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Program Funding Request Form
(Note: A separate Program Funding Request Form must be filled out for each program)
Agency Name:
Program Name:
Program Physical Address:
Program Contact Person:
1. Program Funding History & Request Summary:
Dollar Amount Received
Dollar Amount Requested
(from UWSWMOSEK) in 2014
(from UWSWMOSEK) for 2015
Total Program Expenses
for 2014
Total Program Expenses
Budgeted for 2015
2014 UWSWMOSEK Allocation
Received
% of Overall Program Expenses
(Amount Received divided
by Total Expenses)
2015 UWSWMOSEK
Requested
% of Overall Program Expenses
(Amount Requested divided
by Total Expense Budgeted)
$$ Difference from 2014
Allocation Received and
2015 Requested
2. Number of unduplicated clients served by this program (actual from prior fiscal year):
Infants/Toddlers (Birth-3 Years)
Children (4-12 Years)
Teens (13-17 years)
Young Adults (18-22)
Adults
Seniors (65+)
Total Clients Served:
3. Provide a brief description of the program.
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4. What are the days and hours of program operations?
5. What United Way Community Impact Area does the program align with? (Choose one)
 Education
Helping children and youth achieve their potential by succeeding in school, graduating,
finding work and becoming productive adults.
 Income
Supporting financial independence through employment, job training, money management,
owning or renting a home and saving for the future.
 Health
Promoting healthy choices and behaviors that improve well being.
 Safety Net
United Way of Southwest Missouri and Southeast Kansas assures that our community
always has the capacity to take care of its own by maintaining the safety net. We seek to
safeguard against disaster by supporting emergency services to individuals and families in
crisis to empower them toward regaining self-sufficiency.
6. What Community Level Outcome(s) are you addressing with the program?
(Circle or highlight applicable outcomes; logic model and measurement system must reflect outcome(s) chosen)
Education
Income
Health
Safety Net
Children and youth are Families sustain
ready for school, starting employment.
with the skills they need to
succeed.
Infants have healthy
beginnings.
Individuals, families,
and children live in safe
homes.
Children’s reading skills
are on track by fourth
grade
Families build savings and
assets.
Community members
choose healthy eating.
Individuals, families,
and children live in safe
communities
Youth transition
successfully to and from
middle school.
Living wage employment
opportunities are available.
Community members
choose physical activity.
The community is
prepared for individual
and community level
disasters and
emergencies.
Youth graduate high
school on time.
Families have manageable
expenses.
The community supports
healthy choices.
Youth are working or in Families have access to
advanced education by age affordable housing.
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The community has access
to healthcare.
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7. Briefly describe your target population.
8. Describe the need that exists in the community for your program’s services. Please cite your data sources.
(Some recommended sources include The County Rankings Report, Kids Count, US Census)
9. Which counties are served by this program? (Check all that apply)
Jasper
Newton
Crawford
Cherokee
Barton
10. What are the client eligibility requirements?
11. Are clients charged fees for program services? YES
If no, please skip to question 14.
NO
12. What is the percentage of clients paying fees?
13. Do you have a sliding fee scale? YES NO
If yes, please attach a copy of your sliding fee schedule to this form.
 Other Counties
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14. Is there a waiting list for services? YES
NO
Average number of clients on the waiting list:
Average wait time per client:
15. Who serves as a referral source for the program?
16. Do volunteers work directly with the program? YES
NO
If YES, thinking only about UNPAID volunteers working directly with the
program (Jan 1 2012-December 31, 2012):
(Do not include board members attending board and/or committee meetings.)
Number of Volunteers:
Number of Volunteer Hours:
17. What changes if any will occur within your program if your funding request is not met?
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Geographic Service Area: Please indicate the total number of unduplicated clients served by this program
who reside in each of the following locations.
Missouri
Barton County
Lamar
Liberal
Barry County
Butterfield
Cassville
Exeter
Monett
Purdy
Wheaton
Butterfield
Cassville
Dade County
Arcola
Everton
Dadeville
Greenfield
Lockwood
Arcola
Everton
Dadeville
Greenfield
Lockwood
Greene County
Republic
Springfield
Strafford
Walnut Grove
Willard
Republic
Jasper County
Carl Junction
Carthage
Carterville
Duenweg
Duquesne
Jasper
Joplin 64801
Joplin (64804)
Sarcoxie
Webb City
McDonald County
Anderson
Goodman
Noel
Pineville
Lawrence County
Aurora
Freistatt
Halltown
Marionville
Miller
Mount Vernon
Stotts City
Newton County
Diamond
Granby
Joplin (64804
Neosho
Seneca
Vernon County
Brounaugh
Nevada
Sheldon
Walker
Other MO Counties
Kansas
Bourbon County
Fort Scott
Cherokee County
Baxter Springs
Columbus
Galena
Riverton
Crawford County
Arma
Girard
Cherokee
Frontenac
Mulberry
Pittsburg
Labette County
Chetopa
Oswego
Parsons
Montgomery County
Coffeyville
Independence
Neosho County
Chanute
Erie
Thayer
Other KS Counties
Oklahoma
Craig County
Vinita
Delaware County
Afton
Grove
Jay
Ottawa County
Commerce
Miami
Picher
Quapaw
Other OK Counties
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Program Logic Model
Inputs
Activities
What are the resources What does the
needed to operate your program do with
program?
the inputs?
