2027 Senior Levy Funding Application

2027 Senior Levy Funding Application

Complete each page, upload the required documents, and certify your information before submitting. Contact Melissa Owens, Executive Director, at (740) 345-0821 or seniorlevy@lcap.org with any questions.
Organization Name
Applicant Full Name

First NameMiddle NameLast Name
Job 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
Your Organizations Website Address
Services Please answer all questions on this application to the best of your knowledge. If a question is not applicable to your organization/agency, please indicate NOT APPLICABLE – N/A.
Highlight any key accomplishments for your organizations with services, programs, and activities in 2026.

Services, activities and programs should be consistent with one or more of the follow levy pillars. Identify which of the Senior Levy Pillars the organizations services, activities, and programs addressed including unduplicated counts as requested:

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

Total Number of Unduplicated Seniors Served so far in 2026:
Total Number of Unduplicated Seniors Projected to be served in 2027:
Describe the process and/or tools used to track, report and ensure that Senior Levy funds serve only Licking County residents aged sixty and older.
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?
Provide a copy of the organization’s Statement of Activities through June 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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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 funding or oversight to your organization? Please list, as well as the date of the most recent review or audit.
If your organization conducts an independent financial audit, please include the date of the last audit and a copy of the executive summary.

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2025 Organizational Budget

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2026 Organizational Budget

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Agreement to Certification Statement

I certify that this application is true and correct. If awarded 2027 Senior Levy funding, the organization must enter into a Senior Citizens Levy Agreement with the Licking County Board of Commissioners and remain compliant throughout the agreement. Once the Board of Commissioners approves the recommended 2026 Senior Levy allocation distribution from the Senior Levy Advisory Review Board, an Agreement will then be sent to the Grantee to complete and return. Please attach a complete list of the organization/agency Board Members, Board of Directors, Officers, Chairperson or President, as applicable. Provide contact information such as addresses sand email address for each person.
Current Board/Officer List with Roles, Addresses, and Emails

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Certification Statement
Board President/Chairperson Name

First NameMiddle NameLast Name
Board President/Chairperson Title
CFO/Treasurer Name

First NameMiddle NameLast Name
CFO/Treasurer Title
Executive Director/President Name

First NameMiddle NameLast Name
Executive Director/President Title
Please enter the name of the individual responsible for this document

First NameLast Name
Date
Should be Empty:

2027 Senior Levy Funding Application

Services Please answer all questions on this application to the best of your knowledge. If a question is not applicable to your organization/agency, please indicate NOT APPLICABLE – N/A.

Financial