ALICE Impact Funding Application
Organization Information
Organization or Company Name:
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Organization Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Phone Number:
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Please enter a valid phone number.
Organization Website:
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example@example.com
Mission Statement:
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Applicant Name:
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First Name
Last Name
Applicant Title:
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Applicant Email:
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example@example.com
Name of Executive Director or CEO:
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Organization EIN:
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Request Information
Grant Request Amount:
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Dollar Amount (i.e. $1,500.00)
Use of Funds Summary:
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Program Information
Program Name and Brief Description:
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Who are the individuals and/or groups you are seeking to impact?
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What are the goals and the anticipated outcomes you hope to achieve through this program?
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Describe how the program will be implemented including timelines and key activities related to implementation:
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How does this program help you to achieve your mission as an organization?
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Which of the United Way ALICE impact focus areas does this program align with and how?
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Asset Limited, Income Constrained, Employed
How will you evaluate the effectiveness of this program?
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What impact will your program have in DeKalb County?
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If this is a current program, what are the successes and weaknesses?
If this is a new program, why do you feel like this program is needed in DeKalb County?
Can United Way help promote this program? If so, how?
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Additional Funding Information
Who else have you requested funds from for this program?
Organization Name
Date Requested
Amount Requested
Status
1.
2.
3.
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5.
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Required Supporting Documents
The following documents MUST be provided as additional attachments when applying:
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Copy of IRS determination letter indicating 501(c)(3) Non-Profit Status
Counterterrorism Compliance Act Form (may be completed online)
Current List of Officers and/or Board of Directors
Copy of Most Recent 990 Form (Federal Tax Return)
Detailed Program Budget with Income/Expenses (including, but not limited to: United Way Requested Funds, Other Sources of Funding/Grants, Organizational Funds, In-Kind Donations)
Signature
Date
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Month
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Day
Year
By signing above, you certify that you have the authorization to sign on the behalf of the organization applying and certify all information is factual to the best of your knowledge.
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Submit
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