Jenningscounty United Way 2015 Grant Application

JenningsCounty United Way 2015 Grant Application

Agency:

Address

Contact Person Telephone

Email Address Federal Tax ID #

By signing below we affirm each of the following:

Total amount of funding requested for our program(s), itemized within,is $______
(The combined total of the program funding sheet(s) included withinfor multiple programs)

The budget within was considered and approved by a quorum of our Board of Directors who were present at a board meeting on (meeting date)

We understand that funds must be used for the purpose granted or returned to United Way.

We will be prepared to submit program and financial reports as requested and/or a final evaluation.

We certify that we have conflict of interest, affirmative action and non discrimination policy’s in place, maintain sufficient insurance and additional provisions where appropriate to protect board of directors, employees, facilities, and agency funds.

We understand this application becomes part of our “Artciles of Agreement” if awarded funding.

We have reviewed this grant application on the date below and certify it is complete and accurate.

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Executive Director's Signature (staff)DateTreasurer's Signature (volunteer)Date

Board President's Signature (volunteer) Date Grant Writer Date

Instructions for submitting a complete application:

• The Agency’s Board of Directors must approve budget and application must be signed prior to submission.
• The original grant application with attachments as outlined below must be submitted to Jennings County United Way no later than 4:00pm May 28, 2015. Please retain a copy for your own records.
• Failure to complete any portion or include any of these items will negate your application for funding. Resubmissions will not be considered afterthe due date above.Late applications will not be accepted.

Submit the original, signed application and these attachments; andemail a scanned copy as “.pdf” file(s):

1. Current Board of Directors list with addresses and phone numbers and a schedule of board of directors meetings (include dates, location and time).
2. Most current filed IRS Form 990 or a board approvedletter of explanation stating why a 990 was not filed.
3. A copy of the most recent finanacial audit or alternately an agency with a total budget of less than $50,000 may provide a report of financial status prepared by an outside accountant. A request for a waiver must be submitted in writing stating the reasons for the request, prior to the due date above.

OR: Submit the original as stated above; AND 10 complete paper copiesmade back to back& stapled

Email a complete copyof the signed original as “.pdf file(s)” to:
Mailthe original & attachments to:JenningsCounty United Way, PO Box 446, North Vernon, IN47265
You may also hand deliver to 707 North State Street, North Vernon. A copier will not be available.

For questions or prior to submission: Contact United Way at 812-346-5257or

Agency Program Information

1. Agency's mission as defined in by-laws or other legal documents:

1. List program(s) and service(s) your agency provides:

1. Target population (age, sex, special interests, disability, etc.) :

1. Number of unduplicated units of service (# of individuals) provided in Jennings County:

2011/3 years ago(actual)Individual= one person counted once in a year.

2012/2 yrs ago(actual)Define “unduplicated units of service” below:
2013/Previous Yr.(actual)

2014/Current year(projected)

1. Percentage of administrative and fund-raising expenses for the past year is:

This % must be computed from most recent IRS form 990 -Part 9 lines 25C and 25D divided by “total revenue” (line 12).

1. What specific program(s) or service are you requesting this United Way grant for?

1. Which United Way Impact Areas or goals does this program address?

1. How does this program address Financial Stability issues or increase self sufficiency?

1. What are the specific outcomes or results of this program? (How are lives improved?)

1. How do you measure these results? Please attach survey results and any outcomes measurement tools and findings you have.

1. How are your programs assessed for effectiveness, for meeting your goals or objectives?

1. Please list board development or training your agency has participated in during the year.

1. How does your agency participate during the annual United Way campaign?

1. Which Jennings County United Way Programs does your agency participate in and how?

1. List other United Way events your Board Members or Agency participated in the past year.

1. Beneficiaries - Please list the top 3 companies the majority of your clients (or their parents) work for:

1. What else would you like us to know?(Any special needs or circumstances your agency might have etc.)

Agency Financial History & Budget

These financials are to include complete agency financials and should reconcile with IRS form990.

An Agency serving a wider regionmust also include an additional copy of this sheet reflecting ONLY Jennings County’s numbers.

• Each column must reflect a complete year (12 months).
• Breakdown all Misc. Expenses or In-Kind amounts in detail on pg 6 if necessary
• You may modify line names and include an explanation detailing what is included in lines if you’d like to clairify
• If there are more than 2 programs, you may use additional pages for Program #3 etc

Assets & Liabilities Worksheet

This information should correlate with IRS Form 990.
* Note- Agencies who’s 990 reflects more than Jennings County must complete both columns.

Year ending(date)

Balance Sheet(year)Form 990

Explanations of line items, miscellaneous expenses or “In-Kind” amounts Explain any miscellaneous expenses or in-kind amounts included in the figures throughout this grant application below.Please note the page number and line being referenced.If desired, you may also explain what’s contained in line items here.

Program funding request

Demonstrate what you’re asking for and what you intend to do with it.

This page sumarizesnext year’s program budget(s) and correlates to the “AgencyBudget” area on the History &budget page.
Submit a copy of this page for each individual program- Program requests combined equal the total request on the front page.

AgencyCompliance Evaluation 2015-16

AGENCY: ______

COMPLETED BY:______

DATE COMPLETED: ______

STANDARD 1: ORGANIZATIONAL STRENGTH- GOVERNANCE

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