United Way of Jefferson County 2025 Grant Application

United Way of Jefferson County 2025 Grant Application

Due March 15, 2024 5:00PM
Agency Legal Name*
Agency DBA Name (other than legal name)
Address*

Street Address

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

CityState / 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*

2025 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
2024 Grant Award
2023 Grant Award
2022 Grant Award
2021 Grant Award
2020 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*

OngoingNew
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.?*
18. What kind of special events/mailings do you have planned for 2024.*
19. Request for an exemption of an event/funding campaigns during the United Way black out period of September 1-November 30, 2025. (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 2023. 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 2023. (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 2022 adults/children/families served. If your agency runs on a fiscal calendar, then you can report services statistics from July 1, 2022-June 30, 2023.

	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
Toronto
Unionport
Yorkville
Other areas within Jefferson County not listed above
Total Harrison County Residents served.
Total all other counties residents served.

ADULT RESIDENTS: Total Jefferson County Residents
ADULT RESIDENTS: Total All Residents Served
CHILDREN RESIDENTS: Total Jefferson County Residents
CHILDREN RESIDENTS: Total All Residents Served
FAMILY RESIDENTS: Total Jefferson County Families
FAMILY RESIDENTS: Total All County Families 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.

	2023	2022	2021
Individuals Served

Volunteers Statistics. Please fill in the section below with your agencies volunteer information for 2023, 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 Not Listed
Volunteers 2023
Volunteers 2022

Volunteer Statistics B*

	Under 18	18-25	26-45	46-65	Over 66
Volunteer Ages 2023
Volunteer Ages 2022

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
Type of Volunteer 2023
Type of Volunteer 2022

Total Number of Volunteers: 2022
Total Number of Volunteers: 2023

Volunteer Statistics D*

	Hours
Total All Volunteers Hours 2023
Total All Volunteers Hours 2022

Total In-Kind Value of 2022 Volunteer Hours x 29.95
Total In-Kind Value of 2023 Volunteer Hours x 31.80

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 of Program Major Sources of Funding (Number 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 of Agency Major Sources of Funding (Number 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*

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File Upload: Program Brochure/Flyer 1

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

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File Upload: Agency Budget*

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File Upload: Agency Program Budget*

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File Upload: Budget Form Program Staff Salaries *

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File Upload: 990 (Most recent or must include January 2022)*

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File Upload: Audit (If required)

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

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File Upload: Secretary of State of Ohio Certification*

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

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

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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.

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File Upload: Agency Fundraising Mailer/Collateral piece used in 2023*

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File Upload: Agency Fundraising Mailer/Collateral piece used in 2022

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File Upload: Agency Fee Schedule (If Applicable)

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

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

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File Upload: Optional, letters of commitment of collaborating organization.

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

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

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Should be Empty:

	Yes	No
Provides health or human services in Jefferson County in the state of Ohio and is eligible to receive tax deductible donations within the meaning of the IRS Code Section 170 (c) (1) or (2), which includes 501 (c) 3 organizations.
Does the Agency have a current tax exempt status with the IRS as a 501 (c) (3) charitable, non-profit organization?
Does the Agency have its own federal tax exemption status?
OR Does the Agency instead operate under another organization? Is the Agency registered with the Ohio Attorney General as a Charitable Organization?
Does the Agency file a regular 990 with the IRS each year?
Is the Agency governed by a volunteer board of directors consisting of members from the general community?
Has board meetings at least four times per year. (In-person or online)
Has at least one, paid full time or FTE staff person(s).
OR Has at least one, directing volunteer staff person(s).
Has been in business at least two years.
Has By-Laws.
Has an affirmative action policy, non-discrimination policies.
Provides Directors & Officers insurance.
Has liability insurance.
Has fiscal policies and procedures.
Has personnel policies & procedures.
Has Articles of Incorporation.
Will conduct a workplace campaign to benefit the United Way of Jefferson County.
Does the Agency have a United Way logo sign publicly displayed at the agency? (OR if new applicant will do so).
Does the Agency use the United Way logo and membership on their stationery, publicity, newsletters, and all appropriate correspondence and do you also mention your United Way relationship in all media correspondence? (OR if new applicant will do so).
Does the Agency agree to comply with the terms of the Member Agency Agreement if funded?
Does the agency keep records of the clients/participants it serves?
Does the Agency have appropriate licenses for the operation of programs requiring such? If so who licenses your agency? (If N/A select yes)
Is the Agency and program handicap accessible?
Does the Agency charge fees? If yes, fill out a fee schedule later in this application.
Does the agency have specific requirements for an individual to receive services? If yes, please list requirements later in this application.
Does the Agency have a membership fee?
Does the Agency conduct a membership drive/campaign?
Is the Agency affiliated with a regional or national organization?
Does the Agency conduct background checks on staff?
Does the Agency conduct background checks on volunteers?
Is the Agency registered with the Ohio Attorney General's office as a charitable organization?
Did the Agency update the annual registration with the Ohio Attorney General office by the November 15, 2021 deadline?
Is the Agency registered and current with the State of Ohio office of the Secretary of State?
Does the Agency have a physical address in Jefferson County in the State of Ohio?

	Comply	Do Not Comply
This organization is not on any federal terrorism “watch lists,” including the list in Executive Order 13224, the master list of specially designated nationals and blocked persons maintained by the Treasury Department, and the list of Foreign Terrorist Organizations maintained by the State Department.
This Organization does not, will not, and has not knowingly provided financial, technical, in-kind or other material support or resources * to any individual or entity that is a terrorist or terrorist organization, or that supports or funds terrorism.
This Organization does not, will not, and has not knowingly provided or collected funds or provided material support or resources with the intension that such funds or material support or resources be used to carry out acts of terrorism.
This Organization does not, will not, and has not knowingly provided or collected funds or provided material support or resources with the intension that such funds or material support or resources be used to carry out acts of terrorism.
This Organization does not re-grant to organizations, individuals, programs and/or projects outside of the United States of America without compliance with IRS guidelines.
This Organization does not re-grant to organizations, individuals, programs and/or projects outside of the United States of America without compliance with IRS guidelines.
This Organization does not re-grant to organizations, individuals, programs and/or projects outside of the United States of America without compliance with IRS guidelines.