United Way of Adams County
123 Buford Ave., P.O. Box 3545, Gettysburg, PA 17325
www.uwadams.org
717.334.5809
2016 Program Funding Application Instructions and Check-List
Health, Education, Income
United Way of Adams County invests in three focus areas - - health, education, and income.
All applications must relate to one or more of these areas.
Application and eligibility details also available on www.uwadams.org.
Please be sure to submit all of the following items, including this checklist.
Program Funding
Application
Submit 1 signed, printed copy to 123 Buford Ave., Gettysburg, PA 17325
OR
Submit 1 signed, electronic copy to vickieuwac@centurylink.net
Attachments
Submit 1 copy of each
IRS Tax determination letter
Most recent financial audit
IRS 990 or 990EZ that matches the same year as the completed year audit
Please include this
completed checklist with
application.
Current Pennsylvania Bureau of Charitable Organizations registration
Current list of Board of Directors names and addresses
Application will be evaluated on the following:




Program need
Financial review
Ability to demonstrate financial need
Quantitative goals
● Program results/Community impact
● Organization’s management and governance
● Application clarity and thoroughness
Missing or incomplete documentation may result in the rejection of your application. Do not include a cover letter or
brochures. APPLICANTS MUST USE THE FILLABLE MICROSOFT WORD GRANT APPLICATION FORM AND
STAY WITHIN CHARACTER COUNTS PROVIDED.
MUST BE RECEIVED BY 4:30 P.M., THURSDAY, OCTOBER 15, 2015
Questions: vickieuwac@centurylink.net or 717-334-5809
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United Way of Adams County
123 Buford Ave., P.O. Box 3545, Gettysburg, PA 17325
www.uwadams.org
717.334.5809
2016 PROGRAM FUNDING APPLICATION
Section I – Contact Information
Organization Name
Must be same name that appears on IRS Form 990
Mailing Address
City, State, ZIP Code
Telephone
Fax
E-Mail Address
Website
First & Last Name
Person Responsible for this Grant
25 Word Statement Describing Organization:
Section 2 – Program Title, Amount Requested, Certification
Program Focus Area(s):
Education
Income
Health
Funding Amount Requesting: $
1. In compliance with the USA PATRIOT ACT and other counterterrorism laws, we certify that all United Way of
Adams County funds will be used in compliance with all applicable anti-terrorist financing and asset control laws,
statutes, and executive orders.
2. We certify that an active and responsible governing body directs the organization named in this application whose
members have no material conflict of interest and who all serve without compensation; that publicity and
promotional activities are based on actual programs and operations; and that the organization is chartered or
incorporated under State of Pennsylvania.
We certify that the information provided for this application is true and accurate:
__________________________________
Organization Executive Signature
Printed Name
Date
__________________________________
Organization Board Chair Signature
Printed Name
Date
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Section 3 – Narrative, Question 1
Please provide the following relevant program information so funding reviewers understand the scope of your activities.
Precede each answer with the written question.
1.
State your organization’s mission.
 Summarize the overall issue, content, and scope of the services provided
 What methods do you use to reach potential clients?
2,500 Character Maximum
Section 3 – Narrative, Question 2
2.
In your narrative form, please include the following as relevant to your organization:
 Identify your target population and how you determine eligibility
 Identify any fees charged to clients
 Describe services that are provided and in what amount
 Identify all resources dedicated to the provision of service (i.e. personnel, equipment, facilities, etc.)
2,500 Character Maximum
Section 3 – Narrative, Question 3
3.
This question addresses your program goals. Funding reviewers want to understand your expectations for your program.
Please use S.M.A.R.T. Goals (specific, measurable, achievable, results-focused, and time-bound) to answer. (Note, you may
be asked to share your progress toward your goals during next year’s funding cycle).
●
List a minimum of 3 specific measurable goals for your program
2,500 Character Maximum
Section 3 – Narrative, Question 4
4.
Describe the intended use of United Way of Adams County funding and how this funding would help you meet your
program(s) goals.
2,500 Character Maximum
Section 3 – Narrative, Question 5
5. How do you evaluate your work? What kind of a tool(s) do you use to measure the outcomes for your target population?
Describe your outcomes.
