GUILFORD HUMAN SERVICES COUNCIL

Application for Town Funds

FY 2018-2019

DUE SEPTEMBER 21, 2017

SELECTMEN’S OFFICE, ATTN: HUMAN SERVICES

31 PARK ST. GUILFORD, CT 06437

We plan to meetOctober17th and 24thwith human service providers who have submitted applications. You will get a call/email from us to set up an appointment after we have received your application.

Please plan to discuss changes you will make or have made due to the Connecticut budget cuts.

We are asking for information from agencies that provide a wide variety of services, and not all questions are necessarily applicable to your agency.Please convey to us the nature of the services you provide to the town and its residents and the needs you hope to meet with town funds. Please feel free to use additional pages to add any information you feel is helpful.

PLEASE PROVIDEten printed copies of the completed application

PLEASE PROVIDE one copy of the following, either printed & mailed or emailed to

Most Recent Financial Statement

Form 990 - Must Be 501(c)(3)

List of Board of Directors

Date:

Agency:

Telephone:Website address:

Contact Person:Position:

Email address: Mailing address:

The information furnished in this application is true and accurate to the best of my knowledge

Name:

Signature:______

Title:

FUNDS REQUESTED FOR FY 2018-2019 $

1. TYPE OF AGENCY:

2. GEOGRAPHIC AREA SERVED:

3. PURPOSE AND MISSION OF AGENCY:

4. STAFF:

FULL TIME:

PART TIME:

CONTRACTED:

5. STATISTICS:

OVERALL NUMBERS SERVED BY YOUR AGENCY

  1. OVERALL UNDUPLICATED COUNT(Individual people served—Not number of sessions):

NUMBER OF PERSONS SERVED:

NUMBER OF GUILFORD RESIDENTS:

  1. HOW MANY OF THE ABOVE GUILFORD CLIENTS ARE YOUR SERVICES UNCOMPENSATED OR PARTIALLY COMPENSATED?
  1. CAN YOU RELATE YOUR DOLLAR REQUEST TO A SPECIFIC SHORTFALL EXPERIENCED BY YOU AS A RESULT OF UN- OR UNDERCOMPENSATED SERVICES PROVIDED BY YOU? OR CAN YOU OTHERWISE CHARACTERIZE YOUR NEED FOR THESE DOLLARS IN TERMS OF SERVICES PROVIDED TO THE TOWN OF GUILFORD?
  1. DESCRIBE OR ATTACH YOUR FEE SCHEDULE:

6.WHAT WILL BE THE IMPACT OF FUNDING FROM THE TOWN OF GUILFORD BE ON YOUR GUILFORD CLIENTS?

  1. DOES YOUR AGENCY MAKE PAYMENTS TO OTHER AGENCIES OR SERVICES, INCLUDING PARENT ORGANIZATIONS? IF SO, PLEASE EXPLAIN.
  1. DO YOU ANTICIPATE ANY CHANGES IN THE NEXT YEAR WHICH MIGHT HAVE IMPACT ON SERVICES PROVIDED TO THE TOWN OF GUILFORD, OR YOUR NUMBERS SERVED?

9. PURPOSE OF THIS REQUEST

DESCRIPTION OF PROGRAM(S):

PROGRAM NEED:

PROGRAM OBJECTIVES AND GOALS:

HOW IS PROGRAMEVALUATED?

NUMBER OF PERSONS SERVED:

NUMBER OF GUILFORD RESIDENTS:

TIME BETWEEN REQUEST FOR SERVICE AND RECEIVING IT:

IS THERE A WAITING LIST?

IF YES, HOW MANY PERSONS? AVERAGE WAIT?

INCREASED STAFFING NEEDS FOR THIS SERVICE, IF APPLICABLE?

OUTREACH/PUBLIC RELATIONS FOR THIS PROGRAM?

ALTERNATE FUNDING SOURCES:

You may add any additional information that you think helpful in describing the benefits provided by your agency to the Town of Guilford.

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