COVID-19 Relief Fund Grant Application
Type of Request
*
Please Select
Basic Needs
Nonprofit Support - Operations
Defined on info sheet on previous page
What community condition(s) caused by Covid-19 will these funds address? What critical basic needs will be met? Be specific in connecting the funds to personal suffering in those impacted by the pandemic.
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*ERI funds have been restricted to a narrow definition of "critical basic needs". While our United Way recognizes basic needs have a broader definition in our community, we are confined to the funder's definition and only needs deemed critical will be allowed this round.
How will these funds improve the condition(s) above? How will you relieve personal suffering and meet the critical basic needs described above?
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Basic Information
Organization Name
*
Must match 501(c)3 / FEIN
FEIN
*
Federal Employer Identification Number
Is your agency a 501(c)(3) in good standing with the IRS?
*
Yes
No
No, but our Fiscal Agent is a 501(c)3
Other
Mailing Address
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
CEO / President / Executive Director
*
E-Mail Address
*
Confirmation Email
This is the email address response will be sent to
Phone Number
*
Best voice number right now
Mobile #
This # can receive texts
Year Established
*
Current total # of Staff (jobs)
*
Total # of active Board Members
*
Brief Description of Organization
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Population Served
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Are you willing to accept partial funding?
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Yes
No
Financials
Total Agency Budget
*
What impact has Covid-19 had on the funding streams for your agency?
Upload Files
(Note- If you use the United Way Template (excel file) for your financials, it satisfies both the Agency Financials and Program Budget request below.)
Agency Financials
*
Browse Files
Must include last year Actual and Current year budget
Cancel
of
Program Budget if not using the United Way Template
Browse Files
Must include last year budget to actual and current year budget
Cancel
of
Supporting Documentation
*
Browse Files
Per diem schedules, Invoices / receipts, quotes / estimates etc.
Cancel
of
Percent of Agency Total Budget
*
Request for Funding
Requested Amount
*
Use of Funds - how will these funds be spent and in what time frame?
*
Include specific details- what will these funds pay for? Food for how many people? Rent or utility assistance for how many households? What percentage of the agency's monthly operational costs etc.
Do you use CharityTracker?
*
Basic Needs - (direct client assistance) List projected #'s served (report requests actual)
$ Amount Requested
Serves # Individuals
Serves # Households
Housing
Utilities
Food
Shelter
Gas (for work)
Other (explain below)
Nonprofit Support - operations etc (one calendar month period)
$ Amount
Agency Rent
Agency Utilities (elect, gas, water, phone, internet)
Salaries
Insurance
Other (explain below)
Nonprofit Support - COVID-19 Mitigation / Reopening (one calendar month)
$ Amount
Materials (lumber, plexi glass etc)
Supplies (Masks, hand sanitizer etc)
Equipment
Technology
Other (explain below)
Budget for Total Request (funds spent by July 31, 2021)
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Line Item
Amount Requested
Description / Details
# Indiv served
# households served
01
02
03
04
05
06
07
08
09
10
Total
Explain anything listed as "other".
Anticipated # of jobs retained through nonprofit organizational financial support
*
Grant Report will ask for actual
Electronic Signature
Person Signing
*
First Name
Last Name
Email
*
Confirmation Email
example@example.com
Signature
Be sure to submit your application in the last section.
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Award Amount
Date Approved
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Month
-
Day
Year
Date
Declined
Conditions
Internal Notes
Should be Empty: