2021 United Way of the Adirondack Region, Inc. RFP Application

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2021 RFP APPLICATION
CHECKLIST FOR SUBMITTING 2021 UNITED WAY MEMBERSHIP

Please submit the following to United Way by February 19, 2021:
Agency Name: *
Important: In order to complete this application, you must have your letter of official request for membership, your most recent agency audit & management letter, and annual report (including 990) ready to upload. Use the checklist below to begin this application. *
Please use the Browse Files button below to upload your Letter of Official Request for membership, your most recent agency audit, management letter and annual report (including 990). *

After you have selected your files for upload, please click 'Next' to continue to sections 2:2-3:1
Cancel of

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UNITED WAY OF THE ADIRONDACK REGION, INC. AGENCY INFORMATION REQUEST FORM
In order to maintain records in our office and get the necessary materials to you, we need to know some pertinent information. Please fill out the form below and return it to the United Way office by February 19, 2020. *
Agency Description (25 words or less): *

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NATIONAL TAXONOMY OF EXEMPT ENTITIES

(Needed for the State Employees Federated Appeal)
Agency Name: *
Each organization needs to self-identify up to three categories, in priority order, which most closely identifies the type of mission, services, and activities provided. *
Prioritize your chosen categories: *

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CERTIFICATION
Current in Filing: *
Determination: *
Charitable Services: *
Annual Audit: *
Date of last completed audit and IRS Form 990: *
Organization Fiscal Year ends at the end of: *
Non-Discrimination: *

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OUTCOME REPORT FOR AGENCIES REQUESTING UNITED WAY MEMBERSHIP
Agency Name: *
Amount Received from United Way in 2020: *
Programs/Activities Supported by United Way Funds in 2020: *
Brief Description of Agency Activities/Services Supported by United Way Funds in 2020: *
Measurable Results (Outcomes):
In the field below, how did you measure the impact of the activities and services that have been supported by United Way funds?
Be Specific; provide measurable indicators of success for each activity and service listed above.

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AGENCY BENEFICIARY STATISTICS-ENTIRE AGENCY OPERATION

(All programs & services)
The data displayed below represents the number of individuals in Clinton, Essex & Franklin Counties as well as out of area that have taken advantage of the programs and services being provided by your agencies during 2020:

Number of individuals who've taken advantage of program:

Number of Individuals

Clinton County

Essex County

Franklin County

Out of Area

Total Number of Individuals:
AGENCY BENEFICIARY STATISTICS - PROGRAM SPECIFIC

(Need one for each program requesting funds for.)
1.) Program Name:

Number of individuals who've taken advantage of program #1:

Number of Individuals

Clinton County

Essex County

Franklin County

Out of Area

Total Number of Individuals for Program #1:
2.) Program Name:

Number of individuals who've taken advantage of program #2:

Number of Individuals

Clinton County

Essex County

Franklin County

Out of Area

Total Number of Individuals for Program #2:
3.) Program Name:

Number of individuals who've taken advantage of program #3:

Number of Individuals

Clinton County

Essex County

Franklin County

Out of Area

Total Number of Individuals for Program #3:
4.) Program Name:

Number of individuals who've taken advantage of program #4:

Number of Individuals

Clinton County

Essex County

Franklin County

Out of Area

Total Number of Individuals for Program #4:

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RFP Agencies Requesting Targeted Impact Need Funding (Income, Education, Health)

(Complete one form for each program seeking 2021 United Way Funding, up to three).
Agency (Program) Name:
Targeted Impact Need to be Addressed:
Total Cost of Program:
Total Amount From All Other Sources of Program Revenue:
Amount Requested from United Way:
Brief Description of Program Activities/Services:
Measurable Results (Outcomes)
How will you measure the impact of the program activities and services that will be supported by United Way Funds?
Would you like to include another program seeking 2021 United Way Funding?
If yes, please complete next page

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RFP Agencies Requesting Targeted Impact Need Funding

(Complete one form for each program seeking 2021 United Way Funding, up to three).
Agency (Program) Name:
Targeted Impact Need to be Addressed:
Total Cost of Program:
Amount Requested from United Way:
Total Amount From All Other Sources of Program Revenue:
Brief Description of Program Activities/Services:
Measurable Results (Outcomes)
How will you measure the impact of the program activities and services that will be supported by United Way Funds?
Would you like to include another program seeking 2021 United Way Funding?
If yes, please complete next page

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RFP Agencies Requesting Targeted Impact Need Funding

(Complete one form for each program seeking 2021 United Way Funding, up to three).
Agency (Program) Name:
Targeted Impact Need to be Addressed:
Total Cost of Program:
Amount Requested from United Way:
Total Amount From All Other Sources of Program Revenue:
Brief Description of Program Activities/Services:
Measurable Results (Outcomes)
How will you measure the impact of the program activities and services that will be supported by United Way Funds?
Would you like to include another program seeking 2021 United Way Funding?
If yes, please complete next page

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RFP Agencies Requesting Targeted Impact Need Funding

(Complete one form for each program seeking 2021 United Way Funding, up to three).
Agency (Program) Name:
Targeted Impact Need to be Addressed:
Total Cost of Program:
Amount Requested from United Way:
Total Amount From All Other Sources of Program Revenue:
Brief Description of Program Activities/Services:
Measurable Results (Outcomes)
How will you measure the impact of the program activities and services that will be supported by United Way Funds?
Would you like to include another program seeking 2021 United Way Funding?
If yes, please complete next page

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Almost Finished!
Your Name:
Your Job Title:
Your Email Address:
If you would like to review your application before submitting this application, you may do so now by clicking the 'back' button below or use the "print form" to print a copy. Otherwise, plase click the button below to submit your application for review.
Are you sure you're ready to submit your application?
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2021 RFP APPLICATION

CHECKLIST FOR SUBMITTING 2021 UNITED WAY MEMBERSHIP

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UNITED WAY OF THE ADIRONDACK REGION, INC. AGENCY INFORMATION REQUEST FORM

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NATIONAL TAXONOMY OF EXEMPT ENTITIES

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CERTIFICATION

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OUTCOME REPORT FOR AGENCIES REQUESTING UNITED WAY MEMBERSHIP

Measurable Results (Outcomes):

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AGENCY BENEFICIARY STATISTICS-ENTIRE AGENCY OPERATION

AGENCY BENEFICIARY STATISTICS - PROGRAM SPECIFIC

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RFP Agencies Requesting Targeted Impact Need Funding (Income, Education, Health)

Measurable Results (Outcomes)

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RFP Agencies Requesting Targeted Impact Need Funding

Measurable Results (Outcomes)

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RFP Agencies Requesting Targeted Impact Need Funding

Measurable Results (Outcomes)

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RFP Agencies Requesting Targeted Impact Need Funding

Measurable Results (Outcomes)

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Almost Finished!