Fond du Lac Area United Way
2015 Program Application
Instructions: Submit one original hard copy and an e-copy, to United Way by November 2, 2015.
United Way will not accept applications delivered in person, by fax, or by email after this date. Contact
Amber Kilawee at 920-921-7010, or email to admin@fdlunitedway.org.
GENERAL INFORMATION
Check which United Way community impact
goal you are addressing.
Building Healthy Communities
Building Supportive Communities
Building Educated Communities
Identify United Way Priority Area
Fiscal Year (if requesting funds for a two-year
project check both boxes)
2016
2017
Name of Program
Applicant Name
Applicant Address
Primary Contact
Phone
Email
Fax
Total Cost of Program
Cost Per Participant
United Way Funds Requested
Number of People Served
AUTHORIZING SIGNATURE
By signing below, I certify that the information contained within this application complies with
application guidelines.
Agency Director Name
Signature
Check here if submitted electronically
Date
Board Member Designee Name
Signature
Check here if submitted electronically
Date
Fond du Lac Area United Way
2015 Program Application
FOND DU LAC AREA UNITED WAY USE ONLY:
Board Approval Date
Recommended Award
$
Approved
Approved with Technical Revisions
Revisions Required Before Approval
Disapproved
Revisions required or reason for disapproval:
Funding Timeline
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November 2, 2015 - Grant applications completed by organization
November and December- Grant Application Reviews
January 21, 2016 – Board Meeting and Allocation Decisions
January 28, 2016 - Notification of funding status to organizations
February 22, 2016 Agency Partner Agreements signed and returned to
United Way
Fond du Lac Area United Way
2015 Program Application
1. State how the organization’s mission corresponds to one of the three United Way
Community Impact Goals, i.e., Supportive, Health, Education. 150 word maximum (10
points)
2. Summarize the program services proposed and how they address the chosen United Way
priority. 200 word maximum (10 points)
3. Explain why there is a local need for this program and how the local target population is
helped and how your organization is uniquely qualified to provide the service. Cite local
data to support the need for this program and population being helped. 600 word
maximum (25 points)
4. Write a maximum of three goals and their linkage to your agency’s mission. 300 word
maximum (10 points)
5. Write the SMART objectives linked to the goals above, i.e., Specific, Measurable,
Achievable, Relevant and Time-bound. 500 word maximum (25 points)
6. Describe how this program would stand on its own if United Way funding is decreased or
discontinued. 100 word maximum (5 points)
7. Describe how community partnerships strengthens program services, ie; shared
resources. 200 word maximum (5 points)
8. Provide a budget summary supporting the program costs requested. 500 word maximum
(10 points)
2015 Reviewer Grant Application Rubric
Reviewer Initials:
__________________________
Total Points Awarded:
________________
Rating scores can be between zero and the maximum points assigned to each question. INCLUDE BRIEF comments on the scores
given to each question. Reviewer comments assist organizations with improving their grant writing.
1. Agency mission and how it corresponds to a United Way Community Impact Goal, i.e., Supportive, Healthy, Education.
150 word maximum. (10 point maximum)
10 points
 Clear explanation of how agency mission
directly corresponds to the United Way
community impact goal.
 Clear direct connections stated.
5 points
 Unclear explanation of how agency
mission directly corresponds to the United
Way community impact goal.
 Unclear connections stated.
0 points
 Agency mission does not correspond to a
United Way community impact goal.
 No direct connections stated.
Points Awarded:
Reviewer Comments:
2. Program services summarized and priority area addressed. 200 word maximum (10 point maximum)
10 points
 Program services clearly linked to priority
area chosen.
 Clear direct connections stated.
Points Awarded:
Reviewer comments:
5 points
 Program services somewhat linked to
priority area chosen.
 Unclear connections stated.
0 points
 Program services poorly linked to priority
area chosen.
 No direct connections stated.
3. Local community need for the program, how the local target population benefits, how the organization is uniquely qualified to
provide the service. 600 word maximum (25 points maximum)
25 points
 Need is clearly defined
 How target population is helped is clearly
defined
 Local data supports identified need and
sources cited.
 Clearly defined how organization is
uniquely qualified to deliver program
service.
13 points
 Need is somewhat defined.
 How target population benefit defined
somewhat.
 Local data somewhat supports identified
need.
 Unique qualities of the program
somewhat defined.
0 points
 Need is poorly defined.
 Target population poorly identified.
 No local data provided in support of need.
 Unique qualities of program poorly
defined.
Points Awarded:
Reviewer Comments:
4. Program goals linked to mission statement. 300 word maximum (10 points maximum)
10 points
 Program goals clearly defined.
 Program goals clearly linked to mission
statement.
Points Awarded:
Reviewer Comments:
5 points
 Program goals somewhat defined.
 Program goals somewhat linked to
mission statement.
0 points
 Program goals poorly defined.
 Program goals poorly linked to mission
statement.
5. SMART objectives linked to goals. 500 word maximum (25 points maximum)
25 points
 Objectives are specific.
 Objectives are measurable.
 Objectives are achievable.
 Objectives are relevant.
 Objectives are time-bound.
13 points
 Objectives are somewhat specific.
 Objectives are somewhat measured.
 Objectives are somewhat achievable.
 Objectives are somewhat relevant.
 Objectives are somewhat time-bound.
0 points
 Objectives vaguely defined.
 Objectives not measured.
 Objectives are not achievable.
 Objectives are not relevant.
 Objectives are not time-bound.
Points Awarded:
Reviewer Comments:
6. Describes program sustainability if United Way funding is reduced or discontinued. 100 word maximum
(5 points maximum)
5 points
 Program clearly defines streams of
funding to sustain the program.
 Program clearly defines impact on
program
Points Awarded:
Reviewer Comments:
3 points
 Program somewhat defines streams of
funding to sustain the program.
 Program somewhat defines impact on
program
0 points
 Program poorly defines streams of
funding to sustain the program.
 Program poorly defines impact on
program.
7. Demonstrates how community partnerships strengthen program services. 200 word maximum (5 points maximum)
5 points
 Relationships/partnerships with other
community organizations clearly
defined.
 Resources clearly defined
 Impact on partnerships and resources
clearly defined.
3 points
 Relationships/partnerships with
community organizations are
somewhat defined.
 Resources somewhat defined.
 Impact on community partnerships
and resources somewhat defined.
0 points
 Relationships/partnerships with
community organizations poorly
defined.

Resources poorly defined.

Impact of community partnership
poorly defied.
Points Awarded:
Reviewer Comments:
8. Provide a budget summary, per year, that supports the program costs proposed. 500 word maximum (10 points)
10 points
 Budget clearly defined and linked to
program goals and objectives.
 Rationale for personnel/staffing clearly
defined
 Rationale for non-personnel expenses
clearly defined.
 In-kind value well defined.
Points Awarded:
Reviewer Comments:
5 points
 Budget somewhat linked to program
goals and objectives.
 Rationale for personnel/staffing
somewhat defined.
 Rational for non-personnel expenses
somewhat defined.
 In-kind value somewhat defined.
0 points
 Budget poorly linked to program goals
and objectives
 Rationale for personnel/staffing poorly
defined.
 Rationale for non-personnel expenses
poorly defined.
 In-kind value poorly defined.