Outputs
How many times did
you do the activities and
for whom? (This year –
what will you track in
this area?)
Outcomes
*Outcomes must be quantified by including
numerical targets for change. Example: 90% of
youth will graduate on time.
Initial
Intermediate
Long Term
Outcome
Outcome
Outcome
Measurement Systems
How will you measure
your outcomes?
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PROGRAM BUDGET FORM
(Total Budget for Program)
Name of Program:
Budget figures should coincide with fiscal calendar year (calendar or July-June). Be sure to describe any budget items
that many need clarification in the Budget Narrative Section below.
REVENUE
Requested from United Way SWMO & SEK
Contributions Unrestricted
Contributions Restricted
Fund Raising (Gross)
Contributed by Associated Organization
Government Income
Program Generated Support
Grants
Other Earned Income
Total Revenue
2014 Budget
2015 Proposed Budget
EXPENSES
Salaries
Payroll Taxes
Employee Benefits
Supplies/Equipment
Telephone/Telecommunications
Postage & Shipping
Equipment Rental & Maintenance
Printing/Publications
Travel
Certifications/License Fees
Training/Conferences/Meetings
Program Related Insurance
Occupancy/Utilities
Specific Assistance for Individuals
Depreciation
Fundraising Expense
Payments to Affiliated Organization
Other Expenses
2014 Budget
2015 Proposed Budget
Total Expense
Revenue minus Expense
Budget Narrative:
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Glossary of Commonly Used Terms in the Allocation Process
Activities: What the program does with the inputs to fulfill its mission. Examples: provide job training,
counsel pregnant women, provide food and shelter to homeless families.
Allocation: The annual amount of United Way funds recommended by an allocations review panel and
approved by the United Way board of directors for support of a partner agency program.
Budget: An operating plan expressed in financial terms, embodying an estimate of proposed expenditures for a
given period of time and the proposed means of financing them.
Fundraising: The supporting activities the agency conducts to raise money to finance operating and capital
expenses for programs and general administration.
Initial Outcome: The first benefits or change participants experience, and are the ones most closely related to
and influenced by the program’s outputs. Examples: Teens are knowledgeable of prenatal nutrition,
Participants complete required training, Residents sign up as crime watch organizers for their block.
Inputs: Resources dedicated to or consumed by the program. Examples: Number of Staff, Percentage of Time
Expensed to this program, Volunteers & Volunteer Time, Facilities & Equipment
Intermediate Outcome: Link the program’s initial outcomes to the longer-term, outcome it desires for
participants. They often are changes in behavior that result from the participant’s new knowledge, attitudes, or
skills. Examples: Teens follow proper nutrition and health guidelines, Residents follow Crime Watch
guidelines, Participants pass certification test.
Logic Model: A logic model (also known as a logical framework, theory of change, or program matrix) is a
tool used most often by managers and evaluators of programs to evaluate the effectiveness of a program. Logic
models are usually a graphical depiction of the logical relationships between the resources, activities, outputs
and outcomes of a program. While there are many ways in which logic models can be presented, the underlying
purpose of constructing a logic model is to assess the "if-then" (causal) relationships between the elements of
the program; if the resources are available for a program, then the activities can be implemented, if the activities
are implemented successfully then certain outputs and outcomes can be expected. Logic models are most often
used in the evaluation stage of a program, they can however be used during planning and implementation.
Long Term Outcomes: The ultimate outcomes a program desires to achieve. They represent meaningful
change for the participants often in condition or status. Examples: Infants born to teen mothers achieve
appropriate 12-month milestones for physical, motor, and verbal skills, Crime rate decreases in a neighborhood,
Participants gain employment in their career field, Teen mothers graduate from high school.
Management and General: The following types of activities are included in this supporting function:
Executive director, budget planning, staffing of the Board of Directors, bookkeeping and auditing, personnel
administration; purchasing, office management, legal services.
Outcomes: Benefits for participants during and after program activities. Example: increased skills, changed
attitudes or values, modified behavior. Outcomes must be measurable.
Outputs: The direct product of program activities. Examples: number of classes taught, number of counseling
sessions conducted, number of participants served.
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Partner Agency: An agency that has received a satisfactory administrative review and met the fiscal, program,
and governance requirements to be a United Way agency. A partner agency is eligible to apply for program
funding through the annual allocations process.
Program: Defined as one or more services directed at impacting a single human service need area. The
program will have an identified target population who are the primary recipients of the service(s) and for whom
the agency has specified client outcomes or a primary service to be provided to multiple client populations,
which has specified impact(s) on the need area.
Reserve: A planned fund balance that an agency is reserving for a particular use in some future period. A fund
balance may incorporate more than one type of reserve. Reserves might be maintained for building
maintenance, for contingencies or operating emergencies, or for the purchase of special types of equipment or
supplies.