United Way of Jefferson County 2022 Grant Application

United Way of Jefferson County 2022 Grant Application
Agency Legal Name *
Agency DBA Name (other than legal name)
Address *

Street Address

P.O Box Number if Applicable (Type N/A if not)

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Fax Number *
Please enter a valid phone number.
EIN *
Website URL
Name of Person Completing Application *
Email *
example@example.com
Title *

2022 Grant Amount Request *
United Way funds programs that comprehensively focus on solving the priority needs identified by the United Way Community Impact Initiative as identified by United Way Worldwide. These are (and can include but are not limited to): Education, Health & Wellness, Financial Stability and Basic Needs. Granted funds can only be applied for the use of programs/projects that provide a direct service to an individual or family. Grants will not be considered for capital improvements.

Amounts of Previous Grant Awards. (Put 00 if no grant was awarded in a year or if you are a new agency applying). *

Amount Awarded

Amount Adjusted if Any

2021 Grant Award

2020 Grant Award

2019 Grant Award

2018 Grant Award

2017 Grant Award

1. Organization's Mission Statement *
2. Organization's Vision Statement
Year Organization Was Established *
3. Brief Summary of Organization's History *

Title of Program/Services This Grant Will be Used For *
Is This Program *

Ongoing New
Which of the Following Does Your Program Qualify For? (Select no more than 2)
Months Services are Available (Select all that apply)
Days Services Are Provided (Select all that apply)
Hours of operation. *
Additional hours available to provide services. (If applicable).

4. Summary description of overall program/project to be funded under this grant. *
5. Brief description of population to be served by this program/project. *
6. What is the problem/challenge or need that is unaddressed or unmet? OR What is the community benefit that this program or project will impart? *
7. Timetable for implementation and duration of program/project. *
8. How and with whom will the Agency collaborate on this particular program/project? *
9. How is your program/project different from similar existing projects at other organizations? *
10. Provide specific short-term, intermediate and/or long-term outcomes of this program/project and the time frame within which they will occur. *
11. How will outcomes be measured and who (e.g. staff, consultant, etc.) will measure them? *
12. How will the results be used and disseminated by your organization and/or by others? *
13. How will the project/program constituents and/or clients be actively involved in the evaluating the program/project? *
14. Please list prior year achievements if this is an ongoing project. (enter N/A if this is new project). *
15. Are you expecting funding from any earned revenue? If yes. please explain.
16. Are you expecting funding from any in-kind support such as, volunteer’s hours and financial value of those hours, in-kind services provide your agency and the value of those services, etc.? *
17. What special events did your Agency have scheduled in 2020? Were you able to have them? Due to Covid-19 please share what challenges you faced and some of the ways you we able to overcome event losses. *
18. What kind of special events/mailings do you have planned for 2021. *
19. Request for an exemption of an event/funding campaigns during the United Way black out period of September 1-November 30, 2022. (If applicable).
20. Do you have a sliding fee scale? If yes, please upload your fee schedule at the end of this application.
21. Does Your organization charge fees? If yes, are services at no cost to those in poverty levels? *

Impact Report of Service Statistics for the calendar year 2020. Numbers must be based on what the United Way of Jefferson County funded: specific services of your agency. Instructions: Each individual is to be counted one time only for the year 2020. (Even if they receive multiple services). Note: number of families equals family units served. (Not number of adults served plus number of children served). If you are a new agency applying, enter your 2020 adults/children/families served. If your agency runs on a fiscal calendar, then you can report services statistics from July 1, 2019-Jume 30, 2020.

Number of Adults Served

Number of Children Served

Number of Families Served

Steubenville

Wintersville

Adena

Amsterdam

Bergholz

Bloomingdale

Brilliant

Dillonvale

East Springfield

Empire/Statton

Irondale/Hammondsville

Mingo Junction

Mount Pleasant

New Alexandria

Rayland

Richmond

Salinesville

Smithfield

Tiltonsville

Unionport

Yorkville

Other areas within Jefferson County not listed above

TOTAL JEFFERSON COUNTY RESIDENTS SERVED

Total Harrison County Residents served.

