Community Impact Grant Application

2020-2021 Community Impact Grant Application

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Only electronic versions of the application will be accepted.

You will be required to download the following documents, complete them, and upload them into this application tool.

Program Financial Data & Proposed Budget
Self-Certification Checklist

Click here for Community Impact application guidelines.

Agency's Name

Street Address

City

State

Zip Code

Mailing Address

Agency's Phone Number

Agency's Fax Number

Agency's website address

Number of Employees

Agency Mission Statement

Primary Contact's Information

Primary Contact's First Name

Primary Contact's Last Name

Primary Contact's Email Address

CEO information

CEO's First Name

CEO's Last Name

CEO's Title

CEO's Email Address

Program Name

Program Summary

Amount Requested (minimum = $5,001; maximum request = $20,000)

Current Annual Budget

United Way Request as a % of Total Budget

Impact Area:

Goals

Provide the Program Background

Please describe who will be served by the proposed program.

Explain specifically how UW funding will be used

Provide the number of unduplicated individuals served by this program in Berkeley County

Provide the number of unduplicated individuals served by this program in Jefferson County

Provide the number of unduplicated individuals served by this program in Morgan County

What else would you like us to know about your program

Desired Outcomes

Please provide a minimum of three (3) measures (additional measures are optional)

Collaborative Partners

What is your organization's fiscal year?

List other current funding sources and amounts for this program

Do you have restricted funds? If so, please explain the restrictions.

Does your organization have any indebtedness?

Will this program continue after the grant period?

Do you have a reserve fund?

Dates for fundraising activities

Does your organization plan any capital campaigns in the near future?

Did Your Organization Receive Funds from UWEP in 2019?

Does your organization have a profile on VolunteerEP.org?

Has your organization participated in the Quarterly Partner Agency Meetings this year?

Has your organization supported the United Way community campaign this year?

If yes, mark all that apply:

Other

Did your organization participate in the Unity Campaign?

Did your organization participate in Day of Caring?

Upload your Program Financial Data and Proposed Budget

Upload Self-Certification Checklist

Upload Board Minutes

Upload Most Recently Completed Financial Review or Audit and Management Letter

Upload Most Recently Completed IRS Form 990 or Proforma 990

Upload Most Recent Fiscal Year Organization Budget

Upload Balance Sheet Report as of December 31, 2019

Upload Current List of Board Membership

Upload Copy of 501(c)(3) Tax Exemption Letter from the IRS

Does your agency have a Conflict of Interest policy? If no and approved for funding, you will be asked to create one. A sample is available.

Does your agency have a Whistle Blowers policy? If no and approved for funding, you will be asked to create one. A sample is available.

Additional Documents

I hereby certify and affirm that all statements and documents enclosed in this application are accurate.

Name

Title

2020-2021 Community Impact Grant Application

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