Agency Application for Mini Grant

2021 Allocation Application for 2022 funding.

Your completed application must be submitted by Tuesday, December 7th.

General instructions:

YOU MAY NOT SAVE AND SUBMIT THE APPLICATION LATER. I RECOMMEND PRINTING OUT A BLANK APPLICATION AND GATHERING ALL INFORMATION PRIOR TO COMPLETING. YOU MAY ALSO PRINT IT OUT, FILL ITEMS IN WORD DOCUMENT, REVIEW IT, THEN COPY AND PASTE INTO THE ONLINE FORM.
Many items in the application require files to be attached. This is to streamline the process for all agencies that have the information in various formats. While attaching a document, you must hit upload for the form to submit. Acceptable file types: jpg, jpeg, png, pdf, doc, xls. This form will NOT accept .docx or .xlsx files. 6MB is the file size limit.
Having issues submitting the online application? Make sure you have answered all required questions and uploaded a file for all required fields.
If you have questions about the application, please contact the United Way office, 815-625-7973

1. General Agency Information
Agency Name*
Program Name*
Phone*
Physical Address*
Mailing Address*
Website*
FEIN Number*
Chief Executive Officer: (Director) Name*
Chief Executive Officer: (Director) Title*
Chief Executive Officer: (Director) Email*
Chief Executive Officer: (Director) Phone*
Upload Board of Director Information*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Acceptable file types: jpg,jpeg,png,pdf,doc,xls
What is the mission of your organization.*
Describe the work of your organization and program.*
2. Statement of Financial Position
Upload documents for each item below using figures from most recent FY audit or your financial software program. If you don’t have one of the required documents, you may skip the step, but the form requires that you upload a document so you may upload a blank Word document.
IRS 990*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Acceptable file types: jpg,jpeg,png,pdf,doc,xls
Audit*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Including auditor’s opinion letter and management letter. If your agency budget is less than $100,000, an audit is not required. Just upload a document that explains your organization is not required to submit an audit. Acceptable file types: jpg,jpeg,png,pdf,doc,xls
Profit and Loss*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Upload your most recent fiscal year ended profit & loss report comparative to prior year from your software program (not the auditor’s report).
Balance Sheet*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Upload your most recent fiscal year ended balance sheet comparative to prior fiscal year from your software program (not the auditor’s report).
Program Budget
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Please upload the program budget for the most recent fiscal year ended, if applicable.
3. INFORMATION ABOUT THE PROGRAM
Funding requests for this program – Request this year*
Funding requests for this program – Received last year*
Please explain if there is a significant increase or decrease (+ or – 15%) between the amount allocated last year and the amount requested this year.
4. Program Background
Identify community issues that this program works to prevent, alleviate, or solve.*
Explain what gaps in service would exist if your program is not carried out in our community.*
Who will your agency collaborate with on a formal basis to avoid duplication of services, promote integration of services, decrease costs, and/or achieve desired outcomes.*
How are United Way funds used in this program? (Examples: as matching funds, to meet expenses of low-income clients, for scholarships, etc.)*
Has this program been expanded or reduced in the past year? Please describe.*
5. Individuals Served
Provide number of unduplicated persons served by this program in each geographic area in the fiscal year. (Auxiliary or supportive services, such as survey, brochure, and newsletter are not to be counted as persons served.) Numbers listed below should be UNDUPLICATED numbers. Actual statistics for the most resent fiscal year or calendar year.
Age
Infant/Toddler (0-3 Yr.)*
Pre-School (4-5 Yrs.)*
Child (6-12 Yrs.)*
Teen (13-17 Yrs.)*
Adult (18-59 Yrs.)*
Senior (60+ Yrs.)*
Unknown*
Age Total*
Gender
Female*
Male*
Transgender*
Other*
Unknown*
Gender Total*
Ethnicity
American Indian or Alaska Native.*
Asian*
Black or African American*
Hispanic or Latino*
Native Hawaiian or Other Pacific Islander*
White*
Other*
Unknown*
Ethnicity Total*
Income Level
Low Income*
Moderate Income*
High Income*
Unknown*
Numbers of people served by location
Albany*
Deer Grove*
Erie*
Fulton*
Lyndon*
Morrison*
Prophetstown*
Rock Falls*
Sterling*
Tampico*
Unknown*
Location Total*
6. Promotion
Success Story*
Provide a success story from this program that can be shared publicly. If needed, you may change names to protect the identity of children and those in sensitive situations.
Promotional Picture
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
If possible, provide a photo that can be used publicly, including social media. If the picture includes identifiable people a photo release is also required. A photo will result in additional promotion of your program and will be beneficial to both United Way and your organization.
Photo Release
Accepted file types: jpg, jpeg, png, pdf, gif, xls, Max. file size: 6 MB.
If the picture above includes identifiable people, a photo release is also required. Feel free to use your own photo release form.
7. Signature
In the event any of the information contained in this allocation request is deemed false or misleading, United Way of Whiteside County reserves the right to place restrictions on the Agency’s use of United Way money or to reduce or terminate funding.
Name of Person Preparing Form
Name of Person Reviewing Form, If Different
Date
Anti-Terrorism Compliance Measures
I hereby certify on behalf of my organization that all United Way funds and donations will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes and executive orders.
In compliance with the USA PATRIOT Act and other counter terrorism laws, the United Way of Whiteside County requires that each agency certify anti-terrorism compliance measures.

1. General Agency Information

2. Statement of Financial Position

3. INFORMATION ABOUT THE PROGRAM

4. Program Background

5. Individuals Served

Age

Gender

Ethnicity

Income Level

Numbers of people served by location

6. Promotion

7. Signature