of budget being requested:

How does your program plan to use the UWGL funding?

(250 words or less)

AREA OF IMPACT

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.

PROGRAM INFORMATION

Summary of program. Include a description of the issue/need this program addresses.

(250 words or less)

Describe how your project is innovative for our community:

(250 words or less)

What are the beginning and completion dates of your program?

(250 words or less)

Describe your target population and how you determine eligibility for services. How does this program serve minorities and underserved populations?

(250 words or less)

How many people (unduplicated) do you project will be served through this program?

Are fees charged for services:

YesNo

If yes, describe how fees are charged, including amounts and fee structure. What provisions are made for clients who are unable to pay full fees?

(250 words or less)

Number of staff positions and/or volunteer positions responsible for direct program implementation:

Briefly describe the strategies, techniques and resources used in this program to meet your expected outcome.

(250 words or less)

Describe current collaborative efforts between your program and other agencies which assist your program in achieving program outcomes:

(250 words or less)

FUTURE FUNDING

Describe how the program will be funded on an ongoing basis after the UWGL grant has ended. Indicate funding sources and activities to be pursued.

(250 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 two (2) 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 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-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

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)

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

Annual Accounting

USA Patriot Act Statement of Compliance

Any other supporting documentation

You may include documents you were unable to upload above, or and additional documents you feel are 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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