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.
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.
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.
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.
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.
2021 United Way Counterterrorism Form
Certification for Organization Seeking Funding
In compliance with the spirit and intent of the USA Patriot Act and other counterterrorism laws, the United Way of Jefferson County requests that each funded agency certify that it is in compliance with the United Way of Jefferson County’s and the United Way Worldwide's compliance program prior to be a Funded Partner.
*In this form, “material support and resources” means currency or monetary instruments or financial securities, financial services, lodging, training, expert advice or assistance, safehouses, false documentation or identification, communications equipment, facilities,weapons, lethal substances, explosives, personnel, transportation, and other physical assets,except medicine or religious materials.
I certify on behalf of the Organization listed above that the foregoing is true.
Print Name:First Name Last Name Title: blank Date*
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