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2023 Agency Application for 2 Programs

1. General Agency Information
Agency Name*
Phone*
Physical Address*
Mailing Address*
Website*
FEIN Number*
Chief Executive Officer: (Director) Name*
Chief Executive Officer: (Director) Phone*
Upload Board of Director Information Inlcuding Names and Office Held*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Acceptable file types: jpg,jpeg,png,pdf,doc,xls
Are you in compliance with past/current government tax regulations and all applicable facility and licensure regulations? If no, explain.
What is the mission of your organization.*
Describe the work of your organization.*
2. Public/Private Grants and Capital Fundraisers
Are United Way dollars used to match grants?*
- Yes
- No
Did you conduct a Capital Drive in 2022 or do you plan to launch a campaign in 2023?*
- Yes
- No
Amount Pledged/Raised for Capital Campaign
3. 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).
Agency Budget*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Upload your most recent agency budget.
Grants, Donations And Sponsorships*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
Please provide a list of grants, donations and/or sponsorships over $5,000 received or to be received for the most recent FY .
Donor Restricted Funds*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
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, Max. file size: 6 MB.
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 – Past 12 Months AND Planned Within The Next Year*
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
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. For future fundraisers, list planned dates and projected profit.
4. Program 1's Information
Please prepare one Program Information Section for each United Way of Whiteside County funded program.
Program 1's Name*
Funding requests for this program – Request this year*
Funding received in the last United Way funding cycle for this program*
Please explain if there is a significant increase or decrease (+ or – 15%) between the last amount allocated and the amount requested this year.
5. Program Background
Identify community issues that this program works to prevent, alleviate, or solve.*
Coordination and Collaboration: Explain which programs in our community offer similar services and what your organization does to avoid duplication of services. Who does your agency collaborate with to promote integration of services, decrease costs, and/or achieve desired outcomes. Please discuss in detail providing specific examples.*
Explain what gaps in service would exist if your program is not carried out in our community.*
Do recipients pay a fee, reimbursement 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?*
6. Program Sustainability
Discuss modifications that can be made to the program if United Way is unable to fund your proposal at the requested level.*
Discuss your organization’s ability to sustain this program long-term in the event United Way funding is decreased or eliminated in the future.*
7. 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 most recent completed fiscal year or calendar year.
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 most recent completed fiscal year or calendar year.
Female*
Male*
Transgender*
Other*
Unknown*
Gender Total*
Ethnicity
Actual statistics for your most recent completed fiscal year or calendar year.
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
Actual statistics for your most recent completed fiscal year or calendar year.
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 most recent completed fiscal year or calendar year.
Albany*
Deer Grove*
Erie*
Fulton*
Lyndon*
Morrison*
Prophetstown*
Rock Falls*
Sterling*
Tampico*
Location Total*
8. Outcome Measurements
Use the form provided within the instructions for this application OR any form your agency uses to track outcomes.
Outcome Measurement for Program
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
9. Program Financials
Program Budget, if different than Agency 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.
5. Program 2's Information
Please prepare one Program Information Section for each United Way of Whiteside County funded program.
Program 2's Name*
Funding requests for this program – Request this year*
Funding received in the last United Way funding cycle for this program*
Please explain if there is a significant increase or decrease (+ or – 15%) between the last amount allocated and the amount requested this year.
6. Program Background
Identify community issues that this program works to prevent, alleviate, or solve.*
Coordination and Collaboration: Explain which programs in our community offer similar services and what your organization does to avoid duplication of services. Who does your agency collaborate with to promote integration of services, decrease costs, and/or achieve desired outcomes. Please discuss in detail providing specific examples.*
Explain what gaps in service would exist if your program is not carried out in our community.*
Do recipients pay a fee, reimbursement 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?*
7. Program Sustainability
Discuss modifications that can be made to the program if United Way is unable to fund your proposal at the requested level.*
Discuss your organization’s ability to sustain this program long-term in the event United Way funding is decreased or eliminated in the future.*
8. 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 most recent completed fiscal year or calendar year.
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 most recent completed fiscal year or calendar year.
Female*
Male*
Transgender*
Other*
Unknown*
Gender Total*
Ethnicity
Actual statistics for your most recent completed fiscal year or calendar year.
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
Actual statistics for your most recent completed fiscal year or calendar year.
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 most recent completed fiscal year or calendar year.
Albany*
Deer Grove*
Erie*
Fulton*
Lyndon*
Morrison*
Prophetstown*
Rock Falls*
Sterling*
Tampico*
Location Total*
9. Outcome Measurements
Use the form provided within the instructions for this application OR any form your agency uses to track outcomes.
Outcome Measurement for Program
Accepted file types: jpg, jpeg, png, pdf, doc, xls, Max. file size: 6 MB.
10. Program Financials
Program Budget, if different than Agency 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.
11. Promotion
To reduce the length of this application, we are NOT currently asking for a success story, photo or examples how a donation of a certain amount will impact our organization. Please note that we may ask for this information at a later date.
12. 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*

2023 Agency Application for 2 Programs

1. General Agency Information

2. Public/Private Grants and Capital Fundraisers

3. Statement of Financial Position

4. Program 1's Information

5. Program Background

6. Program Sustainability

7. Individuals Served

Age

Gender

Ethnicity

Income Level

Numbers of people served by location

8. Outcome Measurements

9. Program Financials

5. Program 2's Information

6. Program Background

7. Program Sustainability

8. Individuals Served

Age

Gender

Ethnicity

Income Level

Numbers of people served by location

9. Outcome Measurements

10. Program Financials

11. Promotion

12. Signature