Total all other counties residents served.

Individuals Served Annually. Number of individuals your agency served for the program being funded by United Way of Jefferson County in Jefferson County: USE UNDUPLICATED NUMBERS. Example: If an individual visits your agency once a month for service, you count that individual one time not twelve times. Do not include individuals not served by United Way funding. Volunteers cannot be counted as individual services. Individuals must receive an actual service from the agency that can be documented by the agency.

2021 Expected

2020

2019

2018

Individuals Served

22. How did Covid-19 impact the number of individuals your Agency served in 2020 compared to 2019? For example: did those served needs increase, did you have to reduce/increase services, etc.? *
23. How did you adjust the way services were provided, how was the agency staff effected and how was the day to day workplace environment effected, impacted, etc.? *
24. What adjustments have you put into place to provide services in 2021? *

Volunteers Statistics. Please fill in the section below with your agencies volunteer information for 2020, unless otherwise specified.

Keep in mind that total volunteers in statistics a, b & c should equal the same number of volunteers when you add them across.

Volunteer Statistics A *

Number of Male

Number of Female

Number of LGBTQ

Number of Not Listed

Total all Volunteers

Volunteers 2020

Volunteers 2019

Volunteer Statistics B *

Under 18

18-25

26-45

46-65

Over 66

Total All Ages

Volunteer Ages 2020

Volunteer Ages 2019

Volunteer Statistics C *

From the Community

From another agency

From a College/
University

Form a High School

From a Day of Action

From other sources

Total All Volunteer Types

Type of Volunteer 2020

Type of Volunteer 2019

Volunteer Statistics D *

Hours

Total All Volunteers Hours 2020

Total All Volunteers Hours 2019

Volunteer Statistics E *

Total Value of Volunteer Hours

Total All Volunteers Hours 2020 x $27.50

Total All Volunteers Hours 2019 x $25.43

25. Volunteer Challenges due to Covid-19. Please share the challenges/impact you have had/felt with not being able to use volunteers during the pandemic. Also, you can share the differences from the previous year. Have you learned/used different resources during this time?

Program Major Sources of Funding *

Percentage

% United Way of Jefferson County

% Other United Ways

% Monetary Contributions (Individuals/Corporations)

% Special Events/Fundraisers

% Products/Services

% Miscellaneous Revenue/Support (Investment income/contracts/endowment revenue)

Total Percentage should equal 100%

Agency Major Sources of Funding *

Percentage

% United Way of Jefferson County

% Other United Ways

% Monetary Contributions (Individuals/Corporations)

% Special Events/Fundraisers

% Products/Services

% Miscellaneous Revenue/Support (Investment income/contracts/endowment revenue)

Total Percentage should equal 100%

List of other funders to whom this current proposal has been and will be submitted.

Funder Name

Date submitted/to be submitted

Amount Pending

Amount Funded

Declined

Funder 1

Funder 2

Funder 3

Funder 4

Explanation of Restricted Funds

List any restricted funds for your agency below. If you do not have restricted funds, please skip to the next section.

Answer

Name of Restricted Fund A

Amount

Restricted By Source or Board

Source of Fund

Are investment earnings available for current unrestricted expenses?

Date when restricted became effective

Date when restriction expires

Answer

Name of Restricted Fund B

Amount

Restricted By Source or Board

Source of Fund

Are investment earnings available for current unrestricted expenses?

Date when restricted became effective

Date when restriction expires

Answer

Name of Restricted Fund C

Amount

Restricted By Source or Board

Source of Fund

Are investment earnings available for current unrestricted expenses?

Date when restricted became effective

Date when restriction expires

Answer

Name of Restricted Fund D

Amount

Restricted By Source or Board

Source of Fund

Are investment earnings available for current unrestricted expenses?

