2008 AGENCY APPLICATION FORMS

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2008 AGENCY APPLICATION FORMS Powered By Docstoc
					                          United Way of Hopewell-Prince George
                     2008 Eligibility Application/Certification Checklist

(Items in bold are included in application package)
(See Certification of Attachments for description and details of attachments.)

                                                                                      √
Attachments                  Description               Original +                         United
                                                      Number of                            Way
                                                                                          Check-
                                                        copies                             off
  Agency        Agency/Organization Information                         6
 Application      (Including 25-Word statement for brochure)
   Forms
                   Certification of Attachments-
                Must include Signature of Certifying Official


                             Budget Forms
                 Must include Amount of Request on pg. 2
Attachment A            Summary Information                             6

Attachment B         IRS Determination Letter                      1 original
                            501(c)(3)
Attachment C    Annual Report or Newsletter                             6

Attachment D    Board of Directors Information –                        6
                (including address & telephone)

Attachment E    Most Recent Financial Report.                           6
                (Organizations with income under $25,000
                may file a treasurer’s report)
Attachment F    IRS Form 990                                    1 complete original
                                                                       and
                                                                6 copies of pg. 1-6
Attachment G    Independent CPA Audit (GAAP)                       1 original
                With Auditor’s Statement
                (Necessary only for organization’s with
                annual revenue greater than $100,000.)

Attachment H    Detailed Justification                                  6
                (Necessary if administrative and fundraising
                costs are greater than 25.04%)
Agency          Signed and dated by certified official             1 original
Agreement
Patriot Act     Signed and dated by certified official             1 original

Original and required copies of attachments are due by 3:00 P.M. on Thursday, May 15, 2008.
in person or by certified mail to:
                                         United Way of Hopewell-Prince George
                                         210 N. 2nd Avenue
                                         P.O. Box 394
                                         Hopewell, VA 23860
                                        APPLICATION
          for participation in the 2008 United Way of Hopewell-Prince George Campaign

Agency/Organization (Legal) Name: _____________________________________________________________

EIN#_______________________________________________              Office Hours: _____________________________

Street Address: _____________________________________            City/State/Zip: ______________________________

Mailing Address: ____________________________________            City/State/Zip: ______________________________

Telephone: _________________________________________             Fax: ______________________________________


Total Number of People Served by local organization in 2007: ______ Must provide breakdown for following localities:
    Hopewell_______ Prince George_______ Ft. Lee_______


Executive Director: __________________________________             Telephone Number: _______________________

Executive Director E-Mail Address: __________________________________________________________________


Person Completing Application: _______________________________________ Title: ______________________

Telephone Number: ___________________________Email address _____________________________________

Person to send allocation checks to:

Name:______________________________________ Title:___________________________________________

Mailing Address_____________________________________________________________________________

                _____________________________________________________________________________

                   Information for United Way of Hopewell-Prince George Campaign Brochure

Agency/Organization Legal Name _________________________________________________________
                                (as it should be listed alphabetically in brochure):
Agency/Organization Telephone Number ______________________________________________________

Agency/Organization Web Site: ______________________________________________________________

25-Word Statement: statement should describe your agency/organization’s services, benefits and/or
programs. It should not include your organization’s name, but it can include a former name. If your
statement is over 25 words, it will be edited to fit the required 25-word format. One word per line - &,
a, at, and, the will be counted as a word.
_______________ _______________ _______________ _______________ ______________

_______________ _______________ _______________ _______________ ______________

_______________ _______________ _______________ _______________ ______________

_______________ _______________ _______________ _______________ ______________

_______________ _______________ _______________ _______________ ______________
Is your organization a member agency of another United Way? _____ No ___Yes (specify)___________________
                                       Certification of Attachments

1.   ___ N/A    I certify that the organization named in this application has a substantial local presence in the
                geographical area covered by the local campaign. (Hopewell, Prince George, Fort Lee and
     ___ Yes    surrounding areas)
                Substantial local presence is defined as a staffed facility, office or portion of a residence dedicated
                exclusively to that organization, and available to members of the public seeking its services or benefits.
                The facility must have a telephone dedicated exclusively to the organization.) Complete ATTACHMENT
                A, included in your application package.


     ____ Yes
2.              I certify that the organization named in this application is recognized by the Internal Revenue Service as
     ____ No    tax-exempt under 26 U.S.C. 501(c)(3) and to which contributions are tax deductible pursuant to 26
                U.S.C. 170.

