SPECIAL COMMUNITY IMPACT PROJECTS by QRvnDw

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									                             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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