PROGRAM FUNDING APPLICATION

PROGRAM FUNDING APPLICATION

ORGANIZATIONAL INFORMATION
Organization Name:*
EX: ABC Towing, LLC
Executive Director/CEO:*
Business Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone:*
Business Phone Number
Fax Number:*
Business Fax Number
E-Mail:*
example@example.com
Website*
Business Fax Number
Employer Identification Number:*
Business Fax Number
PROGRAM INFORMATION

(COMPLETE AN APPLICATION FOR EACH PROGRAM THAT YOU ARE REQUESTING FUNDING FOR)
Program Name:*
Program Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Amount of Annual Funding Request:*
YesNo
TARGET POPULATION
1.) Describe your program’s target population and experience serving this population
2.) What criteria do you use to determine program eligibility?
3.) How do you locate participants for your program and assess their needs?
4.) How many participants do you anticipate attending on an annual basis? *
PROGRAM DESIGN
6.) Please answer the following questions relating to the program for which you are seeking funding.
a. What are your days and hours of operation?
b. What core services do you provide through your program?
c. What research or evidence supports the use of these services?
d. What additional services do you provide through other programs or in your organization?
e. Describe any specific partnerships you have with other agencies to meet your participants’ needs
f. How is your program different from other programs offering similar services in the community?
7.) Please describe your current program’s use of volunteers.
8.) What community efforts are your program staff or volunteers involved in related to the identified result?
9.) What percentage of your program is requesting funding from United Way?*
10.) What percentage of budget goes to administration?*
11.) Has this program been funded in the past? If so, how many years? If yes, are you requesting increased funding and why?
12.) Discuss how data collection is undertaken in your program including specific tools and methodology used to track performance.
a. Discuss your use of program performance information and other feedback (including customer satisfaction) to improve program performance.
b. Who is involved in reviewing program outcomes and other feedback?
c. How often are reviews undertaken?
d. What process is used?
PROGRAM BUDGET

Rows	ANNUAL PROGRAM BUDGET	UWGN REQUESTED FUNDS	OTHER FUNDING RESOURCES
PROGRAM PERSONNEL
Personnel
Full Time
Part Time
Fringe
PROGRAM PERSONNEL TOTAL
PROGRAM NON-PERSONNEL
Program Administration
Occupancy/Utilities
Program Supplies
General Office Supplies
Marketing Materials
Printing / Copying
Mailings / Postage
Telephone / Internet
Equipment
Equipment Maintenance/Repairs
Local Travel
Conference Travel
Participant Incentives
Volunteer Incentives
Professional Fees
Interpretation Assistance
Evaluation
Other:
Other:
PROGRAM NON-PERSONNEL TOTAL
TOTAL PROGRAM BUDGET

PROGRAM REVENUE SOURCES

Rows	AMOUNT	SOURCE
PROGRAM PERSONNEL
Grants
Foundation
Local
State
Federal
Contracts
Donations/Member Contributions
In-Kind
Volunteer
Other:
Other:
TOTAL PROGRAM REVENUE

CONCLUSION
14. Is there anything else you would like to share about your program or requested funding?
Other Documents/information to include with program application:
1. Copy of your 501 © 3
2. Copy of your most recent audit and IRS 990
3. Volunteer Board Roster
4. Mission Statement of organization
5. Who else have you asked for funding of this program? (Please be specific)
6. How was this program funded previously?
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Should be Empty:

PROGRAM FUNDING APPLICATION

PROGRAM INFORMATION

TARGET POPULATION

PROGRAM DESIGN

PROGRAM BUDGET

CONCLUSION