P.O. Box 750
Brookings, SD 57006
605.692.4979
uw@brookingsunitedsay.org
www.brookingsunitedway.org
2015 Program Application ~ Short Form
Thank you for your interest in applying for funds from Brookings Area United Way (BAUW). Board Members find this to
be one of the most satisfying parts of their involvement with United Way – investing in the success of our partners and
learning more about the wonderful programs you provide to meet the critical human needs in our community. This
Short Form Application is intended for Programs seeking United Way funding of less than $5,000 in 2015.
(Programs seeking funding of 5,000 or greater will be asked to complete the Program Application ~ Long Form.)
You will notice that we are asking Programs to clearly identify the outcomes of the program for which you are seeking
funding. BAUW focuses on measuring program results and sharing our priorities with the community more effectively.
We have a set of 3 priority funding areas and will be making investments in programs which address these priorities.
The application will ask you to identify which priority area you feel your program fits.
Education –
Promoting the development of work and life skills
Increasing positive social, emotional and academic youth development
Preparing youth for success in school and community
Income/Financial Stability –
Increasing self-sufficiency
Providing basic needs such as food, safety, shelter
Providing support during times of crisis
Health –
Supporting vulnerable populations
Promoting independence for individuals
Providing access to basic and preventative health care services
I look forward to working with each of you during this process. If at any time, you find you have questions, please do not
hesitate to contact me. Thank you again for your interest in partnering with United Way in meeting the needs of
thousands of individuals in Brookings County. Your work in this area is deeply appreciated.
Heidi Gullickson,
Heidi Gullickson
Executive Director
2015 Program Application Short Form
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2015 Application Checklist
To ensure your application is successfully submitted, please make sure the following elements have been
completed and are enclosed in your application.
One, single sided copy of the Application and corresponding documents must be emailed in a pdf format to:
uw@brookingsunitedway.org
Page one of the Application including the required signatures along with the attached Memorandum of
Understanding Agreement with required signatures must be mailed to Brookings Area United Way: Box 750,
Brookings, SD 57006
Application Deadline – 5:00 p.m. Monday, November 10, 2014.
A complete Program Application, including original cover page (pg 3) with required signatures.
A copy of your IRS determination letter stating you are a tax-exempt / 501(c) (3) organization
(submit only if applying for the first time or if exempt status has been updated in the past 12
months)
A list of members currently serving on your Board of Directors including address, phone number,
title, term.
A copy of the Counterterrorism Compliance Certification Form (included in this packet)
A copy of your Agency’s board-approved non-discrimination policy
A current copy of your Agency’s constitution and by-laws (submit only if updated in the past 12
months for existing BAUW Partner Agencies)
A current copy of your Agency’s Code of Ethics Statement
A copy of your most recent Balance Sheet
A copy of your Agency’s most recent Profit and Loss Statement or Cash Flow Statement in a
format currently viewed and used by your Board of Directors
A copy of your Agency’s overall budget in the format currently viewed and used by your Board of
Directors
A signed copy of the Memorandum of Understanding agreement for 2015 Funded Agencies
(included on page 7 & 8 in this packet)

All funding decisions will be suspended for Applications that are not submitted prior to application
deadline- 5:00 pm - Monday, November 10, 2014.
2015 Program Application Short Form
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2015 Program Application ~ Short Form
(for Programs seeking United Way funding of less than $5,000 in 2015 )
Agency:
Program:
What is your Program’s Mission and Purpose?
Indicate United Way Priority Area most related to your program: Education, Income, Health
Address:
Contact Person:
Phone No:
Email Address:
Please indicate the Fiscal/Calendar year end for your
most recent filing of the IRS Form 990/990 EZ/990 N:
FED TAX ID #
Amount Requested: $
Purpose of United Way Funds: (please attach additional documentation if needed)
Additional Comments:
Signature
United Way Staff Contact: Heidi Gullickson
Telephone: 605.692.4979
Email: uw@brookingsunitedway.org
2015 Program Application Short Form
Title:
Date:
For Office Use Only:
Date received: ___________
Page 3 of 8
GENERAL INFORMATION
1. Specific services that are provided through your program:
2. Who and how many individuals are served by your Agency:
3. Why is this Agency necessary in this area? Please provide existing agency data, waiting lists, US
Census data, or any other dependable research and include citations
4. Outcomes you hope to accomplish this year:
5. How you will measure the program’s success:
6. Describe examples (if any) of how your program collaborates with other organizations in the
community, particularly other United Way funded programs.
7. Other than United Way, list other funding sources you will have?
8. If you do not apply for grants, matching funds or participate in fundraising activities, please
explain why:
9. If you received funds in 2014, describe in detail how the funds received were used. Is there any
remaining funds that were not used? If funds were not fully used, please describe in detail the
reasons why.
10. Did any changes occur in the intended program during the current funding year? Do you anticipate
any changes to the program in the upcoming year?
11. 2015 Program Funding Request: Briefly describe your request for 2015, including how dollars will
be spent.
2015 Program Application Short Form
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Success Story:
Please provide one (1) example of how this program helped someone in the past
12 months. This story may be used in marketing to demonstrate how United Way donations are utilized.
Thank You!
2015 Program Application Short Form
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Counterterrorism Compliance
In compliance with the spirit and intent of the USA PATRIOT Act and other counterterrorism laws,
Brookings Area United Way requests that each funded program (“Organization”) certify that it is in
compliance with United Way of America’s Compliance Program.
“I hereby certify on behalf of ___________________________________ [name of
organization/grantee] 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.”
Print Name ____________________________
Title ___________________________
Signature: ______________________________
Date: ___________________________
2015 Program Application Short Form
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Memorandum of Understanding Agreement between
(hereinafter referred to as United Way)
And
_______________________
(hereinafter referred to as the Agency)
for funding year 2015
The signing of this agreement will allow the release of allocated dollars, if awarded, for the coming year.
Brookings Area United Way and the Agency enter into this agreement in order to:
PROMOTE social, civic, health, welfare, and recreational services in the areas of Income, Education and
Health to the citizens of Brookings County.
PROMOTE the overall social welfare of people by encouraging cooperation and community planning among
its citizens and its civic, health, recreational and welfare agencies and departments of government.
PROMOTE high standards of accountability, efficiency with all member agencies.
It is the mutual objective of Brookings Area United Way and United Way partner agencies that the optimal amount of
money be made available for the provision of health and human services in our area. The United Way annual
fundraising campaign is represented to the community as an opportunity to make one pledge of support to help meet the
human service needs of Brookings County.
United Way’s role in helping raise these funds is based upon the concept of a single annual campaign that elicits a
response from the entire community, raising more money than would be likely with multiple, competitive fund raising
campaigns. United Way’s role is also based upon the desire of employers to conduct one annual campaign in the
workplace.
It is agreed that United Way:
1. Will assume the responsibility for an annual community-wide fundraising campaign in support of the selected and
approved Agency and/or program(s).
2. Will pay the allocation for the year on a quarterly basis.
3. Will set the total annual campaign goal based on Agency program needs, community needs and the prevailing
economic conditions.
4. Recognizes the right of the Agency to determine its programs and services, its policies of operation and to
administer its own internal affairs.
5. Will, in cooperation with the Agency, direct its own public relations and marketing efforts so as to assist the Agency
with the educational campaign of its funded programs. United Way will publicize its affairs and those of the
Agency’s supported programs as widely as possible.
2015 Program Application Short Form
OVER Page 7 of 8
It is agreed that the Agency:
1. Will cooperate fully in the annual fundraising effort and will encourage and enlist the participation of its
constituency and members in such activities. The Agency will conduct an annual United Way campaign among its
employees and its Board of Directors.
2. Will not conduct their agency fund-raising campaign during the United Way campaign in September and October.
3. Agrees to participate in United Way’s review process and provide necessary documentation.
4. Agrees to maintain responsible management, including a Board of Directors and an Executive Director, or a like
position.
5. Agrees to cooperate with other human service agencies, both public and private, in preventing duplication of efforts
and in promoting efficiency and economy of administration in human service programs.
6. Agrees to participate in meetings with Agency Directors to prevent duplication of efforts and to promote efficiency.
7. Agrees to report to United Way any major program/budget changes that may affect how United Way allocated
dollars are spent.
8. Agrees to mention its participation as a United Way agency in news releases, media programs, brochures, etc where
United Way dollars are a part of the program or service, and in verbal presentations where appropriate.
9. Agrees to provide campaign information in a timely manner when requested.
10. Will return to United Way any funds allocated to the Agency that may no longer be used for their intended
purposes, where by any act or default on the part of the Agency, or by an operation or process of law, or by any
means whatsoever.
11. Will refrain from taking actions or conducting activities likely to damage the reputation of United Way. All
concerns must be directed immediately to a United Way representative.
12. Agrees to contact the United Way Board Member “Liaison” who is assigned to the agency several times throughout
the year. Contacts could be made via:
a. A site visit by the liaison to learn more about the agency’s work in the community
b. Attendance by the liaison at an agency board meeting or staff meeting (if possible)
c. A visit to review or clarify the agency’s Mid-Year Report (June/July)
d. A visit to review or clarify the agency’s Application for funding (October/November)
e. Attendance by the liaison at a special event or fundraiser
f. A phone call or email to check-in or provide information
Signed this___________ day of _____________________, ______
Agency:
_________________________________________________________
Chief Volunteer Officer
_________________________________________________________
Chief Professional Officer
Brookings Area United Way:
_________________________________________________________
Brookings Area United Way, Board Chairman
2015 Program Application Short Form
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