United Way Partner
Agency Application 2014-2015
United Way
of Southwest Missouri
& Southeast Kansas
Please email your completed application including the 2014-2015 Agency Fact Sheet and
Program Funding Request Form(s) to bgraham@unitedwaymokan.org
Applications and required attachments are due to United Way by Monday, December 15, 2014.
**Required Attachments
Audit (unless already on file with United Way)
IRS Form 990 (unless already on file with United Way)
Management Letter (unless already on file with United Way)
EEO Statement/Policy
Board Roster (including name, address, & position)
Most Recent Agency Budget
Anti-Terrorism Compliance and Charitable Status (page 5)
 if attached
**Attachments can be scanned and sent with the applications electronically,
faxed to (417)624-0356 or mailed to 3510 East 3rd Street, Joplin Mo 64801
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2014-2015 Agency Fact Sheet
Legal Name of Organization:
Contact Person:
Title:
Address:
City:
State:
Telephone #:
Fax #:
Zip Code:
E-mail address:
Web site, if applicable:
Agency’s Mission Statement:
Agency’s Vision Statement:
Legal/Regulatory Certifications
Yes  No Is Independently incorporated as a nonprofit on __________________ [Date]
Yes  No Is Tax Exempt and has (Check one):
 Its own 501(c)3 IRS determination letter dated ______________ [Date]
 IRS 501(c)3 goes through another organization
Name of organization:
Yes  No Filed IRS Form 990 for fiscal year ended ___________on __________[Date]
Most current Form 990 must be attached or already on file with UWSWMOSEK
Yes  No EEO statement dated ______________________is attached to this proposal.
Yes  No The agency is currently operating in compliance with all health, safety and environmental laws, governmental
ordinances and codes for every occupied facility.
Attach explanation if not in compliance.
Yes  No The agency is currently in compliance with all-applicable and material program-licensing requirements.
Attach explanation if not in compliance.
Yes  No The agency is currently in compliance with applicable and material program accrediting bodies.
Attach explanation if not in compliance.
Yes  No Compliant with regulations and reporting requirements annually under the U. S. Internal Revenue Service and
all applicable state regulation and statutes.
GOVERNING BODY*
*If the agency is the local arm of a statewide or national organization directed by a state or national
governing board, or if it fulfills a specific mission of a local multi-mission organization directed by a
governing board, the organization must have its own local active Advisory Board or Council.
Yes
Yes
Yes
Yes




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No
No
No
No
The agency’s bylaws allow for ___________________[number] local, volunteer directors.
Provide a current roster of the board reflecting name, address, and board position is attached.
The governing board regularly reviews the agency’s budget(s) at least quarterly
The agency’s governing board has adopted, and adheres to, written policies on board membership rotation,
length of service, and conflict of interest.
Yes  No The agency’s governing board has met to conduct agency business at least four times during the past 12
months.
Yes  No The agency’s governing board maintains written minutes for each Board meeting that documents attendance,
deliberations, and decisions of the Board.
Yes  No The agency has at least one paid staff member who is responsible to the governing board for the agency’s
administration and operations.
Yes  No An annual review of the chief executive/administrative officer’s performance has been conducted in the last
twelve months.
Yes  No The composition of the governing board reflects the diversity of the agency’s geographic service
FINANCIAL/FISCAL MANAGEMENT
Yes  No The agency documents and follows internal policies and procedures for fiscal control.
Yes  No The agency has an annual independent audit performed and financial statements prepared in accordance
with United States of America generally accepted auditing standards to ensure financial statements are in
conformity with accounting principles. Indicate the fiscal year end the last audit covered:
Attach if not in compliance.
Yes  No Unless already on file with the United Way office, attach a copy of the annual independent audit and
management letter issued by a certified public accountant within 6 months after the end of the fiscal year. If
no management letter is issued, then a letter from the certified public accountant stating one was not needed
will be accepted. Attach a copy of the audit and management letter.
