Attachment A



UNITED WAY OF FAYETTE COUNTY, INC.

2020 Agency Funding Application

|Agency | |       |

|Street Address | |       |

|Mailing Address | |       |

|City/State/Zip | |       |

|Telephone | |     -     -      ext.       |

|Alternate Telephone | |     -     -      ext.       |

|FAX | |     -     -      |

|e-mail address | |      |

|Federal Tax ID # | |      |

| | | |

| | |      |

|Executive Director | | |

| | | |

| | | |

| | | |

| | | |

|Board President | |Name:       |

| | |Phone:       |

| | |Email:       |

| | | |

| | | |

Please provide a 25-word (maximum) descriptive statement about the program for which you are requesting funding, to be used for promotional purposes, should you receive United Way funding.

1. What is your program’s mission?

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2. Description of current program for which you are requesting funding.

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3. What amount of funding are you requesting from United Way?

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4. Cite specific data to prove this program is needed in Fayette County.

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Program Questions

Answer all questions and provide a written explanation for any “no” answers.

YES NO

|Do you have an active, governing Board of Directors with no material | | |

|conflict of interest and a majority of whom serve without | | |

|compensation? | | |

|*Agency must submit as Attachment E, most recent list of directors. | | |

|Do you have stated policies of non-discrimination and comply with | | |

|all the requirements of state and federal laws and regulation on non- | | |

|discrimination and equal opportunity with respect to clients, offices, | | |

|employees and volunteers? | | |

|Do you make available to the general public an annual external audit by an independent public accountant, or in the case of | | |

|organizations with annual budgets less than $100,000, make available a copy of IRS Form 990? | | |

| | | |

|*Agency must submit as Attachment F, most recently completed IRS Form 990. Organizations that file IRS Form 990 EZ must submit the | | |

|990 EZ along with completed pages 1, 9 and 10 of the IRS form 990 (long form) with the following written at the top of each page | | |

|“This form was completely solely for the purpose of submitting an application to the Ohio Combined Charitable Campaign.” | | |

|Is your agency current in its requirements to register, pay and file the annual financial report with the Ohio Attorney General? | | |

|*Agency must submit as Attachment K, Verification of Registration. | | |

|Is the agency recognized as tax exempt under 26 U.S.C. 501c(3) and eligible to receive tax deductible contributions? | | |

|*Agency must submit as Attachment H a copy of its 501c(3) verification letter. | | |

10. Does your agency have administrative costs of less than 25%?

Calculate your program’s administrative costs as a percentage of total expenses using the following

formula and figures from your most recently completed IRS Form 990. Please include your most

recently completed IRS Form 990 in the Office Copy.

| Line 25C (pg 10): Management & General |      |

|Line 25D (pg 10): Fundraising + |      |

|Total of Lines 25C +25D = |      |

|Enter Line 12A (pg 9): Total Revenue |      |

     %

11. Provide an explanation if administrative costs exceed 25% of total expenses and the agency’s plan to reduce administrative costs.

|      |

12. List the target population served by the program. (age, gender, special interest, etc) Include any requirements for assistance (income, etc).

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13. Describe specifically how United Way dollars will be utilized for this program.

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14. Do you charge a fee for your services? If yes, explain:

15. How do you communicate your services to the public?

16. How do you communicate United Way support of your program?

17. Number of Individuals Served in Fayette County ONLY:

|Total # unduplicated individuals: |Served by your program in |

| |Fayette County ONLY. |

| | |

|2 Years ago |      |

|Last Year |      |

|Projection Next year |      |

Average number of times an individual is served:      

18. Volunteers and Employees – For this program in Fayette County Only.

| | | Staff: |

| |Volunteers: | |

| | | |

|2 Years ago |       |       |

| | | |

|Last Year |      |      |

| | | |

19. Are there any other agencies or organizations that provide the same services

for which you are seeking United Way funding. Please list and explain.

20. Did your agency conduct an employee/agency United Way campaign last year? Explain.

|      |

21. What is the intent of this program? This should be an outcome statement describing benefits a participant receives as a result of the program or changes in participant behavior(s) that can be expected as a result of the program. Example: To improve school attendance among 12-18 year olds. Low income families will be better able to manage their resources. To educate adults about the dangers of smoking. It can be anything from learning about something, to changing behavior over the medium term or even long term.

22. What measurement will be used to document and verify success of your program?

     

23. What were the results/outcomes last year for your program? Be SPECIFIC….ie number of meals served, shelter nights provided, % of clients reaching a goal, etc.

24. What percent of your agency’s total projected revenue will be from these United Way dollars?

|     % |

25. Explain how your request was calculated. Please provide an explanation of any unusual changes in revenues and expenses. Include any external issues or trends that may affect the program.

