Grant Form

ALLOCATIONS GRANT APPLICATION

Application Deadline - May 10, 2024
Contact Information
Full Legal Organization Name*
Organization Website*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization President / Executive Director*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
E-Mail Address*
example@example.com
Contact Person*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
E-Mail Address*
example@example.com

Organization Information
501(c)(3)?*

YesNo
Year Established
FEDERAL TAX ID EIN#*
File Upload - 501c3 Letter of Determination *

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File Upload - List of Board of Directors*

List of all officers, and/or Board of Directors. Include names, titles, addresses, email, contact numbers.
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Total # of Board Members
Total # of Staff
File Upload - List of Paid Workers*

List of any paid workers of your agency. Include total amount of gross compensation paid in last fiscal year.
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Organization Mission Statement
Brief Description of Organization
Description of Organization Programs

Geographic Area Served
List of Towns/Cities and number served
Population Served in Athens, LaRue, New York, TX, LaPoynor
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Chandler, TX, Murchison, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Gun Barrel City, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Brownsboro, Moore Station, Poynor, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Eustace, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Mabank, Payne Springs, Enchanted Oaks, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Vand Zandt County
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Trinidad, Cross Roads TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Malakoff, Antioch, Caney City, Log Cabin, Star Harbor TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Seven Points, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Tool, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Kemp, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Population Served in Berryville, Coffee City, Frankston, TX
Number of Adults, Men, Women, Children, Ethnicity Metrics
Please Explain any Service Challenges or Gaps in Service experienced this past year?
Organization Diversity Statement
Diversity Equity Inclusion
We participate in the United Way Annual Campaign in the following ways:
Diversity Equity Inclusion
Total Organization Budget*
File Upload - Current Annual Budget *

Current year itemized report of anticipated revenue and sources itemized detailed report of all proposed usage of funds.
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File Upload - Balance Sheet Last Fiscal Year-end*

Balance Sheet reflecting all assets and liabilities as of the last fiscal year-end (include fund balances).
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File Upload - Profit & Loss Statement Last Fiscal Year-end*

Profit & Loss Statement itemized detailed report of all (revenues) sources and uses (expenditures) from each source during the last fiscal year and since last fiscal year-end.
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File Upload - Most recent IRS Form 990

Most recent IRS Form 990
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Organization General & Management costs (IRS 990, Part IX, Line 25 Column C)*
IRS 990, Part IX, Line 25 Column C
Fundraising costs (IRS 990, Part IX, Line 25 Column D)*
IRS 990, Part IX, Line 25 Column D
Total Revenue (IRS 990, Part VIII, Line 12 Column A)*
IRS 990, Part VIII, Line 12 Column A
Administrative Percentage % (Organization General & Management costs + Fundraising Costs divided by Total Revenue)*
Organization General & Management costs + Fundraising Costs divided by Total Revenue
Funding Request
Program / Project Name
Total Program/Project Budget*
Requested Amount*
Percent of Organization Budget*
Type of Request*
Describe in detail the program for which you are requesting funding.*
What impact area(s) does this program serve? What is your target population? Detailed overview of the program service(s) and specific activities to be provided to your clients. List the resources dedicated to the program: staff and staff time, volunteers, community collaborations with other agencies, facilities, funding, equipment and supplies. Also list any constraints on the program.
What else would you like the Allocations Committee to know about your program?
Most recent grants received from this funder:
Last Funding Cycle Requested $
Last Funding Cycle Awarded $

Agreement with Participating Members

For the purpose of sharing the joint fund to be raised by the Henderson County United Way, each member organization so sharing shall agree: a) Henderson County United Way works because of the collective sharing of resources by the members of the community. In that same spirit we expect agencies and programs assisted by United Way to participate in, and generously support those sponsored events and activities of the Henderson County United Way intended to further its mission in Henderson County. b) After being given full consideration and hearing to accept the apportionment of funds made to it by the Allocations Committee and approved by the Board of Directors. c) To maintain a responsible management, with a qualified Board of unpaid directors of administrative committees which will meet at least (4) four times a year. d) To cooperate with other social agencies in preventing duplication of effort, and in promoting effective service, efficiency, and economy of administration. e) To keep complete and regular books of accounts open to inspection by a representative of the Henderson County United Way. f) To file with the Henderson County United Way at the end of each fiscal year and otherwise upon request, a certified copy of a complete and satisfactory audit of all accounts and holdings of the organization, unless exempted by the Executive Committee of the Henderson County United Way. To submit to this organization such other reasonable information concerning finances, programs, etc., and in such form as the Board of Directors may require. g) Any agency can call upon the Henderson County United Way for portions of its budgeted financial needs in advance of the final distribution of general funds, by presenting to the Allocations Committee a formal written request for funds which the Henderson County United Way Board of Directors will evaluate. h) Annually, upon completion of the general fund drive, the Board of Directors shall appropriate all budgeted funds according to the approved budgeted needs of each agency, and shall direct the Treasurer to pay over to each agency its portions of such funds, in quarterly payments, less and advances which may have been made in accordance with paragraph g) of this section. The Board may advise the Treasurer to pay funds that the agencies are to receive over the next twelve (12) months in some manner other than on quarterly payment. i) As a condition to receiving funds from the Henderson County United Way we agree to make contact with potential volunteers, as well as our own board members, to help participate in and assist in with the 2024-2025 Henderson County United Way Campaign scheduled to begin September 2024.
We hereby certify the above Agency has agreed to abide by the Henderson County United Way Agreement with Participating Members.
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ALLOCATIONS GRANT APPLICATION

Contact Information

Organization Information

Funding Request

Most recent grants received from this funder:

Agreement with Participating Members