                 Include a copy of the organization’s most recent IRS Determination Letter as ATTACHMENT B.
                Interim IRS 501(c)(3) letters that have expired will only be accepted with proof of application to the IRS
                for permanent 501(c)(3) status. If the name of the applicant organization is different from the name,
                which appears on the IRS determination letter, IRS Form 990, audited financial statements, or annual
                report, official documentation authorizing this name change must accompany the application. The
                Federal Tax ID number must be included.

3.   ___ Yes    I certify that the organization named in this application is chartered/incorporated under a governmental
                entity. This entity or State is____________________________.
     ___ No


4.   ___ Yes    I certify that the organization named in this application prepares and makes available to the public an
                annual report that includes a full description of the organization’s activities and supporting services, and
     ___ No     identifies its directors/governing body and chief administrative personnel. A more frequently published
                document, such as a quarterly newsletter, may be used to meet this requirement provided that such
                document is available to the general public upon request and describes the organization’s activities and
                supporting services and identifies its directors and chief administrative personnel.

                Include as ATTACHMENT C a copy of the organization’s most recent annual report (or substitute
                as described above) covering the fiscal year ending on or after June 30 of the previous year.
     ____ Yes
5.              I certify that an active and responsible governing body, whose members have no material conflict of
     ____ No    interest and a majority of which serve without compensation, directs the organization named in this
                application.

                 Include as ATTACHMENT D a listing of the organization’s current board of directors with address
                and phone number. (Do not submit copies of the organization’s by-laws or articles of
                incorporation.

6.   ___ Yes    I certify that this organization is registered with or granted an exemption from registration with Virginia
                Department of Agriculture and Consumer Services (VDACS), Division of Consumer Affairs, Charitable
     ___ No     Solicitation Section or has filed all materials required by the Virginia Solicitation Contributions Law to
                register, renew registration or request an extension of time to file or request an exemption from
                registration. To verify registration or exemption call VDAC at (804) 786-1343.

                Name as it appears in VDACS listing: ______________________
                Expiration Date*: _______________________________________
                Extension Date (if filed): __________________________________
                Type of Exemption: _____________________________________

                *All participants that are not exempt from registration must register, renew, or request an
                extension to become eligible.
7.     ___ Yes     I have completed as ATTACHMENT E, the most recently completed Financial Report for the
                   organization named in this application.
       ___ No      (Organizations with income under $25,000 may file a treasurer’s report)


8.     ___ Yes     I certify that the organization named in the application accounts for its funds in accordance with
                   generally accepted accounting principles (GAAP).
       ___ No


9.     ___ Yes     Included, as ATTACHMENT F, is a completed copy of the organization’s IRS Form 990,
                   covering fiscal year ending on or after June 30 of the previous year, and including signature
       ___ No      on page 6 marked “Signature of Officer”. The preparer’s signature alone is not sufficient.
                   Note: Smaller organizations that file the IRS Form 990EZ may submit IRS Form 990EZ, but
                   must also complete and attach pages 1 and 2 of IRS Form 990 as well as page 6 (signed only)
                   of that document. Failure to attach pages 1 and 2 as well as page 6 (signed only) of IRS Form
                   990 will result in a denial of your application. Please note that if the organization’s annual
                   revenue is greater than $100,000 and an audit referred to below as ATTACHMENT G must be
                   submitted, IRS Form 990 must cover the same fiscal period as the audit and be prepared on the
                   accrual basis of accounting.


                Complete Certification 10 if your organization’s annual revenue is greater than $100,000

10.    ___Yes     I certify that the organization named in this application was audited in accordance with generally
                  accepted auditing standards (GAAS) by an independent certified public accountant the
       ___ No     immediately preceding year. Included as ATTACHMENT G is a copy of the organization’s most
                  recent annual audit with auditor’s statement. Such audit must show expenses by function.
       ___ N/A    Combined and consolidated financial statements are not accepted unless the applicant’s
                  financial information is reflected in a separate audited combining or consolidating schedule. The
                  audit must cover fiscal year ending on or after June 30 of the previous year, must cover the
                  same fiscal period as the IRS Form 990 referred to above as ATTACHMENT F, and be
                  prepared on the accrual basis of accounting. If revenue and expenses of the two documents
                  differ, these amounts must be reconciled either on the IRS Form 990, Parts IV-A and IV-B, or by
                  the accounting firm that completed the audit in an accompanying signed statement.