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26. What are your alternative sources of funding if United Way is unable to fund your request?

Certification

___________________________________________________

The undersigned officer certifies that the Board of Directors of the above organization has approved this application, and that the information is correct to the best of their knowledge, and is aware that attendance at the interview is mandatory to be considered for funding.

________________________________ ______________

Signature Date

___________________________

Title

Applications are due by 4:00pm on Friday, May 17, 2019

Applications may be mailed or hand delivered to:

United Way of Fayette County

133 S. Main St

Suite 20

Washington Court House OH 43160

*Please email a copy of the completed application to: uwfayette@

Agency Brochures – ATTACHMENT A

Please include copies of brochures that relate to the program for which you are requesting funding.

BUDGET INFORMATION

Previous Allocations Expenditures - ATTACHMENT B.

If your organization received United Way funding from April 2014 – January 2015, please provide a detailed breakdown of how you spent your allocation. You may insert your own page(s) listing the expenses and amounts paid – the total must equal the full allocation that you received in 2014/2015.

Please include:

Date

Amount

Description of Expense

If your organization did not receive funding in 2014, but has previously, include expenditures from most recent year United Way funding was received. You do not need to include client names, but can indicate gender and age (i.e. – Male, 64 years old).

Agency Budget – ATTACHMENT C

|SUPPORT REVENUE & EXPENSES *Round to the |LAST YEAR Fiscal |CURRENT Fiscal |NEXT FISCAL YR Proposed |

|nearest dollar |Actual |Budgeted | |

|Please write in your fiscal year dates (from/to) |  |  |  |

|Public Support & Revenue - All sources: |  |  |  |

|1. Allocation from THIS United Way |  |  |  |

|2. Contributions |  |  |  |

|3. Special Events |  |  |  |

|4. Legacies & Bequests (Unrestricted) |  |  |  |

|5. Monies from other local charitable trusts/groups |  |  |  |

|6. Allocated by Other United Ways |  |  |  |

|7. Fees & Grants from Government Agencies |  |  |  |

|8. Membership Dues |  |  |  |

|9. Program Services Fees & Net Income Revenue |  |  |  |

|10. Sales of Materials |  |  |  |

|11. Investment Income |  |  |  |

|12. Misc. Revenue (Attach Schedule) |  |  |  |

|13. Total Support & Revenue (Add 1 through 12) |0 |0 |0 |

|Expenses: |  |  |  |

|14. Salaries (Attach Schedule) |  |  |  |

|15. Employee Benefits | |  |  |

|16. Payroll Taxes, etc. |  |  |  |

|17. Professional Fees |  |  |  |

|18. Program Services |  |  |  |

|19. Supplies |  |  |  |

|20. Telephone |  |  |  |

|21. Postage & Shipping |  |  |  |

|22. Occupancy |  |  |  |

|23. Rental Maintenance of Equipment |  |  |  |

|24. Printing & Publication |  |  |  |

|25. Travel |  |  |  |

|26. Conferences/Meetings |  |  |  |

|27. Special Assistance to Individuals |  |  |  |

|28. Membership Dues |  |  |  |

|29. Awards & Grants |  |  |  |

|30. Miscellaneous (Attach Schedule) |  |  |  |

|31. Total Expenses (Add lines 14 through 30) |0 |0 |0 |

|32. Payments to Affiliated Organizations |  |  |  |

|33. Board Designations for Specified Activities |  |  |  |

|34. Total Expenses for Budget Period for All Activities (Add lines 31 + 32 + |0 |0 |0 |

|33) | | | |

|35. Excess (Deficit) of Total Support & Revenue Over Expenses (line 13 - 34) |0 |0 |0 |

|35. Depreciation of Buildings & Equipment |  |  |  |

|36. Major Property & Equipment Acquisition ($1,000+) |  |  |  |

Program Testimonial & Photo – ATTACHMENT D

Narrative: Interview at least one person who has benefited from your program in the past year. In approximately 300 words, write a story based on your interview (including quotes, if possible) and provide a photo. This story should be a real-life testimonial as to how your program has helped change or improve their life. The client is also welcome to right their own accounts in first –person of their story and how they’ve been helped. If the person wishes to remain anonymous, please state this. A photo must accompany the testimonial and be in jpeg format, emailed to uwfayette@. The client providing the testimonial must sign the Release Form.

Agency:

Program:

Name of client being interviewed: Age of client:

Hometown of client:

|      |

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Divide the total of Lines 25C + 25D by Line 12A. The result is the percentage overhead. Place that number in the box below.

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