The Community Investment Grant Fund
UNITED WAY FOX CITIES
Mission: United Way Fox Cities improves lives by bringing diverse people together to build a stronger, more caring community for everyone.
GENERAL GRANT APPLICATION
Monday, April 24, 2017
Monday, October 2, 2017
United Way Fox Cities’ service area includes
Outagamie,northern Winnebago and northern Calumet counties.
GENERAL GRANT APPLICATION COVER SHEETApplicant Organization: / Application Date:
Applicant Address: / City: / Zip:
Phone: / Web Site Address:
Chairperson of Governing Body:
Name and Title of Contact Person:
Contact Person’s E-mail Address: / Phone:
Federal Employer Identification Number (EIN)
Organizations Collaborating on Project:
Duration of Project: From / To / When are funds needed?
Amount Requested: / Total Project Budget:
APPLICANT INFORMATIONDate Established: / Number of Employees: Full Time / Part Time
Total Operating Expenses for Past Fiscal Year: / For Current Year:
Percent of the Past Fiscal Year’s Actual Expenses that were Fundraising Expenses:
(Refer to your organization’s most recent 990 Form to calculate the fundraising percentage.)
Does the organization or parent organization have an endowment fund?
Yes / Current value is: / No
Does your governing board agree to provide this program / project regardless of ability to pay, race, religion, color, gender, nationality, sexual orientation, disability, age, or any other characteristic protected by law?
Yes / No
Does the organization have IRS FEDERAL tax exempt status? / Yes / No
If no, please explain.
Has this request been authorized by the organization’s governing body? / Yes / No
The application must be signed by the chief professional officer or another officer of the organization’s governing body.
Signature / Title / Date
UNITED WAY FOX CITIES
Please enter responses on this form. Please limit the narrative to three pages only.
- Please provide a brief description of the agency.
- Please identify the reason for the funding request (check the appropriate box).
Unexpected program need / Capacity building / Other short-term need
- Please provide a response to each of the following items:
- Describe the community need / problem addressed by the program for which you are requesting funding.
- Describe the United Way Fox Cities’ priority or ranked issue being addressed by the program. If the priority or ranked issue has a goal, please explain how the program will assist in achieving that goal. If the goal has strategies, actions and indicators, please explain how the program will address the strategies and actions and measure the indicators.
- Describe the program’s evidence-based approach to addressing the community need / problem.
- Describe the population served and trend in client numbers in the United Way Fox Cities service area of Outagamie, northern Winnebago and northern Calumet counties.
- List the intended outcomes for clients, if not part of a specific goal. (Who will be better off and how?)
- Describe current challenges to delivery of services.
- Describe how General Grant dollars will be used and the rationale for the amount requested.
- What is the amount of the funding request?
- Please list other proposed/secured funding.
REVENUE / PROPOSED/
PENDING / APPROVED/
2. Foundations (list)
3. Other United Ways (list)
4. Fees for Service from Government
5. Government Grants
6. Membership Dues
7. Program and Client Service Fees
8. Other (list)
9. In-Kind Contributions
10. United Way General Grant
1. Salaries (Direct Program Staff)
2. Salaries (Administration)
3. Payroll Taxes and Benefits
4. Professional Fees (Accounting, Legal, etc.)
5. Supplies, Telephone, Postage and Shipping
6. Advertising, Marketing, Outreach, Printing
8. Professional Development and Training
10. Major Property and Equipment Acquisition
11. In-Kind Expenses (Must equal In-Kind Contributions in Revenue above)
12. Other (please list)
Total Revenue and Total Expenses should be equal amounts.