Date when restricted became effective

Date when restriction expires

What is your agency’s administrative overhead cost percentage?

Note: This cost MUST BE LESS THAN 28%. Otherwise, you must include an explanation below and the plan to reduce these costs to less than 28% at the time of application. This explanation must be more than just a plan to raise more funds.
If the agency does not file a regular IRS Form 990, the agency must still complete at the minimum page 1 and sign it, and pages 9 and page 10, all from the regular IRS Form 990. This is for United Way purposes only. The correct 990 is found on the IRS website at www.irs.gov and it is easy to complete. If the IRS does not require your organization to file the Form 990 or requires you to file another form, you must still complete the regular IRS 990. IRS Forms 990 EZ, 990PF, and comparable forms are not acceptable. These IRS 990 forms are for application purposes only and will not be filed with the IRS. Please attach a copy of the most immediate year to this application, even if you have already submitted it to our office at another time. A fillable Form 990 is available on our webpage.

Fill in the information from the most recent 990 that is uploaded with this grant application. *

Amount

1.) Page 10, Line 25 Column C: Management & General Expenses

2.) Page 10, Line 25 Column D: Fundraising expenses

3.) Page 10 Total line 25 Column C+D

4.) Page 9, Line 12, Column A Total Revenues

5.) Total Administrative %. Divide Total #3 into Total #4

26. Explanation and plan to reduce administrative costs to less than 28%, If needed: OR attach explanation letter at the end of the application.

Agency Certification Letter
I certify that the as a representative of Type agency name duly noted the above Funding Request is presented to the United Way of Jefferson County for confidential use in its Funding process.
I agree and understand that any falsification of information herein, regardless of the time of discovery, may cause forfeiture on our part of any funding by United Way of Jefferson County.
I certify that, to the best of my knowledge, the agency has the financial capacity to deliver the programs for the period of time covered by this application.
In addition, I certify that to the best of my knowledge, we are in compliance with any legislation, ordinance, codes, taxation laws, rules and regulation applicable to not-for-profit organizations.

Name of person completing this section:     First Name   Last Name
Title:
Date
Signature

File Upload: Agency Brochure/Flyer *

Cancel of
File Upload: Program Brochure/Flyer 1

Cancel of
File Upload: Program Brochure/Flyer 2 (If you have an additional flyer you wish to share, upload here).

Cancel of
File Upload: Agency Budget *

Cancel of
File Upload: Agency Program Budget *

Cancel of
File Upload: Budget Form Program Staff Salaries *

Cancel of
File Upload: 990 (Most recent or must include January 2019) *

Cancel of
File Upload: Audit (If required)

Cancel of
File Upload: IRS 501 (c) 3 Verification Letter *

Cancel of
File Upload: Secretary of State of Ohio Certification *

Cancel of
File Upload: Verification of Registration with the Ohio Attorney General's Office *

Cancel of
Agency Board Member List. The list should include board member name, position if an officer, email, phone number & mailing address. *

Cancel of
File Upload: Agency Local Jefferson County Advisory Council, if applicable. The list should include member name, position, if an officer, email, phone number & mailing address.

Cancel of
File Upload: Agency Fundraising Mailer/Collateral piece used in 2020 *

Cancel of
File Upload: Agency Fundraising Mailer/Collateral piece used in 2019 *

Cancel of
File Upload: Agency Fee Schedule (If Applicable)

Cancel of
File Upload: Explanation of Plan to Reduce Administrative Costs. Upload only if your costs are above 28%.

Cancel of
File Upload: Specific requirements for an individual to receive services if you answered yes to this question in the Agency Eligibilities and Assurances Section.

Cancel of
File Upload: Letters of commitment of collaborating organization. Optional.

Cancel of
File Upload: Additional piece 1: Optional, if there is an additional document you wish to share.

Cancel of
File Upload: Additional piece 2: Optional, if there is an additional document you wish to share.

Cancel of
Should be Empty: