Tri-City Area United Way
P.O. Box 1143
Marinette, Wisconsin 54143
Serving Marinette and Oconto Counties, Wisconsin and Menominee County,
Michigan
Year 2016 Program Grant
Complete one program grant application for each program
Organization Name: __________________________________________________________________
Program Name: ________________________________ Program Telephone# ____________________
Contact Name: ________________________________ Email: ________________________________
Direct Phone Number___________________________ Website: _______________________________
Amount Applied for: $_____________ Category Applied to: __________________________________
(Please see TCAUW categories on pages 4 and 5)
Brief Program Narrative (Situation, priorities, and outcomes)
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(Inputs)
Is this a new program? ( ) Yes ( ) No
Have you applied for funding for this program in the past? ( ) Yes ( ) No
$ _______________ applied for, $ _______________ received last year
If yes, describe your successes and obstacles in attaining the goals described in your previous application,
and also any changes:
__________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Describe the resources necessary to implement the program.
a. Number of staff _______ If a new program, will you be hiring ( ) or using existing staff ( )?
b. Cost of staff __________
c. Cost of equipment _______
d. Other cost __________________________________
Supplement Program
Does the Program collect fees for services provided? ( ) Yes ( ) No
If yes, please submit fee schedule.
Does your program request include funding to defray or reduce service fees to program recipients?
( ) Yes ( ) No
If yes, how is the reduce fee structure designed? _______________________________________
Can services ever be denied? Briefly explain; _________________________________________
______________________________________________________________________________
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Program: _____________________ Logic Model
Situation:
Outcomes -- Impact
Outputs
Inputs
Activities
Participation
Short
Evaluation Metrics
Medium
Long
Success Stories
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Tri-City Area United Way Grant January 2016
PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT THE SPECIFICS OF THE
PROGRAM FOR WHICH YOU ARE SEEKING FUNDING.
The Tri-City Area United Way Board of Directors are focusing more of our resources to programs
that are attacking the root cause of issues such as substance abuse, lack of parenting skills and
providing educational opportunities and activities outside of normal school programing to our
youth from birth to career. The more your programs can match this focus, the greater the impact
will be on funding. Reactionary, or Community Needs, funding such as senior citizen needs or
homeless services are still a known significant need and will not be ignored.
Please note, there are now two general categories, Community Impact Funding and Community Needs
Funding. You can apply using either one or both categories.
CATEGORIES FOR COMMUNITY IMPACT FUNDING:
(Please indicate which one category best fits each program. Pick category heading – than pick
bullet points under that heading which best describes your program)
List your category _________________________
List the Bullet points that best describes your program:
___________________________________________
___________________________________________
___________________________________________
Educational Success – Cradle to Career
Helping Children and Youth Achieve their potential.
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Children are developmentally ready to succeed in school at time of entry
Children are prepared to succeed in 4th grade and beyond by reading
proficiently by the end of third grade
Provide positive STEM programs for grades 5th – 8th during non-school
hours;
Provide services to youth who are at risk of graduating on time;
Provide grades 6-10th opportunity to explore job options available in our
community
Income: Promoting Financial Stability & Independence for
families and individuals
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Increase the number of low income to participate in the Getting Ahead
Program
Enable community members to maintain their independence and
meaningful lifestyles;
Increasing self-sufficiency among working families
Maximizing income
Increasing savings
Provide the basic needs; food, shelter in times of crisis & safety,
Increase awareness of the Earned Income Tax Credit
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Health: Improving People’s Health & Well-Being by
reducing at-risk behavior
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Children are born healthy
Healthier children by reducing at-risk behaviors
Enable community members to maintain their independence and
meaningful lifestyles;
Provide nutritional food for our most vulnerable residents
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CATEGORIES FOR COMMUNITY NEEDS FUNDING:
(Please indicate which one category best fits each program. Pick category heading – than pick
bullet points under that heading which best describes your program)
List your category _________________________
List the Bullet point(s) that best describes your program:
___________________________________________
___________________________________________
___________________________________________
Aging
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Companionship
Food
Health and medical (includes mental health)
Activities
Other
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Poverty
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Avoiding imminent poverty
Getting out of poverty
Other
Food
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Providing food
Education on proper foods and health
Growing/providing for food
Other
Homelessness/Housing
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Avoiding imminent homelessness
Emergency Sheltering
Long term sheltering
Home affordability/maintenance guidance
Other
Other
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List key points describing your program
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1. Use your blank logic model form to briefly describe how this program will provide services needed in the
category you picked. What is the situation and your programs priorities that help make the decision to
pick this area.
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_____________________________________________________________________________________
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2. What are your inputs that can be invested in this program?
_____________________________________________________________________________________
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3. What are your outputs? What are you currently doing that will help you meet your outcomes?
_____________________________________________________________________________________
_______________________________________________________________________
4. Who do you want to reach?
_____________________________________________________________________________________
_______________________________________________________________________
5. What are the desired outcomes (impact) of the program?
What are the short term result:
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________What are the medium term
results
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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What is the ultimate impact or long term results
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________
6. Briefly explain method of measuring and evaluating your success in achieving outcomes.
_____________________________________________________________________________________
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PROGRAM GRANT BUDGET (Use this form only)
Program Title________________________
(Please submit a program budget for each program grant application.)
Program
2015
Actual
SUPPORT & REVENUE
1. Contributions..................................................
2. Special Events ................................................
3. Government Fees and Grants.........................
4. Membership Dues/Individuals .......................
5. Program Service Items ...................................
6. Sale of Supplies & Services ...........................
7. Investment Income .........................................
8. Miscellaneous Revenue .................................
9. Transfer from Restricted Funds .....................
10. TCAUW Projected Revenue ..........................
11. TOTAL SUPPORT & REVENUE .............
2016 Total
Program
Budget
2016
TCAUW
Award Budget
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EXPENDITURES
14. Salaries ...........................................................
15. Employee Benefits .........................................
16. Payroll Taxes .................................................
17. Professional Fees ...........................................
18. Legal Fees ......................................................
19. Supplies ..........................................................
20. Telephone .......................................................
21. Postage & Shipping........................................
22. Occupancy (Utilities, rent etc) .......................
23. Equipment Rental & Maintenance .................
24. Printing & Publications ..................................
25. Travel .............................................................
26. Conference Meetings .....................................
27. Specific Assistance ........................................
28. Awards & Grants ...........................................
29. Insurance ........................................................
30. Miscellaneous ................................................
31. Dues or Affiliation Payments.........................
32. Administrative Costs (non-local) ..................
33. Purchase of Fixed Assets ...............................
34. TOTAL EXPENSE ........................................
35. SURPLUS/DEFICIT......................................
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Jan- Dec 2015
2015 NUMBER SERVED REPORT (NON-DUPLICATED)
(Use a separate copy of this form for each Program funded)
Agency______________________________ Name of Program__________________________
Contact (Person who fills out this portion ____________________________________________
Street Address__________________________________________________________________
Mailing Address_______________________________________________________________
Telephone Number _____________________________________________________________
E-mail address _____________________________FAX _______________________________
List your 2015 Funding distribution per program.
Program
Total Grant
List your category
$
Total Funding expended
$
For the program listed above, explain the full year’s results. Show what kind of impact this program had on the tri-county area
or specific populations. This information will be reviewed in addition to your application to compare what the program has
accomplished in 2015 and what it will attempt to accomplish in 2016.
Total Program Budget for:
Age range
Program Age Range
Gender breakdown
2015 ___________
2016 ___________
0-5____ 6-12 _____ 13-18 _____ 19-24 ____ 25-59 ____ 60 & up___
Female________
What proportion of your program
participants do you consider at-risk?
Male __________
_________%
Provide Numbers served by Counties
_______ Marinette County ______ Oconto County
_ _____ Menominee County, MI _______ Other Counties
How do you measure success for the
category you picked for 2016?
(Evaluation metric)
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Please provide a short narrative in the space below of some of your past success stories and overall
community impact, and how you will convey those to internal and external stakeholders and funders?
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