11.    ___Yes     I certify that the organization named in this application has spent 25% or less of its total support
                  and revenue on administrative and fundraising expenses. The actual percentage of
       ___ No     administrative and fundraising expenses for the organization named in this application is
                  ____.__%. (Computed to the tenth of a percentage point) This percentage has been
                  computed from information on the IRS Form 990, referred to above as ATTACHMENT F,
                  by adding the amount spent on “management and general” (line 14) to “fundraising” (line
                  15) and dividing the resulting total by “total revenue” (line 12).
                                                                   – OR –
       ___ Yes    I certify that the organization named in this application has spent more than 25% of its total
                  support and revenue on administrative and fundraising expenses and that these expenses are
       ___ N/A    reasonable under all circumstances presented. The actual percentage of administrative and
                  fundraising expenses for the organization named in this application is ____.__%. Note: If the
                  annual percentage for administrative and fundraising expenses is greater than 25.04% include
                  as ATTACHMENT H, a detailed explanation of administrative and fundraising expenses and a
                  formal plan to reduce these expenses to 25.04% or below.


                                           Signature of Certifying Official

As the duly appointed representative of _______________________________________________________,
I am authorized to certify and affirm all statements enclosed in this application.


Signature of Certifying Official _________________________________________________________________

Title __________________________________________               Date__________________
ATTACHMENT A - SUMMARY INFORMATION
      Organization Name ________________________________________
      Date organization was founded: _____________________________

      1. Statement of local presence:     ( See Certifications for details)



      2. List a description of the programs, services, benefits, etc. provided by the organization within the
      previous year.




      3. Please provide a statement of services that will clearly define your organization.
      Additionally, discuss the eligibility requirements for an individual to receive services.
      What determines the amount of aid provided?
      If charges are made for services rendered, how are levels determined and in what cases are the
      charges waived, if any?




      4. Target population served: (age, sex, special interest, etc.)




      5. Total number of individuals served by the local organization:
                                2 yrs         last
               3 yrs ago__________ ago__________ year____________

      6. Geographic area covered:



      7. How are agency programs/services assessed for effectiveness?




      8. What new or different programs/services does your agency contemplate providing next year?




      9. How will these new or different programs/services be financed?
                                               UNITED WAY OF HOPEWELL-PRINCE GEORGE
                                                     Agency Application Budget Forms

Name of organization ________________________________________________________
This budget was considered and approved by the Board of Directors meeting on _____________________________

                                                                          2             3                       4
Recap of Revenue and Expenses                                         Fiscal         Fiscal              PROPOSED
                                                                     ________       ________               BUDGET
                                                                     Last Year      This Year             _________
                                                                     ACTUAL         BUDGET               ESTIMATED
    Recapitulation of Public Support & Revenue - All Sources
                            (4000-6999)
 1 4000 Contributions - Unrestricted
 2 4100 Contributions - Restricted
 3 4200 Special Events
 4 4400 Other - Direct Public Support
 5 4700 Allocated by Federated Fund Raising Organizations
 6 4900 Other-Indirect Public Support
 7 5000 Fees & Grants from Government Agencies
 8 6000 Membership Dues - Individuals
 9 6200 Program Service Fees
10 6300 Sales of Supplies & Services to Local Member Units
11 6400 Sales to Public
12 6500 Investment Income
13 6900 Miscellaneous Revenue

14 TOTAL SUPPORT & REVENUE FROM ALL SOURCES
              Recapitulation of Expenses (7000-9999)
15 7000 Salaries
16 7100 Employee Benefits
17 7200 Payroll Taxes, etc.
18 8000 Professional Fees
19 8100 Supplies
20 8200 Telephone
21 8300 Postage and Shipping
22 8400 Occupancy
23 8500 Rental/Purchases and Maintenance of Equipment
24 8600 Printing and Publications
25 8700 Travel
26 8800 Conferences, Conventions & Meetings, Training
27 8900 Specific Assistance to Individuals
28 9000 Membership Dues
29 9100 Awards and Grants
30 9400 Miscellaneous
31 9691 Payments to Affiliated Organizations

32 TOTAL EXPENSES FOR BUDGET PERIOD


                                                 FINANCIAL RECAP
                                                                    Last Year       This Year            Next Year
Total Support and Revenue - All Sources (Line 14)
Total Expenses for Budget Period (Line 32)
33   Excess (Deficit)

34 9999 MAJOR PROPERTY & EQUIPMENT ACQUISITIONS
 (Info. Only)




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UNITED WAY OF HOPEWELL-PRINCE GEORGE
      Agency Application Budget Forms




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UNITED WAY OF HOPEWELL-PRINCE GEORGE
      Agency Application Budget Forms




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UNITED WAY OF HOPEWELL-PRINCE GEORGE
      Agency Application Budget Forms




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  Agency Budget Forms (cont'd)

  Organization Name _______________________________________________________




$____________________Amount requested from United Way of Hopewell-Prince George
                       for 2009 allocation.


