United Way of Charlotte County
INSERT AGENCY NAME
United Way of Charlotte County
2016 Program Funding Request
Agency Name:
Address/EIN #:
Fax
Number:
Agency
Website:
Phone Number:
Director’s Email:
Executive
Director/CEO:
Board President:
Agency Representative that attended
Mandatory Application Review meeting:
Agency Mission:
Summary of Program Funding Requests from United Way
Program Name
Totals
Total Program
Budget
Funding Requested
from UWCC
$
$
$
$
$
$
Summary of Program Funding Requests from Board of County Commissioners, if any.
Program Name
Totals
Total Program
Budget
Funding Requested
from BOCC
$
$
$
$
$
$
Summary of Program Funding Requests from City of Punta Gorda, if any.
Program Name
Totals
Page 1
Total Program
Budget
Funding Requested
from UWCC
$
$
$
$
$
$
United Way of Charlotte County
INSERT AGENCY NAME
Program Request for 2016
Complete these two pages for each program for which funding is requested. Grant cycle begins April, 2016
Program Name:
Brief description of
Program:
Identified Need from
Assessment:
□ Education □ Employment □ Family Services
□ Health
□ Poverty
□ Transportation
(See pg. 4 of the Needs Assessment Executive Summary accessible through
www.unitedwayccfl.org)
Description of how this
program works to
eliminate poverty:
What are the lasting
impacts of this program
in our community?
Funding Request:
Continued Program Funding
New Program Request
Amount: $
% of Program Budget:
% of Total Agency Budget:
How did you determine
the amount of money to
request?
How will you assure that your services will be accessible to the population you propose to serve? (Refers to
information, cost, location, transportation, etc.)
How well/often do you collaborate with other agencies within the community? Give examples.
For currently funded partners only: Score your agency on your United Way partnership. Are your quarterly
reports submitted in a timely manner? Do you participate in United Way events like Day of Caring?
(5=Excellent, 4=Very Good, 3=Satisfactory, 2=Needs Improvement, 1=Poor)
MATCHING FUNDS: If United Way of Charlotte County/Charlotte County Government/or City of Punta
Gorda Grant funds are to be used as matching dollars from other sources, please note below:
Source:
Page 2
Budget:
Match %:
United Way of Charlotte County
INSERT AGENCY NAME
Program Request for 2016
Program Name:
Program Goals (List)
1.
2.
3.
Page 3
Specific Program Activities
to Reach each Goal
Quantified Measures to Determine
Success for each Goal
How client benefits from
program...must be
measurable
United Way of Charlotte County
INSERT AGENCY NAME
Program Request for 2016
Program Name:
Activities
List Activity from 2nd column of
previous page
(1) Intervention
Page 4
Outcome/Indicator
Measurable Outcome Timeline
Data Source
Personnel
Projected # and % of
clients who will
achieve each
outcome.
or
Projected # and % of
units expected to be
achieved.
Indicate when each measurable
outcome will be reached.
Measurement Tool, Data
Collection (including data
storage, method and frequency
of data collection, and reporting)
How many and
what type of
personnel
(paid/volunteer)ar
e involved in
TOTAL
PROCESS
program/service
(idea, delivery,
evaluation & data
collection)
(2) Intervention
(3) Accountability
(4) Accountability
United Way of Charlotte County
INSERT AGENCY NAME
Program Request for 2016
Complete these two pages for each program for which funding is requested. Grant cycle begins April,2016
Program Name:
How long has this
program been
operating?
Is there an anticipated
end date for program?
# Unduplicated Clients
Served*
Anticipated with this request
Cost/Client
Per visit:
OR
Served Last Year:
Per Entire Program:
# Hours/day that
Program Operates:
# of Volunteers
# of Volunteer Hours
Does your agency do
fundraising for this
program?
Anticipated fundraising
goal for this program?
$
Can your organization
leverage dollars? For
instance, if $1 is
donated, does it
translate into more than
$1 in goods or services.
What type of In-Kind
donations do you
receive for this
program?
Donation/Service
Estimated Value
* Unduplicated client is defined as an individual or family that is counted only once, no matter how
many direct services, per program, they receive during a funding year. List only the number you
anticipate serving, not the number eligible.
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United Way of Charlotte County
INSERT AGENCY NAME
Other Comments: What information would you like the Community Impact Panel members to take into
consideration in determining your United Way/BOCC/City of Punta Gorda allocation? (This is an opportunity to
emphasize needs, discuss benefits, clarify costs, and indicate unique features of the agency’s ability to provide
services to the Charlotte County community.)
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United Way of Charlotte County
INSERT AGENCY NAME
Agency Information
How often does the Agency Board meet:
Does the Agency Board have a Board Training program in place:
Briefly describe:
Agency Structure: Are there any separate corporations or foundations that are directly or indirectly associated
with your agency? Please name them and explain the association.
How does the Agency Board provide oversight to the Agency's operations, programs and finances:
Besides the Charlotte County United Way, please list any other community partnership(s) or
collaborations in which the Agency participates:
The partnership between the Charlotte County United Way and its partner agencies has powerful
marketing opportunities. How does the Agency inform the community it is a Charlotte County United
Way Partner Agency?
Please describe how the Agency communicates with its clients/members, community and other
agencies:
How many total volunteer hours did the Agency utilize last year for all programs:
Does the Agency sponsor fundraisers?
Are they specific to a particular program?
Yes
Yes
No
No If yes, which one?
Briefly Describe (Please note differentiation between efforts for requested program and agency in
description):
If Agency's service area includes more that Charlotte County, please describe any fundraising efforts
within Charlotte County:
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United Way of Charlotte County
INSERT AGENCY NAME
Agency Financial Information
What is your Agency’s annual operating budget? $
What are your TOTAL unrestricted net assets: $
What are your cash or cash equivalents AND Certificates of Deposit under current assets $
Do you have temporarily restricted funds?
purpose for each.
Yes
No. If yes, please list the current amount and
Explain any pending litigation, claims, or assessments against the agency of which you are aware.
Does your agency have endowment, quasi-endowment or permanently restricted funds?
yes, please list the current amount and purpose for each.
Yes
No. If
Operating Surplus: If your operating budget for your last completed fiscal year shows a surplus, comment on
the agency’s plans for the disposition of the surplus.
Operating Deficits: If your operating budget for your last completed fiscal year shows a deficit, state what
actions have been taken or will be taken by the agency to deal with the deficit. Be specific, such as liquidation
of capital, program cutbacks, borrowing from financial institutions, personnel reductions, draw from surplus,
more aggressive fundraising strategies, etc.
Describe any significant changes in your organization’s operations or service delivery during the past year.
Do you anticipate any significant changes in your organization’s operations or service delivery in 2016-2017?
Yes
No. If yes, please explain.
The information contained in this application is confirmed by the CEO/Executive Director and an
authorized Officer of the Board.
Date:
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Typed Name of Executive Director
Typed Name of Authorized Officer of the Board
Signature of Executive Director
Signature of Authorized Officer
Date: