2012 United Way of Pueblo County MENTAL HEALTH IMPACT GRANT APPLICATION United Way of Pueblo County P.O. Box 11566, Pueblo, CO 81001 2631 E. 4th Street 719-583-4455 Mission Statement: To develop donor resources to enhance the quality of life for the people of Pueblo County. United Way of Pueblo County will award a one-time only special project grant(s) to nonprofit organizations in Pueblo County. Programs that qualify should address a pressing, unmet mental health need not currently funded by United Way dollars. Both current United Way partner agencies and non-United Way partner agencies may apply. Mental Health Impact Grant Guidelines Grant(s) are intended as one-time only special program grants that focus on improving the mental health of the citizens of Pueblo County. Grant(s) will be awarded to the program that can demonstrate a significant, measurable impact on the community. Who may apply: Non-profit organizations in Pueblo County with a 501(c)3 designation. Appropriate projects: Projects consistent with United Way's mission and supporting new initiatives that are aimed at producing measurable improvement to mental health services needs in Pueblo County. The following will not be funded: proposals to fund prior year deficits, projects directed by for-profit organizations; proposals to fund established programs already funded with United Way dollars. Application Deadline: July 6, 12 noon, no exceptions will be made Finalists will be interviewed as part of the decision making process. Amount of Awards: Range of $5,000 to $27,000 Award Date: August 2012 Grant Funding Period: Grants are intended as a one-time special project grant(s) only. Therefore, United Way funding is short term. Funds will be available for one year after notification of grant award. 2012 MENTAL HEALTH IMPACT GRANT APPLICATION PROCEDURES A complete application includes 13 copies, with a 3 hole punch that contain the following: **Please do not place in folders, binders, plastic covers etc. A simple paper clipped copy is sufficient. Cover Sheet Use the attached cover sheet Program Budget Current Board Approved Organization Budget Proposal (no more than 5 pages): Your concise proposal must contain the following information clearly identified with headings: 1. Brief history and explanation of mission of organization 2. Describe your organizational accomplishments over the last twelve (12) months. 3. What challenges has your organization faced over the last twelve (12) months? What have you learned from these challenges? 4. Project/Program Description 5. Specific target population and estimate of number of lives affected 6. Expected goals AND outcomes of program 7. Evaluation procedure description (method for measuring expected outcomes) 8. Future funding sources for project/program. Explain in detail how you will sustain this program into the future. 9. Implementation schedule for the project (specific dates) 10. Plan for acknowledging United Way as a funding source 11. Please answer the following questions regarding your operating reserves. a) Dollar amount of operating reserves: $ _______________ b) Difference in operational reserves from previous 12 months (+ or -): $ _________________ c) Operating reserves are ___________% of total agency budget d) Operating reserves will support ________________ months of operation e) Your ideal amount of operation reserves: $ ___________________ f) If you have operating reserves and have used it in the last year, please explain why/what you used it for. g) What is your board’s policy regarding use of operating reserves? h) Please indicate if any portion of your operating reserves are restricted, and briefly explain those restrictions. 12. Complete the sources of income table below for the organization as a whole, based on the most recently completed fiscal year. SOURCES OF INCOME TABLE Percentage Funding Source ____% Government grants (federal, state, county, local) ____% Government contracts ____% Foundations ____% Business/Corporate Contributions ____% Special Events (include event sponsorships) ____% Individual contributions ____% Fees for service ____% United Way ____% Other _________________ ____% Total (must equal 100%) ALSO REQUIRED: Verification of IRS 501(c)3 status (1 copy) Most recent audited financial statement & 990 (both audit & 990 years should match) (1 copy) Current List of Board of Directors (1 copy) Proof of Directors, Officers & Liability Insurance (1 copy) If you have received a community impact grant award in the past, you must include the full final/summary report for that grant award. GRANT MONITORING Quarterly Reports and Final Summary Report If you are awarded with funds, you will be required to submit quarterly reports and a final summary report. The report should include: A written narrative report that should address progress on outcomes listed in the proposal. Financial report detailing how grant money is/was being used. An oral report to United Way Board of Trustees at a time to be determined, but no later than the September 2013 board meeting. United Way of Pueblo County 2012 Mental Health Impact Grant Application Cover Sheet Date of Application: _______________________ Name of Organization: _____________________________________________________________ Mailing Address: __________________________________________________________________ Contact Person, Title: ______________________________________________________________ Phone Number: __________________________________ Fax: ___________________________ Email: __________________________________________________________________________ Program/Project Title: ______________________________________________________________ Dollar Amount Requested: __________________________________________________________ Program/Project Dates: _____________________________________________________________ Total Project Budget: _______________________________________________________________ Annual Agency Operating Budget: ____________________________________________________ Total number of Lives Affected: ___________ Summarize your request in 30 words or less: ____________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Other Sources of Revenue for the Program/Project (Please list confirmed and pending sources, use attachment if necessary) ________________________________________________________________________________ ________________________________________________________________________________ By signing this cover sheet, we understand that quarterly narrative and financial reports must be submitted to United Way, AND a final report within 30 days of the conclusion of the project. _____________________________________________________ ________________ Contact Person signature print name Date _______________________________________________ ________________ Chief Professional Officer signature print name Date _______________________________________________ ________________ Board Chairman/President signature print name Date PLEASE BE SURE TO PROVIDE 13 COPIES with a 3 hole punch OF THE APPLICATION AS DESCRIBED. **Please do not place copies in folders, binders, plastic covers, etc. A simple paper clipped copy is all that is needed.
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