                                                         Last Year             This Year             Next Year
                                                         ACTUAL               BUDGETED
ALLOCATIONS RECEIVED:                                                                               PROPOSED

A. UNITED WAY OF
   HOPEWELL-PRINCE GEORGE

B. GOVERNMENT
   FEDERAL
   STATE
   LOCAL - SPECIFY
            HOPEWELL
            PRINCE GEORGE
            PETERSBURG
            COLONIAL HEIGHTS
            CHESTERFIELD
            DINWIDDIE
            OTHER - SPECIFY



C. TOTAL GOVERNMENT
D. REVENUE FROM FEES AND DUES
E. OWN FUNDRAISING               (detail on next page)
F. ALL OTHER
    DEFERRED BEQUESTS
    SALES OF OTHER GOODS
    FOUNDATION GRANTS - SPECIFY




OTHER UNITED WAYS - SPECIFY
  United Way of Gr. Richmond/Petg.



 CFC (Combined Federal Campaign)
 LGS (Local Govt. & Schools UWS Campaign)
 CVC (Commonwealth of Virginia Campaign)
G. TOTAL ALL OTHERS

  GRAND TOTAL A + C + D + E + G




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   Agency Budget Forms (cont'd)

   Organization Name _______________________________________________________


Results of supplementary fundraising activities conducted in previous year.


      Date Conducted              Fundraising Activity            Area Covered   Net $ Results




Supplementary fundraising activities planned for upcoming year.
(United Way Campaign period of September 15 thru November 30 should be avoided)

 Beginning/            Fundraising Activity-         $ Goal        Location or    Project Coordinator
  Ending                                                          Area Covered   Name/Address/Phone #
   Date




                                                            3                      8737de47-b6b6-406e-b52a-03886e1bdf9b.xls
                                     EXPLANATION OF RESTRICTED FUNDS
                                (Source Restricted Only - Exclude Board Restricted)


A. Name of Restricted Fund:                                                  Amount: $

    1. Restricted by:

    2. Source of fund:

    3. Purpose for which restricted:

    4. Are investment earnings available for current unrestricted expenses? _________Yes ________No

                                    If Yes, what amount:   $_____________________

    5. Date when restriction became effective:

    6. Date when restriction expires:



B. Name of Restricted Fund:                                                  Amount: $

    1. Restricted by:

    2. Source of fund:

    3. Purpose for which restricted:

    4. Are investment earnings available for current unrestricted expenses? _________Yes ________No

                                    If Yes, what amount:   $_____________________

    5. Date when restriction became effective:

    6. Date when restriction expires:




C. Name of Restricted Fund:                                                  Amount: $
    1. Restricted by:
    2. Source of fund:
    3. Purpose for which restricted:
    4. Are investment earnings available for current unrestricted expenses? _________Yes ________No

                                    If Yes, what amount:   $_______________________

    5. Date when restriction became effective:

    6. Date when restriction expires:




                                                             4



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                               EXPLANATION OF BOARD DESIGNATED RESERVES
                                  (For Funds Which Are Not Donor Restricted)

A. Name of Board Designated Reserve:                                          Amount: $

    1. Date of board meeting at which designation was made:

    2. Source of fund:

    3. Purpose for which designated:

    4. Are investment earnings available for current unrestricted expenses? _________Yes ________No

                                     If Yes, what amount:   $___________________________

    5. Date when board designation became effective:

    6. Date when board designation expires:



B. Name of Board Designated Reserve:                                          Amount: $

    1. Date of board meeting at which designation was made:

    2. Source of fund:

    3. Purpose for which designated:

    4. Are investment earnings available for current unrestricted expenses? _________Yes ________No

                                     If Yes, what amount:   $_____________________

    5. Date when board designation became effective:

    6. Date when board designation expires:



C. Name of Board Designated Reserve:                                          Amount: $

    1. Date of board meeting at which designation was made:

    2. Source of fund:

    3. Purpose for which designated:

    4. Are investment earnings available for current unrestricted expenses? _________Yes ________No

                                   If Yes, what amount:     $__________________________

    5. Date when board designation became effective:

    6. Date when board designation expires:




                                                              5




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                                  AGREEMENT BETWEEN

                            ________________________________________
                                (Referred to hereinafter as the Agency)



              _______UNITED WAY OF HOPEWELL-PRINCE GEORGE_____________
                             (Referred to hereinafter as United Way)



This agreement is entered into in the mutual beliefs of the above-named parties who recognize that
(a) the participation of representative citizens in community-wide planning, allocations, communications,
    and fund raising for local agencies is essential;
(b) a combined fund-raising approach is the most effective way to provide for the financial needs
    of agencies;
(c) consideration of the total needs of the community in the establishment, continued maintenance,
    and improvements of effective and necessary human services forms the basis for this working
    relationship.

