Equity Fund Statement of Interest
Date
-
Month
-
Day
Year
Date
Primary Contact Name
*
First Name
Last Name
Email
*
example@example.com
Job Title
*
Phone Number
*
Tax Exempt EIN
*
To be tax-exempt under section 501(c)(3) of the Internal Revenue Code, an organization must be organized and operated exclusively for exempt purposes set forth in section 501(c)(3), and none of its earnings may inure to any private shareholder or individual. In addition, it may not be an action organization, i.e., it may not attempt to influence legislation as a substantial part of its activities and it may not participate in any campaign activity for or against political candidates.
Agency Name
*
Equity Fund Program(s) Name:
*
0/10
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Information
1. Agency Status
*
Nonprofit organization
Fiscal Agent
1a. If the agency is using a fiscal agent, please enter the name of the organization below:
2. Neighborhood(s) or zip code to be served with Equity Fund project:
*
3. Funds will be requested to implement resident-identified solutions for their neighborhood
*
Yes
No
4. Community to be served is 30% or greater low income according to census data (under $25,000 household income).
*
Yes
No
5. Residents to be targeted are majority persons of color.
*
Yes
No
6. Proposed activities will address the below priority area(s) of inequity. Please select all that apply.
Economic Development
Strengthening Community Engagement and Leadership
Affordable, Safe, Quality Housing and Home Ownership
Community and Public Safety
Access to Health Eating/ Active Living Opportunities
7. Applicant will be able to report the results of United Way’s investment by Sept. 30, 2023
*
Yes
No
Submit
Should be Empty: