United Way of North Central Iowa Application for Venture Grant Funding

Instructions
To fill out: Download application and open in Word.
Submit four (4) hard copies and one e-copy, to United Way of North Central Iowa. Applications should be sent to 2911 4th Street SE, P.O. Box 1465, Mason City, IA 50402. For any questions or to request additional information, please contact Jen Butler, Community Impact Director, by phone at (641) 423-1774 EXT. 11, or by e-mail at .
General Information
Full Legal Agency Name / Enter Agency Name /
Mailing Address / Click here to enter street address /
City / Enter City / State / Choose an item. /
Zip Code / Enter Zip Code /
Agency Website / Click here to enter text /
Agency Executive Director / Click here to enter text /
Title / Click here to enter title /
Phone Number / Enter phone number / E-Mail Address / Enter email /
Contact Person (if different) / Enter Contact Person here /
Title / Enter title /
Phone Number / Enter phone number / E-mail Address / Enter email /

Request Narrative: This section of the application requires a description of the grant you are seeking matching funds for. Please be specific and concise.
Grant Name: / Click here to enter grant name /
Match Funding Requested: / Click here to enter amount requested /
Purpose of the Grant for which you are asking Match for:
Briefly describe the purpose or the overall goal for the grant funding request. Please describe, in detail, how grant funding will be used, who will be served and activities in which program participants are engaged.
Click here to describe purpose
Program Need:
Please describe the unique local needs/problems/gaps addressed by this grant funding request.
Click here to describe program need
Service Location: Please identify which United Way of North Central Iowa counties and associated zip codes will be served by the grant request you are requesting match for. (Check all that apply)
Counties: / ☐ / Cerro Gordo / ☐ / Floyd / ☐ / Franklin / ☐ / Hancock
☐ / Kossuth / ☐ / Mitchell / ☐ / Winnebago / ☐ / Worth
Associated United Way Zip Codes: / ☐ / 50514-Armstrong / ☐ / 50604-Ackley / ☐ / 56027-Elmore
☐ / 50661-Plainfield / ☐ / 50578-Ringstad / ☐ / 50628-Elma
☐ / 56033-Frost / ☐ / 50666-Riceville

United Way of North Central Iowa Application for Venture Grant Funding

Impact Area: This section is designed to help you identify which of the following United Way Impact Area best describes what the grant request will impact. Select: Education, Income Stability, or Health
☐Education: Helping community members connect with the tools they need to reach their potential / ☐Income Stability: Provide connections to aid in financial stability & independence / ☐Health: Increase access to ensure health & well-being
Grant Funding Impact: Please describe how receiving the grant you are applying for will impact the area identified above.
Click here to enter Grant Funding Impact.
/
Program Funding

Please provide a budget summary supporting the program costs requested.

Click here to enter budget narrative, an excel sheet may be copied below

Please describe the long-term strategy and plan for sustainability of the program. Please include the program’s long-term funding plan.

Click here to describe long-term strategy and plan for sustainability of the program

United Way of North Central Iowa Application for Venture Grant Funding

Additional Information

Please include any other information you would like to include about the project/grant funding.

Click here to enter additional information

United Way of North Central Iowa Application for Venture Grant Funding

The undersigned hereby certify:

The information contained in this application, and various attachments, is accurate and correct to the best of my knowledge.

I further certify that our Board of Directors endorses this funding application and agrees to the requirements set forth in the Grant Application Requirements.

Executive Director (Please Print)
Board Chair (please print)
Signature
Signature
Date
Date
Email Address
Email Address