Application for 2025-2027 Funding
For Agencies with budgets under $20,000
Full Legal Name of Organization
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Mailing Address
*
Mailing Address
Street Address Line 2
City
State
Zip Code
Organization Website
Physical Address (if different from above)
Street Address
Street Address Line 2
City
State
Zip Code
Name of CEO/ Executive Director
*
First Name
Last Name
Title
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Name of Contact Person (If different from above)
First Name
Last Name
Title
Phone Number
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Area Code
Phone Number
E-mail
Total Amount Requested for All Programs
*
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Is organization a 501(c)(3)?
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Yes
No
Year Organization was Established
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Federal Employer Identification No.
*
Organizational Mission Statement
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Brief Description of Organization
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List of names of the organization's actual and/or anticipated five largest donors for the current and next fiscal year (governmental entities, foundations, corporations, businesses, individuals or any other entities) and amount of contribution or pledge of each.
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List the members of your organizations governing body, including professional business and community affiliations
*
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Organizational Budget
Please insert the income & expense budget for the organization. If the organization's fiscal year is not the same as the calendar year, please insert the budget that includes January 2019.
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Total Income of organization for last completed fiscal year.
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Total Expenses of organization for last completed fiscal year.
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Have you had or do you anticipate any changes of 10% or more in income or expenses for the current year and/or next year?
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Program Information
Name of Program
*
Amount Requested from MCUW for this Program
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Approximately How Many individuals will be served each year by this program.
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Please count each individual only one time regardless of the number of times served.
Describe the Program and its objectives.
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How will you evaluate the program's success in accomplishing its objectives?
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Program Budget
Please insert the income and expense budget for the program for which you are requesting funding. (Not necessary if the organization only has one program.)
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I certify that to the best of my knowledge and belief the information contained in this proposal for funding is true and correct and that I am duly authorized by the governing body of this organization to sign and submit this proposal for funding.
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First Name
Last Name
Title
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Signature
*
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