Attach explanation if not in compliance.
Yes  No The agency is current with past and present IRS obligations.
Yes  No Utilize a financial accounting system that facilitates the preparation of year-end financial statements
conforming to accounting principles and audit standards generally accepted in the United States of America.
Yes  No The agency provides adequate insurance coverage including liability insurance, bonding of staff and
volunteers, and coverage of property and equipment.
Yes  No Allow the United Way of Southwest Missouri & Southeast Kansas to share financial and program
information submitted by the Agency with mutual funding sources.
Agency’s Fiscal Year is from to
Please attach your most recent agency budget.
UNITED WAY MEMBER AGENCY REQUIREMENTS
Yes  No The agency commits to conducting an annual United Way campaign with its employees.
Yes  No The governing board of the agency will involve themselves directly and actively in the United Way annual
funds campaign as part of the agency’s participation that will be assigned.
Yes  No A member of the agency’s governing board or administrative staff will attend Quarterly Agency Director
meetings, United Way campaign meetings and United Way Annual Meeting.
Yes  No The agency will submit client success stories to United Way at least quarterly.
Yes  No The Agency shall state its United Way affiliation when publicizing its organization in print and other forums,
such as annual meetings, awareness and fundraising events, etc. This would include but not be limited to live
mention of United Way at your public events, display of member Agency signage at your location, use of
United Way logo on your brochures, invitations, letterhead, program materials, fliers, newsletters, etc.
Yes  No The agency has registered its programs with 2-1-1 Missouri or 2-1-1 Kansas.
PROGRAM
Yes  No The agency operates in a non-discriminatory manner with regard to serving, clients, or demonstrates a valid
basis for variance from non-discriminatory practices.
Yes  No Program sites are located in areas that are easily accessible to the target population and within the United
Way of Southwest Missouri and Southeast Kansas service area.
Yes  No The days and times of program operation are appropriate to the needs of the target population.
Yes  No The agency fosters cooperation, coordination and collaboration with other local human service organizations,
to periodically assess the need for human service programs, to seek solutions to human service needs, to assist
in the development, expansion or modification of local human service programs as needed, and to work with
other human service organizations in the development of such programs.
Yes  No Agency provides those services and operates those programs approved for funding to the best of the agency’s
abilities and informs United Way as soon as possible if, for any reason, the organization/agency is unable to
fulfill this obligation.
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Please list ALL Program(s) for which United Way 2014-2015 funding is being requested:
Program Name
Which Community
Dollar Amount
Dollar Amount
Impact Area does the
Received
Requested
(from UWSWMOSEK)
(from UWSWMOSEK)
program align with?
in 2013
for 2014
(Please check one)
 Education
 Income
 Health
 Safety Net
Education
 Income
 Health
 Safety Net
Education
 Income
 Health
 Safety Net
Education
 Income
 Health
 Safety Net
Education
 Income
 Health
 Safety Net
Education
 Income
 Health
 Safety Net
Please check if
this is the first
time you have
requested
funding for this
program.
 New Program
 New Program
 New Program
 New Program
 New Program
 New Program
This application hereby applies to the United Way of Southwest Missouri and Southeast Kansas for
campaign support through an allocation in accordance with United Way policies.
We, the undersigned, have thoroughly read and understand the Agency Fact Sheet and attest that the information
provided is true to the best of our knowledge.
Board Chairperson:
Date:
Agency Executive Director:
Date:
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Anti-Terrorism Compliance and Charitable Status
In compliance with the USA Patriot Act and other counterterrorism laws, the United Way of Southwest Missouri
& Southeast Kansas requires that each agency certify the following:
agency name
“I hereby certify on behalf of
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.”
Additionally, I hereby certify that the above named organization is eligible to receive charitable contributions
as defined under section 170(c) of the Internal Revenue Code.
Print name:
Title:
Signature:
Date:
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