RENEWAL - Community Partners Grant Application

RENEWAL - Community Partners Grant Application - Due March 1, 2025 (Year 3)

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FISCAL AGENT/FISCAL SPONSOR

Does your Program operate under the oversight of a Fiscal Agent/Fiscal Sponsor?

YesNo

FISCAL SPONSOR INFORMATION

Fiscal Agent/ Fiscal Sponsor Important Information

If utilizing a Fiscal Agent/Fiscal Sponsor United Way of Greater Lima will need to collect additional information as seen in the required documents section at the end of the form. These additional documents will replace some of the other documents previously required. United Way of Greater Lima will require all Agencies utilizing a Fiscal Agent/Fiscal Sponsor to provide a written agreement confirming the Fiscal Agent/ Fiscal Sponsor relationship. This agreement must include a statement regarding the Fiscal Agent's/Fiscal Sponsor's ability to retain discretion and control over the donated funds. In addition to the agreement United Way of Greater Lima will also require an annual accounting for all funds received from UWGL. This document will replace the previously asked for 990 and should show how and where the funds were used for the designated program.

A Fiscal Agent/Fiscal Sponsor must be a 501(c)3 nonprofit organization. Since Churches are granted automatic tax exempt status, they meet United Way of Greater Lima's requirements needed to serve as a Fiscal Sponsor.

Fiscal Agent/Fiscal Sponsor Name

Street Address

City/Town:

State:

Zip:

If Mailing Address is different Please Check Here-->

Mailing Address

Street Address

City/Town:

State:

Zip:

Fiscal Agent/Fiscal Sponsor Main Phone:

First and Last Name Executive Director/CEO:

Email Address Executive Director/CEO:

Phone Number Executive Director/CEO:

Fiscal Agent/Fiscal Sponsor Agency Mission Statement:

AGENCY INFORMATION

Agency Name

Physical Location in Allen County (Street Address):

City/Town:

State:

Zip:

If Mailing Address if different Please Check Here-->

Mailing Address

Address

City/Town:

State:

Zip:

Agency Main Phone:

Agency Fax:

Website:

Agency Fiscal Year:

Your 12 month accounting period.

First and Last Name Executive Director/CEO:

Email Address Executive Director/CEO:

Phone Number Executive Director/CEO:

First and Last Name Person Completing:

Title Person Completing:

Email Address Person Completing:

Phone Number Person Completing:

Agency Mission Statement:

Describe any significant Agency changes that have occurred in the past funding year (e.g. change in leadership, board, programs, revenues, funding sources, or expenditures) and any additional information you feel is pertinent.

(maximum 250 words or less)

PARTICIPATION IN UWGL ACTIVITIES

Which of the following UWGL activities has your Agency participated in this past funding year? Please check all that apply:

Please explain why you have not participated. How can we help you get more involved in the future?

INTERNAL CAMPAIGN

Did your agency run an internal United Way Campaign last year?

YesNo

Total Number of Employees in the agency:

How many of your staff participated in your internal campaign?:

Percent of your staff who participated in your internal campaign:

How much did your staff raise for the United Way Campaign last year'? (Any amount is appreciated!)

Estimates are acceptable.

If not, can you explain why not? How can we help you get a campaign going next year?

Provide a brief description of the Agency's use of the UWGL partnership in marketing materials and the media:

(250 words or less)

PROGRAM INFORMATION

Program Name:

First and Last Name Program Director:

Title Program Director:

Email Address Program Director:

Phone Number Program Director:

CURRENT REQUEST FOR GRANT FUNDING

Total program annual budget:

Amount received for this program LAST year:

Do not include designations received; this number should reflect only the UWGL awarded amount.

Amount of Award that was expended between July 1 and December 31:

If you have not expended at least half of the grant monies or more, please explain:

(250 words or less)

Amount requested for this program THIS year:

This equals an increase (decrease) in amount requested:

Percent of program budget being requested:

If you are requesting an Increase in UWGL funding for your program, how do you plan to use the increase? (If not, state "no increase".)

(250 words or less)

PROGRAM OUTCOMES/IMPACT

HOW ARE PEOPLE'S LIVES IMPROVED BECAUSE OF YOUR PROGRAM SERVICES?

