United Way of Greater Fort Dodge

United Way Grant Application

2014-2015

Applications are due July 16th, 2014

_________________________________________Agency

Please include each of the following:

___ Funding application

___ Agency description (400 words or less)

___ 501(c) 3 IRS determination letter

___ Copy of your IRS 990 form

___ Attachment A (Board of Directors)

___ Attachment B (Agency Activity)

___ Certificate of Performance (Background Checks)

___ A recent audit may be requested but does not need to be included in this application

Community Impact Areas

Building Youth

One of our community’s most precious resources is our children, but much of their potential is going unrealized. Poverty and the social ills that accompany it conspire to rob them of the gift of each new generation. Locally, we can do little to affect the ills of the nation, but we do have ability to impact the quality of children’s lives in our own community. It is critical we apply our resources in ways that will make a difference in their lives.

Funding from the Fort Dodge Community Foundation and United Way will be allocated to agencies and organizations that offer programs and services that will help youth thrive and reach their full potential academically, socially and developmentally.

Building Families

The importance of the family in the society is essential and it requires our attention. The moral and economic stability of the family contributes to the fundamental stability of our economy and our culture in our community and our nation. Children thrive when they are part of safe, nurturing and strong families. The family is one of the most important units of society. It plays an essential role in fulfilling the emotional and physical needs of youth, which is necessary for the achievement of economic and social development. The family unit has to be supported and sustained.

The Fort Dodge Community Foundation and United Way has identified ten strategic priorities that are critical to our long-term goal of building strong youth and strong families. United Way funding priority will be given to organizations and agencies that are addressing one or more of the eight strategic priorities listed here. Using the United Way of America’s Community Impact Model, priority will be given to projects and programs that are collaborative and are able to meet measurable outcomes.

Strategic Priorities

Hunger Homelessness

Education Strong Families

Public Safety Early Childhood Development

Emergency Support Positive Youth Development

Health & Wellness Mental Health

Fort Dodge Community Foundation and United Way

Request for Funding: Community Impact Funds

Grant Year: 2014 - 2015

Organization Name

Director or C.E.O.

Phone:

Email:

Address:

Federal Identification Number (EIN number)Number of employees Full-time:

Part-time

Annual Payroll

Grant Amount Requested Total Program Cost2014-2015

Community Impact Project Title:

(400 words or less). Please provide a summary of how your organization proposes to address a community impact area identified above. Please state your program goals and expected outcomes. Briefly describe the activities, processes, systems and methods for delivering the services that will accomplish these goals. Describe the strengths, assets and experience your agency has that qualifies it for administering the program effectively. Explain any collaboration, partnering or sharing of resources involved in the program.

RESOURCESDescribe the elements and resources that constitute this program. Resources would include staff, volunteers, facilities, equipment, other funding sources, etc.

ACTIVITIESDescribe the activities, methods and processes that will be used to achieve your goals for this program.

DEMOGRAPHICSIf possible, please identify (by number or percentage) the age categories, gender and socio-economic status of the people that your organization serves.

Identify the total estimated number of people served:

2014 – 2015 _______________

PROGRAM OUTCOMESIdentify program outcomes and measurable benefits that you expect to achieve. Outcomes include such things as changes in personal welfare, behavior, skills, knowledge, attitude, etc. Describe your data collection process and your plan for measuring results and evaluating program outcomes.

AGENCY BUDGETFOR FISCAL YEAR 2014

This is your agency budget for operations in the Fort Dodge - North Central Iowa area.

FISCAL YEAR COVERED BY PROPOSED BUDGET:

_____ Jan. 1, 2014 – Dec. 31, 2014 _____ July 1, 2014 – June 30, 2015 _____ Other

REVENUE Current Budget

Proposed Budget

Percent Change(+ or -)

Fort Dodge Community Foundation and United Way

Foundations & Private Grants

Government Grants

Fundraising & Special Events

Program Service Fees

Other Revenue

TOTAL REVENUE

EXPENSE Current Budget

Proposed Budget

Percent Change(+ or -)

Salaries, Benefits, & Taxes

Program Supplies & Equipment

Occupancy & Utilities

Travel & Vehicles

Specific Assistance to Individuals

Miscellaneous Expense

TOTAL EXPENSE

MARGIN (DEFICIT)

If you have any miscellaneous information, comments or data regarding your program that will support your application for funding, please provide this information here or attach the information to this application.

