Agency Application For 1 Program

1. General Agency Information
Agency 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 Inlcuding Names and Office Held*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
Acceptable file types: jpg,jpeg,png,pdf,doc,xls
Does your agency have a foundation?*
- Yes
- No
Are you in compliance with past and current government tax regulations? If no, explain.
Are you in compliance with all applicable facility and licensure regulations? If no, explain.*
What is the mission of your organization.*
Describe the work of your organization.*
2. Public or Private Grants
Does your agency apply for any matching state, federal or private grants?*
- Yes
- No
Are United Way dollars used to match grants?*
- Yes
- No
Does your agency have any outstanding grant proposals for the program(s) for which you are requesting funding?*
- Yes
- No
If so, please summarize briefly.
3. Capital Fundraiser
Capital Fundraisers are one-time campaigns set within a definite time frame for a special or specific major project (building, endowment, and/or major equipment usually over $25,000).
Did you conduct a Capital Drive in 2020?*
- Yes
- No
Amount Raised $
Further Amount Pledged $
NOTE: AGENCIES INTENDING TO CONDUCT CAPITAL CAMPAIGNS ARE OBLIGATED TO COMPLY WITH UNITED WAY’S POLICY ON FUNDRAISING ACTIVITIES.
4. 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.
Acceptable file types: jpg,jpeg,png,pdf,doc,xls
Audit*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
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.
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.
Upload your most recent fiscal year ended balance sheet comparative to prior fiscal year from your software program (not the auditor's report).
Agency Budget*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
Upload your most recent agency budget.
Grants, Donations And Sponsorships*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
Please provide a list of grants, donations and/or sponsorships over $1,000 received or to be received for the fiscal year that includes December 2020.
Donor Restricted Funds*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
Please provide a list of donor restricted funds including the amount, reason for restriction, and if any investment earnings are available for unrestricted expenses.
Endowment Fund*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
If your agency has an endowment fund please includ the amount, reason for the fund, and if any investment earnings are available for unrestricted expenses.
Fundraisers - Planned Within The Next Year*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
Please attach the same list for any fundraisers planned within the next year.
Fundraisers - Past 12 Months*
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
Please attach a list of all fundraisers (including direct solicitations) your organization had in the past 12 months. List dates of each, location and net profit.
INFORMATION ABOUT PROGRAM 1
Please prepare one Program Information Section for each United Way of Whiteside County funded program.
Program Name*
1. Funding Requests For This 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.
2. Program Background
A. Identify community issues that this program works to prevent, alleviate, or solve.*
B. Explain how the program you are requesting funding for fits into the missions of both your organization and United Way.*
C. Elaborate on which programs in our community offer similar services. To the best of your ability, compare and contrast these programs with yours, considering clients reached, geography, etc.*
D. Explain what gaps in service would exist if your program is not carried out in our community.*
3. Coordination and Collaboration
Who will your agency collaborate with (specifically on this program) on a formal basis to avoid duplication of services, promote integration of services, decrease costs, and/or achieve desired outcomes. Please discuss in detail providing specific examples.*
Do recipients pay a fee or membership dues for services provided?*
- Yes
- No
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. If there is a waiting list, what measures are being taken to eliminate a waiting list?*
Do you anticipate changes for this program in the coming year?*
- Yes
- No
4. Program Sustainability
A. Discuss how United Way funding can assist your agency in leveraging matching funds and/or other resources for this program.*
B. Discuss modifications that can be made to the program if United Way is unable to fund your proposal at the requested level.*
C. Discuss your organization’s ability to sustain this program long-term in the event United Way funding is decreased or eliminated in the future.*
D. Explain measures your organization is taking to move your clients toward self-sufficiency and decrease the overall need for these services in the community.*
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.
Age
Actual statistics for your funding (calendar) year 2020
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
To which gender identity did your client most identify? Actual statistics for your funding (calendar) year 2020.
Female*
Male*
Transgender*
Other*
Unknown*
Gender Total*
Ethnicity
Actual statistics for your funding (calendar) year 2020.
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
If available as defined by your agency. Actual statistics for your funding (calendar) year 2020.
Low Income*
Low Income Guidelines*
How does your agency define low income?
Moderate Income*
Moderate Income Guidelines*
How does your agency define moderate income?
High Income*
High Income Guidelines*
How does your agency define high income?
Numbers of people served by location
Actual statistics for your funding (calendar) year 2020.
Albany*
Deer Grove*
Erie*
Fulton*
Lyndon*
Morrison*
Prophetstown*
Rock Falls*
Sterling*
Tampico*
Location Total*
6. Outcome Measurements- Must use template
Use the form provided within the instructions for this application.
Outcome Measurement for Program 1
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
7. United Way Community Pillars
Please indicate where your United Way allocation dollars will be spent. The dollar amount in all the categories should equal the amount of total dollars requested. The undefined category is for those programs that do not serve persons in the other categories.
Which United Way Pillar will your program serve?*
- Education
- Financial Stability
- Health
- Crisis or Emergancy Services
- Undefined
How much will be spent on Education?*
Based on your request for program funding, how much will be spent on this United Way focus area?
How much will be spent on Financial Stability?*
Based on your request for program funding, how much will be spent on this United Way focus area?
How much will be spent on Health?*
Based on your request for program funding, how much will be spent on this United Way focus area?
How much will be spent on Crisis or Emergency Services?*
Based on your request for program funding, how much will be spent on this United Way focus area?
How much will be spent in Undefined service areas?*
Based on your request for program funding, how much will be spent on this United Way focus area?
8. Program Financials
Program Budget, if different than Agency Budget
Accepted file types: jpg, jpeg, png, pdf, doc, xls.
Please upload the program budget for the most recent fiscal year ended, if applicable.
COVID-19*
How has COVID -19 affected your organization? How do you think it will affect your organization in 2021?
9. 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.
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.
If the picture above includes identifiable people, a photo release is also required. Feel free to use your own photo release form.
Help us monetize the value of donor support.*
Use specific examples for each of the dollar amounts below explaining how a donation of that amount will impact the community. Example: Your gift of $5 per week helps children recover from the effects of child abuse with four counseling sessions. Fill in the dollar amounts below with specific examples of how a donation of that amount will impact the community. $1 per week ($52) $5 per week ($260) $10 per week ($520) $25 per week ($1300)
10. 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.
Exective Director/ CEO Signature*

1. General Agency Information

2. Public or Private Grants

3. Capital Fundraiser

4. Statement of Financial Position

INFORMATION ABOUT PROGRAM 1

1. Funding Requests For This Program

2. Program Background

3. Coordination and Collaboration

4. Program Sustainability

5. Individuals Served

Age

Gender

Ethnicity

Income Level

Numbers of people served by location

6. Outcome Measurements- Must use template

7. United Way Community Pillars

8. Program Financials

9. Promotion

10. Signature