Measuring the success of your agency initiatives is an important part of effectively managing a program. UWGL must be able to show our donors that their contributions are truly making a positive difference in our community. Therefore, part of applying for funding is to offer evidence that what you are doing is effective.

We ask you to share your desired outcomes for this program in the coming year. In each instance, we require a minimum of two (2) outcomes, and a maximum of four (4).

Program Outcomes/Impact ANTICIPATED IN THE COMING FUNDING YEAR (July 1 through June 30)

	Outcome Desired	Data/Tools Used to Track Progress	Target # of Clients Receiving Service	Target # Achieving Desired Outcome	Target % Achieving Desired Outcome
Outcome #1
Outcome #2
Outcome #3
Outcome #4

Comments on FUTURE outcomes anticipated in the coming funding year:

OPTIONAL (250 words or less)

COMMUNITY IMPACT OF YOUR PROGRAM

What would $1 per pay period ($26/yr) fund or support?

(150 words or less)

What would $4 per pay period ($104/yr) fund or support?

(150 words or less)

What would $10 per pay period ($260/yr) fund or support?

(150 words or less)

What would $20 per pay period ($520/yr) fund or support?

(150 words or less)

REQUIRED DOCUMENTATION

United Way standards require specific documentation from its' partners. Please upload the MOST RECENT version of all the following documentation. In addition, please follow these instructions for uploading successfully.

All attachments in pdf format should have portrait orientation and be sized to 8 1/2 x 11 only.
The file size should not exceed 35 MB.
If a document consists of multiple pages, it needs to be uploaded in one file. Do not attempt to upload one page at a time on any question requiring upload.
The file extensions accepted by the system are pdf, doc, docx, xls, xlsx, ppt., pptx. PDF is preferred.

Success Stories

One of the most powerful tools UWGL can use to raise funds in support of our community partners is the success/impact stories. Donors who hear specifics of how an individual or family has been helped are much more likely to give than those not exposed to stories. Stories should give anecdotal evidence of the effectiveness of your program's services, describing how the client's life was changed. This information will be used by UWGL's communication and marketing efforts.

Download Forms Needed to Complete Application

Please visit www.unitedwaylima.org/agency-portal to download the following forms for submission:

1. Success Story Release
2. USA Patriot Act Statement of Compliance
3. Program Budget Form (Required)
4. Optional Worksheet for Completing Program Outcomes

Upload Agency Information

Resolution or Written Agreement between Fiscal Agent/Fiscal Sponsor and Program Agency (must contain who has control over the United Way Funds)

501(c)3 IRS Determination Letter

Board of Directors List (including position held, number of years served, and contact information)

USA Patriot Act Statement of Compliance

Annual Audit or Financial Review

IRS Form 990 (complete document) or 990EZ (Part I - Part X only)

Annual Accounting

Agency Balance Sheet

Agency Profit and Loss

Any other supporting documentation

You may include any documents you were unable to upload above, as well as anything else you feel is pertinent to your program.

Upload Program Information

Board Approved Program Budget

Please complete the Program Budget Form" (found at the link listed above) with the simplified financial budget of only the program for which you are requesting funding.

ONE Success Story

Please be sure to include one NEW success stories from the past year.

Success Story Release

Additional Comments Regarding Submitted Documents?

OPTIONAL (150 words or less)

ENVISION THE FUTURE WITH US!

The hope of UWGL is to inspire the community to give every campaign year. We want to move our county from a mindset of “desperation” (just hoping to hit a campaign goal) towards one of “inspiration” (considering what might be possible if more people participated in the campaign). Sometimes the stories of what you are unable to do because of lack of funds is just as motivational as stories of what has been accomplished. To move towards inspirational thinking we need you to dream with us. What would be possible if we were able to double your United Way Grant? We will use this information to inspire more people to give more money in next year’s campaign. Thank you!

Dream a Little!

OPTIONAL (400 words or less)

AUTHORIZATION

I verify that I have reviewed the information provided and it is accurate and correct to the best of my knowledge. I also verify that I have reviewed it with my Program Director and have received Board support/approval.

Agency Executive Director/CEO - First and Last Name:

Date Completed:

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