2,500 Character Maximum
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Section 3 – Narrative, Question 6
6. If your agency/program is part of collaborative relationships that provide services through a formal agreement, please
describe. If none, proceed to the next question. Please do not provide referral lists.
2,500 Character Maximum
Section 3 – Narrative, Question 7
7.
Do other organizations provide similar services locally? If yes, discuss how your program is different.
2,500 Character Maximum
Section 4 – Budget, Financial, Governance, Questions 1-9
Fiscal Year
1. What were the total revenues for the program last fiscal year? $
2. What were the total umbrella organization revenues for last complete fiscal year? $
Name of Program:
PROGRAM REVENUES
1. Direct Support
a. Contributions/Designations
Fiscal Year 2014-2015
Fiscal Year 2015-2016
Fiscal Year 2016-2017
b. Special Events
c. Foundations/Trusts/Bequests
2. Government Fees/Grants
3. Other
a. Membership Dues
b. Program Service Fees
c. Sales of
Materials/Products/Retail
d. Investment Income
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e. Other Income
4. Indirect Public Support
a. UWAC Allocation
b. Allocations from other United
Ways
c. Other Indirect Public Support
5. TOTAL PROGRAM
REVENUES
PROGRAM EXPENSES
6. Compensation/Taxes/Benefits
7. Fund Raising Expenses
8. All Other Expenses
9. TOTAL PROGRAM EXPENSES
10. EXCESS (DEFICIT) REV/EXP
3. How many Full Time Employees for your program?
How many Part Time Employees for your program?
4. How many Full Time Employees for your organization?
How many Part Time Employees for your organization?
5. Is your program on track for similar revenues this year?
Same
Higher
Lower
6. Provide insight into changes that are affecting your business. Describe changes or what is occurring that affects your
Organization’s financial security or insecurity?
2,500 Character Maximum
7. Describe your board of directors’ involvement in your organization governance, planning, and fundraising. How often
Do they meet?
2,500 Character Maximum
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8. How much does your IRS Form 990 report as in-kind $
, if any.
Briefly discuss what kind of in-kind services and/or products.
2,500 Character Maximum
9. Identify any board designated or donor-restricted funds held by your organization for any program. Discuss when and
for what purpose the Board restricted them.
2,500 Character Maximum
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Section 5 – Data
Calculate and explain the unit of service cost for the program using budget page and Client Data (below).
Total actual expenses for last complete fiscal year
DIVIDED BY
Total number of participants served with a specific service in that same fiscal year
EQUALS
Unit of Service Cost
If the program includes different components, you may need to calculate more than one unit of service cost to
Account for different types of service. The total actual expenses of all multiple calculations should total the
Amount of actual expenses reflected on your budget page for your most recent completed year.
Example: $1000 divided by 250 participants for 1 hot meal = $4 per meal
Example: $1000 divided by 10 clients to attend 10 sessions each of counseling services = $100 per client
2,500 Character Maximum
Number of participants DIRECTLY served in previous year, by zip code of residence:
17301
17307
17324
17340
17353
17303
17310
17325
17343
17372
17304
17316
17331
17344
17375
17306
17320
17337
17350
Other
Total:
Percent of clients: Male
%
Female
%
Estimate
Percent of low-income clients (200% of poverty or less):
%
Indicate the age range of clients that you serve (target population).
0-5 years
6-18 years
19-59 years
60+ years
%
%
%
%
Estimate
Estimate
or Actual
or Actual
or Actual
Number of volunteers utilized by program over past year:
Number of volunteer hours for program:
Program Name
Agency Name
Staff Contact
Email
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Section 6 – Impact Stories – Must be a current stories from within the last year
Provide 3 success stories. These are narrative descriptions of programs participants’ success. The stories should be
about an actual person, not a program composite. This information helps reviewers better understand your program
and its outcomes. Protect your client confidentiality by changing names and details. Stories may be shared with the
community.
Success Story 1
1,250 Character Maximum
Success Story 2
1,250 Character Maximum
Success Story 3
1,250 Character Maximum
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