                         ______________________________________________


IN FURTHERANCE OF THESE MUTUAL BELIEFS,

A. BOTH UNITED WAY AND THE AGENCY AGREE (Having been determined incorporated,
     not-for-profit, and tax-exempt or having a 501(c)(3) purpose)

       1.     To maintain an active, rotating volunteer structure which assumes and fulfills
              the responsibility of managing its affairs within the scope and spirit of respective
              bylaws and this agreement.

       2.     To provide needed services on a non-discriminatory basis.

       3.     To strive to increase the public’s understanding and appreciation of and participation
              in human service programs; and

       4.     To consult and work together on matters of common interest in an effort to achieve
              the best interests of the community as a whole.
B. THE AGENCY AGREES

         1.    To support and assist in the United Way fund-raising campaign in all appropriate
               ways;

         2.    To engage in an effective public relations program in which the objectives, services
               and accomplishments of the Agency, and the United Way support of such services,
               are adequately publicized; to cooperate with and assist the United Way in its public
               information programs; and to make use of the United Way logo at all of its public
               functions;

         3.    To submit its proposed budget request each year to the United Way and to cooperate
               with the Fund Distribution Committee in accordance with its review procedures;

         4.    To prepare and adopt a balanced budget based upon the available funds from the
               United Way and other sources.

         5.    To have a complete audit of its financial affairs made each year by a certified public
               accountant and to furnish a copy to the United Way Board as soon as it becomes
               available. Agencies whose annual revenue is less than $100,000 may submit Internal
               Revenue Service Form 990, Return of Organization Exempt from Income Tax, in lieu
               of an audit report;

         6.    To conduct its operation in accordance with its budget;

         7.    To carry out the program of the Agency in such a manner as will best meet the needs
               of the community and will be consistent with standards of service, efficiency and
               economy;

         8.    To cooperate with other Agencies and coordinate services to best meet the needs of
               the community;

         9.    That no type of fund-raising activity for operating funds by or in behalf of the agency
               shall be conducted during the period extending from September 15 through November
               30
               of each year without discussing the particular event with United Way. Also, the
               agency shall not request or accept public service advertising during this period, except
               such coverage to build community understanding and support of the United Way
               Annual Campaign.

         10.   That no capital fund-raising solicitation, promotion, or publicity activities of any kind
               shall be conducted by a member agency during the period September 15 through
               November 30 of any year.
C. THE UNITED WAY AGREES:

       1.      To respect the Agency’s prerogative of determining its own policies and programs
               within the community;

       2.      To develop its recommendations for the campaign objectives for the annual fund-
               raising campaign with due regard for the requirements of all participating Agencies,
               fund-raising realities and other pertinent considerations to raise the maximum of funds;

       3.      To use its best efforts to achieve the campaign objectives.

       4.      To provide a reasonable and comprehensive volunteer review for the Agency.

       5.      To act as responsible steward of funds publicly contributed to the United Way
               by fully informing contributors of the allocations and use of such funds, and

       6.      To submit all its financial records to an audit by a certified public accountant.



This agreement shall remain in effect until modified by mutual agreement of the parties or until
revoked by either party. This agreement may be revoked by either party as of June 30 of any year by
such party giving notice to the other party 90 days before its desire to terminate this agreement.
The party to whom notice of termination is given shall have the right to a hearing before the governing
board of the other party to request consideration of any such revocation.

This agreement has been read and approved at the meeting of the governing body of this agency
held on _____________________________and at a meeting of the United Way governing board.


UNITED WAY OF
HOPEWELL-PRINCE GEORGE                                AGENCY_________________________________


Signed:________________________________              Signed___________________________________
             Chief Volunteer Officer                                 Chief Volunteer Officer



Signed:________________________________              Signed___________________________________
            Chief Executive Officer                                  Chief Executive Officer



DATE:_________________________________                DATE:___________________________________
                   ANTI-TERRORISM COMPLIANCE MEASURES


In compliance with the USA PATRIOT Act and other counterterrorism laws, the

United Way of Hopewell-Prince George requires that each agency certify the following:



           “I hereby certify on behalf of __________________________
                                              (organization name)
           that all United Way funds and donations will be used in

           compliance with all applicable anti-terrorist financing and

           asset controls, statutes and executive orders.”



Print Name: ____________________________               Title: ___________________


Signature: _____________________________               Date: __________________

				
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