2027 Senior Levy PROVIDER Funding Application

2027 Senior Levy Funding Application

Complete each page, upload the required documents, and certify your information before submitting. Please email seniorlevy@lcap.org with any questions.
Organization Name
Applicant Name

First NameMiddle NameLast Name
Applicant Title
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Organization Website
Services

If a question is not applicable to your organization/agency, please indicate NOT APPLICABLE – N/A.
Highlight any key accomplishments for your organization with services, programs, and activities in 2026.

Services, activities and programs should be consistent with one or more of the follow levy pillars/service areas. Identify how many unduplicated clients you serve in each pillar below.

Rows	2026 Unduplicated Clients Served (Jan-June)	2026 Total Projected Unduplicated Clients Served	2027 Total Projected Unduplicated Clients
Food, Nutrition & Health
Home & Housing
Transportation
Community Engagement & Lifelong Learning
Safety & Security

Total Number of Unduplicated Seniors Served So Far in 2026:
Total Number of Unduplicated Seniors Projected to Serve in 2027:
Describe the process and/or tools used to track, report and ensure that Senior Levy funds serve only Licking County residents over the age of 60
What is the percentage of Licking County Seniors served compared to your total population served?
Do you plan to offer any new or extended programs in 2027? Are you eliminating any programs in 2027?
Do you currently have any waiting lists for your levy-funded services? Do you have a plan to address this waiting list?
How does your organization ensure accessibility to levy-funded services? Please describe any public awareness efforts, customer service practices, location accessibility, expanded hours, etc
How does your organization cooperate and coordinate with other organizations in the delivery of services as opposed to duplicating services or competing for clients?
Financial
How much are you requesting in funds for 2027?

2027 Budget Request (If you want to submit your own copy and not use this table, you may attach it at end of application)

Rows	Expense Type (rent, utilities, salaries, benefits, program costs, etc.)	Amount of Levy Funds Used as of June 2026	Amount of Levy Funds Requested for 2027
Expense 1
Expense 2
Expense 3
Expense 4
Expense 5
Expense 6
Expense 7
Expense 8
Expense 9
Expense 10
Expense 11
Expense 12
Expense 13
Expense 14
Expense 15

Were levy funds carried over from 2024–2026?
Carried Over Amount (USD)
Explanation of Carried Over Funds
Are there any pending IRS penalties or unresolved government citations?
If "Yes" please explain
Do any organizations provide monitoring or oversight to your organization? Please list, as well as the date of the most recent review or audit.
Attachments and Additional Items
2026 Statement of Activities (as of June 30, 2026) that includes sufficient details to: 1. Identify each revenue/income source, the amounts received, and to pay for services and supports to Licking County seniors. 2. Identify all expenditures specific to services and supports funded in part by the Licking County Senior Services levy.

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Independent financial audit (If your organization conducts an independent audit, please include a copy of the executive summary.

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2027 Proposed Budget Request (if above form did not work or you want to attach your own)

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List of Board of Directors

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Agreement to Certification Statement

I certify that this application is true and correct. If awarded Senior Levy funding, I understand that our organization must enter into a Senior Citizens Levy Agreement with the Board of County Commissioners. Grantee must also remain in compliance throughout the term of said agreement. Once the Board of Commissioners approves the recommended 2026 Senior Levy allocation distribution from the Licking County Aging Partners’ Senior Levy Allocations Committee, an Agreement will then be sent to the Grantee to complete and return.
Certification Statement
Executive Director/President Name

First NameMiddle NameLast Name
Date
Should be Empty:

2027 Senior Levy Funding Application

Services

Financial

Attachments and Additional Items