2025-26 Allocations Application for Funding - United Way of the Upper Ohio Valley

Total Administrative %. Divide Total #3 into Total #4
Name

First NameLast Name
2025-26 Allocations Application for Funding - United Way of the Upper Ohio Valley

Agency Information
1. Agency Legal Name*
2. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Phone Number*
Please enter a valid phone number.
4. Fax Number*
Please enter a valid phone number.
5. EIN #*
6. Website URL*
7. Year Agency was Established*
8. Agency Executive Director/CEO*

First NameLast Name
9. Agency Executive Director/CEO Email*
example@example.com
10. Agency's Mission Statement*

0/100
11. Brief Summary of Agency's History*

0/500
12. Does the Agency utilize and actively keep updated and current the following (Select all that apply)*

WebsiteX (Formerly Twitter)FacebookInstagramDigital/Physical Newsletter
13. Number of Full Time Employees*
14. Number of Part Time Employees*
Name of Person Completing the Application*

First NameLast Name
Title*
Email*

Funding Requests

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): Healthy Communities, Youth Opportunity, Financial Security, and Community Resiliency. 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.
15. 2025-2026 Amount Request*

16. Amounts of Previous Grant Awards.*

	Amount
2024-2025
2023-2024
2022-2023
2021-2022
2020-2021

Impact Statistics

Impact Report of Service Statistics for the fiscal year July 2023-June 2024. Numbers must be based on what the United Way of the Upper Ohio Valley funded: specific services of your agency. Instructions: Each individual is to be counted one time only for the year. (Even if they receive multiple services). Note: number of families equals family units served. (Not number of adults served plus number of children served).

47. Impact Stats 2023-2024*

	Number of Children Served	Number of Adults Served	Number of Families Served
Hancock County
Brooke County
Ohio County
Marshall County
Wetzel County
Tyler County
Belmont County

48. Individuals Served Annually. Number of individuals your agency served for the program being funded by United Way of the Upper Ohio Valley: 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.*

	2024-25 (YTD)	2023-24	2022-23	2021-22
Individuals Served

Volunteer Information
49. Total Number of Volunteers: July 2024-June 2025 (YTD)*
50. Total Number of Volunteers: July 2023-June 2024*

51. Total Volunteer Hours*

	Hours
Total Volunteer Hours July 2024- June 2025 (YTD)
Total Volunteer Hours July 2023- June 2024

Funding Sources

52. Program Major Sources of Funding*

	Percentage
% United Way of the Upper Ohio Valley
% Other United Ways
% Monetary Contributions (Individuals/Corporations)
% Grants
% 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)*

53. Agency Major Sources of Funding*

	Percentage
% United Way of the Upper Ohio Valley
% Other United Ways
% Monetary Contributions (Individuals/Corporations)
% Grants
% 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)*

54. List of other funders to whom this current proposal has been and will be submitted. Put N/A in top row if none.*

	Funder Name	Date submitted/to be submitted	Amount Pending	Amount Funded	Declined
Funder 1
Funder 2
Funder 3
Funder 4

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 agency 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.

55. 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

Total Administrative %. Divide Total #3 into Total #4*
Attach letter of explanation and plan to reduce administrative costs to less than 28%

Cancelof

Agency Certification Letter
I certify that as a representative of   Type Agency Name*   duly noted the above Funding Request is presented to the United Way of the Upper Ohio Valley 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 the Upper Ohio Valley.
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:      Title*
Date:   Date*
Signature*

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56. Agency Budget Form*

Cancelof
57. 990 and/or Audit (Most recent or must include January 2022)*

Cancelof
58. IRS 501 (c) 3 Letter*

Cancelof
59. Agency Board Member List*

Cancelof
Should be Empty:

	Under 18	18-24	25-34	35-44	45-54	55-64	65+	Total #
Male
Female
Non-Binary/Transgender/Other

	Under 18	18-24	25-34	35-44	45-54	55-64	65+	Total #
Male
Female
Non-Binary/Transgender/Other

	Under 18	18-24	25-34	35-44	45-54	55-64	65+	Total #
Male
Female
Non-Binary/Transgender/Other

	Under 18	18-24	25-34	35-44	45-54	55-64	65+	Total #
Male
Female
Non-Binary/Transgender/Other

	Yes	No
Provides health or human services in Hancock, Brooke, Ohio, Marshall, Wetzel, Tyler counties in the state of West Virginia and/or Belmont 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 agencies..
Does the Agency have a current tax exempt status with the IRS as a 501 (c) (3) charitable, non-profit agency?
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)
Has By-Laws.
Has fiscal policies and procedures.
Has personnel policies & procedures.
Will conduct a workplace campaign to benefit the United Way of the Upper Ohio Valley.
Does the Agency agree to provide volunteers for United Way of the Upper Ohio Valley Events
Does the Agency have a United Way logo sign publicly displayed at the agency?
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 digital media correspondence?
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?

2025-26 Allocations Application for Funding - United Way of the Upper Ohio Valley

Funding Requests

Programs

Program(s) Details

Impact Statistics

Volunteer Information

Funding Sources

What is your agency’s administrative overhead cost percentage?

Agency Certification Letter

Document Uploads