ONE TIME GRANT APPLICATION

Check area of application (choose only one):

Due March 28, 2014 – Open to all

$17,500 grant request – Dental and vision

$17,500 grant request – GED education scholarships

Due April 25, 2014

$25,440 grant request – Youth services East St. Louis only

$1,000 Basic Needs grant request – Clinton County only

$1,000 Basic Needs grant request – Monroe County only

$1,000 Basic Needs grant request – Randolph County only

$ 2,500 grant request – Employment Support

St. Charles, Warren and Lincoln County only

Due May 23, 2014 - Open to All

$20,000 grant request – Stability funding gap

$20,000 grant request – Second generation multi-generational solutions

$20,000 grant request – Urban male employment and/or entrepreneur opportunities

$1,000 Basic Needs grant request St. Clair County

Agency is incorporated as a 501(c)3 organization: Yes No

Agency is a United Way member agency: Yes No

EIN Number:

Organization Name:

Organization Address & Zip Code:

Organization Telephone Number:

Program Name:

Executive Director: Email:

Primary Program Contact Email :

Area served by program (check all that apply):

Missouri: Illinois:

Jefferson County Calhoun County Monroe County

Lincoln County Clinton County Randolph County

St. Charles County Greene County St. Clair County

St. Louis City Jersey County

St. Louis County Macoupin County

Warren County Madison County

Total Program Budget: Total Agency Budget:

# of participants currently served by program: Expected increase if grant is awarded:

I hereby authorize the submission of this application to the United Way of Greater St. Louis:

______

Executive Director/ President, C.E.O (Typed Name)

By clicking here you acknowledge and agree to the following:

1.)  To use the grant within one calendar year for its intended purpose as outlined in the original one time grant application.

2.)  Failure to expend the funds in the agreed upon manner will result in forfeiture and immediate repayment of awarded grant. The application must be received by by 5:00 p.m. on the deadline. Late applications will not be considered.

3.)  DO NOT MAIL APPLICATION. Only applications submitted by email will be permitted

*Note only use the space provided for your responses to the questions. You will not be allowed to include additional information or materials.

AGENCY DESCRIPTION

Briefly describe the agency’s mission, goals, current programs and experience in providing services similar to those proposed.

COMMUNITY PROBLEM

Describe the circumstances or conditions in the community that the program seeks to change.

# OF DIRECT CLIENTS SERVED

Direct clients generally receive extensive and/or long term services in small groups or one-on-one. In take records could be used to determine the number of direct clients being served.

PROGRAM SUMMARY

Describe the program including: goals, target population, activities, projected outcomes, and evaluation methods.

1.  When does the program operate?

2.  Describe in detail services provided

3.  Current number of clients served

4.  Proposed number of clients served if funding awarded

5.  How will you ensure program will reach target population?

6.  If awarded what, what outcomes will program try to achieve in 2014?

7.  What indicators will be used to determine if the program achieves the outcomes?

8.  What program data will be collected?

FUNDING REQUEST

If awarded, how will the dollars be spent? Be very specific. If the program will expand, then describe in detail the expansion plans.

AGENCY:

2013 Agency Budget / 2014 Program Budget
Contributions
Special Events
Corporate/Foundation Grants
Government Grants/Fees
Program Service Fees
Investment Income
Miscellaneous/Other
TOTAL UNRESTRICTED REVENUE
Salaries, Benefits, Taxes, Contract Staff
Operating Expenses
Assistance to Individuals
Dues to National Organization
Occupancy Related Expenses
Depreciation
TOTAL EXPENSES
Increase (Decrease) in Unrestricted Net Assets

ANTI-TERRORISM COMPLIANCE MEASURES

In compliance with the USA PATRIOT ACT and other counterterrorism laws, the United Way of Greater St. Louis requires that each agency certify the following:

“I hereby certify on behalf of (Name of grantee here)

That all United Way funds and donations will be used in compliance with all applicable anti-terrorist financing and asset control laws, statues and executive orders.”

Print Name Title

Please type either "YES" or "NO" in space below. By typing "YES", the Executive Director attests to the member agency's compliance with the United Way counterterrorism mandate above.

¨Yes ¨ No

Date

NOTE: Anti-terrorism form should be completed by non-United Way member agencies only.