United Way of Dane County Foundation Application Form

Agenda for Change focus: Moving More People on the Pathways out of Poverty

A. Organization Information

Applicant Organization:

Executive Director: ______Contact Person______

Mailing Address:

City: Zip Code, all 9 digits:

Phone: FAX:

E-Mail: ______

B. Summary information for proposed project:

Project Name / Amount Requested / Contact Person / Phone / E-mail
$

B.1 Indicate which category this project falls into.

Single Program Funding / Collaboration (application must be signed by your collaborative partner or partners)

C. How to apply

To be considered, please submit 1 copy of this application form via email to with the subject line LE Foundation Proposal. Each applicant organization will have the opportunity to make a brief presentation to the United Way Loaned Executives on Tuesday, August 11 between 11:00 and 2:00. You will be notified by August 7 of your assigned presentation time. Bring 20 copies of your most recent annual report with you when you present on August 11.

Schedule:

Application Due: / August 3rd by Noon (we will not accept late proposals)
Presentation Date: / August 11
Applicants Notified of Results / September 1
Funding released
Report on the use of funds / October 30 after Board meeting
October 30, 2016

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D.  Program Name:

(Indicate the name of the program proposed for United Way Foundation funding)

D1. PROJECT DESCRIPTION:

What is the general nature of this project? Please include the location(s) of where services will be provided, target group, number of people who will benefit, and key project activities. (1/4 page )

D2. Describe how you will engage the targeted population. (Answer should be no more than one-half of page)

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D3. Projected Target Population for Service

Number of families to be served: Number of children expected to be impacted:

D4. Budget: Provide budget information for the proposed program only. (Do not include amounts for the entire agency budget). Please indicate if this program is a pilot project. Please also tell us how you are planning on sustaining this program beyond this one-time investment.

Pilot project ______Yes ______No

Item / Unit cost for this item / Funding Request
Personnel: general identification of activities / hrs of staff spent on this effort / $ / $
Supplies and materials: / # of items… / $ / $
Direct Assistance to Individuals / $ / $
Other Costs, specify
Other cost center, specify / $ / $
TOTAL / $ / $

What are your plans for sustaining this program?

E. PROJECT OUTCOME OBJECTIVES:

What is the intended impact for the participants and/or the community? How will these outcomes be measured? Which of the key strategies will be impacted by services?

F.  ORGANIZATION SIGNATURE (Proposal cannot be accepted without a signature):

Executive Director: ______

Date: ______

Collaborative Partner(s) Signature

Executive Director: ______

Date: ______

Executive Director: ______

Date: ______

Executive Director: ______

Date: ______

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