__

The undersigned certifies that the information provide in this application for funding is accurate and that he/she has the legal authority to represent the agency or organization.

_________________________________Organization

__________________________________ __________________Signature of Executive Director Date

__________________________________Printed name

Agency Summary

Please provide a 200 word or less summary of your organization that can be used to describe your organization, your mission, the services you provide, etc. Please include basic information such as the number of employees you have, the number of people you serve, the number of years you have been operating, etc. This information may go on the Fort Dodge Community Foundation and United Way web site, and with your permission, may be used in a public communications effort with the Messenger newspaper and other media outlets.

Certificate of PerformanceStaff/Volunteer Background Checks

Because the Fort Dodge Community Foundation and United Way believes the safety of persons served through the Foundation funded programs is very important, agencies receiving funding are required to complete and return this Certification of Performance prior to receipt of the first community investment grant payment.

____________________________________hereby certifies that all staff and volunteers who provide Agency direct service/support to vulnerable populations (minors, seniors, persons with disabilities, etc.) have passed criminal and abuse registry background checks prior to supervising a Fort Dodge Community Foundation and United Way funded program participants or participating in unsupervised activities with Fort Dodge Community Foundation and United Way funded program participants.

Signed:

Executive Director

Date

ATTACHMENT A

BOARD OF DIRECTORS(Please provide the most current list of your Board of Directors)

Authorized number of directors, according to your AGENCY by-laws:

Term of Office:____________________________________

Board President:___________________________________

Address: _________________________________________________

Phone # ______________ Email: ____________________________

Director Name Director Name

How often did your Board of Directors meet during the last 12 months? ____________

ATTACHMENT B

AGENCY ACTIVITY

During the past 12 months: Y N1. Were you unable to make any employee payrolls in full or

on time?2. Were you unable to pay any bills within 60 days of the due

date?3. Did you lose your 501 (C) 3 Tax Exempt status?

4. Did you buy or sell any real estate?

5. Did you hold any fundraising events in which expenses exceeded 50% of the gross?

6. Did you become or remain delinquent in the transmission of employee payroll taxes to the IRS or the state of Iowa?

7. Were any legal suits filed against you asking for judgment in excess of 2% of your organization’s total assets?

8. Did United Way withhold any payments from your agency?

9. Did you request an advance payment of your United Way allocation?

10. Were any major revenue sources either non-recurrent or known to be uncertain as to continuation?

11. Did your AGENCY operate in a deficit in the past? Does it now? Do you foresee a deficit situation in the near future? If so, please attach your plans for eliminating the deficit.

Please explain any YES answers with attached sheets.

Fort Dodge Community Foundation and United Way

POLICY AGAINST COERCION

Approved by the Board of Directors March 20, 2002

The Fort Dodge Community Foundation and United Way knows that fundraising success depends on how much potential donors know and understand about organizations seeking support. Fundraising always should be conducted in a voluntary manner; coercion creates animosity, hinders communication and understanding, and eventually leads to decreased support.

United Ways across the country have been concerned for years about the use of undue pressure in fundraising and are opposed to any type of coercion. Any semblance of pressure – whether real, implied, or perceived – is contradictory to the United Way operating standards. The United Way continually strives to prevent the use of coercion in their Campaigns by encouraging peer solicitation, rather than solicitation of employees by managers. In addition, United Way training programs are conducted for fundraisers that stress information and education, and discourage the practice of seeking 100 percent participation in the Campaign, as that may inadvertently encourage coercion.

To underscore our conviction about this policy, the Fort Dodge Community Foundation and United Way Board of Directors adopted the following policy statement:

The Fort Dodge Community Foundation and United Way Board of Directors believes that the most responsive contributors are those who have the opportunity to become informed and involved. A well-planned Campaign with an effective communications program conducted by committed volunteers will ensure responsive contributors. While we have always been unalterably opposed to coercion, we do recognize a responsibility to state our beliefs formally, as freedom of choice is a basic tenet of our democratic society.

Giving is a personal matter and decision; no form of coercion is acceptable to the Fort Dodge Community Foundation and United Way.