• Request for Funding

    PY 2024-2026
  • Format: (000) 000-0000.
  • IRS Determination Letter Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Organization Financial Information

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  • Organization's Affiliation

  • Is your organization affiliated with any national or state organizations or initiative?*

  • Counterterrorism Compliance

    Indicate your compliance with each of the following
  • This Organization is not on any federal terrorism "watch lists," including the list in Executive Order 13224, the master list of specially designated national 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, has not knowingly provided or collected funds or provided material support or resources with the intention 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 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 regrant to organizations, individuals, programs and/or projects outside of the United States of America with out compliance without IRS guidelines.*
  • This Organization takes reasonable, affirmative steps to ensure that any funds or resources distributed or processed do not fund terrorism or terrorist organizations.*
  • This Organization takes reasonable, affirmative steps to ensure that any funds or resources distributed or processed do not fund terrorism or terrorist organizations.*
  • This Organization takes reasonable steps to cerify against fraud with respect to the provision of financial, technical, in-kind or other material support or resources to terrorists and terrorist organizations.*

  • * In this form, "material support and resources" means currency or monetary instruments or financial securities, financial services, lodging, training, expert advice or assistance, safehouses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials.

     

  • I certify on behalf of the Organization listed above that the foregoing is true.*

  • Organization Checklist

  • United Way of Trumbull County serves as stewards of our donor's dollars. We assure our donors that their gifts are used to provide needed services in Trumbull County that are provided by fiscally sound and responsible agencies. Just as United Way of Trumbull County is required to demonstrate our organization adheres to all legal and ethical standards, we require all funded agencies to demonstrate those same legal and ethical standards. Those that we require are as follows:

     

  • Provides health or human services in Trumbull County in the State of Ohio and is eligible to receive tax -deductible donations within the meaning of IRS Code Section 170(c) (1) or (2), which includes 501(c)(3) organizations.*
  • Is governed by a volunteer board of directors consisting of members from the general community.*
  • Has board meetings at least four times per year.*
  • Has at least one, paid full-time or FTE staff person(s).*
  • Has been in business at least 2 years.*
  • Measures and evaluates program effectiveness.*
  • Has By-laws*
  • Has an affirmative action policy/non-discrimination policies.*
  • Provides Directors and Officers Insurance.*
  • Has liability insurance. *
  • Has fiscal policies and procedures*
  • Has Articles of Incorporation.*
  • Has personnel policies and procedures.*
  • Will conduct a workplace campaign to benefit United Way of Trumbull County.*

  • Program Data

  • Has this program received funding from United Way of Trumbull County previously?*

  • Which priority does the program focus on?

    Select one or two options that fit your program.

  • Program Summary

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  • Do you have permission to use the real names/photos of the client(s) in the photo*

  • Program Budget

  • Revenue/Support*
    Rows
  • Expenses*
    Rows

  • Program Financial Narrative

  • Enter all other anticipated funding for this program, including earned revenue, in-kind support, special events, fundraisers, etc.

  • Demographics

    Please complete each chart for the clients served in 2023.
  • Age Demographics*
    Rows
  • Gender Demographics*
    Rows
  • Race/Ethnicity Demographics*
    Rows
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