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United-Way of Susquehanna County

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					United Way of Susquehanna County
2009-2010 Application Checklist

Please return 1 original and 5 copies of the following application to the United Way by Thursday, October 16, 2008.
Note: Only this original application will be accepted. Retyped, reworded and/or incomplete applications will not be considered. Attach additional pages as necessary.



Application: Complete Pages 1 and 2 as an overview of the organization. Pages 3-5 are to be copied and filled out for each program for which funds are requested.

Please attach 1 copy of the following to your application in order to be considered for funding:

       

Current List of Board Members: Include addresses and phone numbers, and indicate the board officers. Copy of your most recent brochure. Copy of your IRS determination letter: New applicants only. Current Certificate of Registration under Solicitation Law: by the Pennsylvania Commission on Charitable Organizations. If you do not file for this please list the reason under question #5. Most recently Completed Audit: If your audit is not available or if one is not done please indicate the reason on question #5. Organization Agreement: Signature of authorized board member and date is required.

Most recent Financial Statements: Include the Balance Sheet and Income Statement. Total Agency Current Fiscal Year budget: This should include the total agency budget, including both programs that are funded by the United Way of Susquehanna County and those that are not.

NOTE: This application is for two 1-year funding cycles, 01/01/09 – 12/31/09 and 01/01/10 – 12/31/10

Telephone (570) 278-3868

6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net

Page 1

United Way of Susquehanna County
*2009-2010 Program Year Application
* NOTE: This application is for two 1-year funding cycles, 01/01/09 – 12/31/09 and 01/01/10 – 12/31/10 Organization Name: Address: Contact Person: Phone Number: Email address: FAX Number: Web Site:

General Information: 1. Please provide a short narrative about your agency and list the program(s) for which you are requesting funds.

2. Indicate major changes in Organization and/or program(s) since last application, if applicable.

3. Please list the ways in which your Organization has supported the United Way in the past year. (e.g. Participated in the Punt, Pass & Kick Contest, UW logo on stationary and on display in the office, link to UW webpage from your webpage…)

4. Do you have any Questions, Concerns or Comments for the allocation committee to take into consideration?

Telephone (570) 278-3868

6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net

Page 2 5. Organization Special Funds & Accounts (savings, CD’s, reserve accounts, endowments, building funds, etc) List funds, special accounts and values. Please also list any restrictions that may apply to these funds. Account/Fund Value Restrictions

6. How was the money that you received last year from the United Way of Susquehanna County for nondesignated funds spent per program? Please provide details.

Funded Program

Funding Amount

# served 01/01/08 - 09/30/08 * specify persons or households

Activities and Benefits of Program (quantify if possible)

Total Amount:

$__________

 Note: Numbers served for the period of 10/01/08 – 12/31/08, 01/01/09 – 12/31/09 and 01/01/10 – 12/31/10 will be requested separately.

Telephone (570) 278-3868

6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net

Page 3 COMPLETE PAGES 3-5 FOR EACH PROGRAM FOR WHICH FUNDING IS BEING REQUESTED Program Specific Information (If applying for more than one program, please make copies of these pages) Please provide the following information for each Susquehanna County program you wish to have considered for funding: 1. Program Name and Location(s)

Is this a new _______, existing _______ or existing with modifications_______ program? (Check one) 2. What is the goal of the program?

A. Does this program provide human services that are essential, the lack of which could result in death? (Food, Clothing, Shelter, Medical Services and Safety) Y or N B. Does this program provide services that directly contribute to an individual’s needs? (Education, Culture & Arts, Recreation) Y or N C. Does this program provide services that contribute to an individual’s quality of life? (Preservation of the Environment, Community Development) Y or N

3. Service Area: Will your program service all of Susquehanna County? If not, what towns (townships) will you cover?

4. What percentage of individuals served will be Susquehanna County residents?

5. What similar organizations provide a program comparable to this one in Susquehanna County?

6. Is there a client waiting list for your program services? Y or N (If yes, tell us how many are on the waiting list. What do prospective clients do while waiting for services? What is the approximate wait time?)

Telephone (570) 278-3868

6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net

Page 4 7. Please state how you will implement this program in Susquehanna County for the period 01/01/09 – 12/31/09? (A separate request will be made for the period 01/01/10 – 12/31/10) Please be specific so that we can accurately report to the public how their donations are used. Method Segment Served Dates of when services will be provided
Sept 5th & Oct 12th Mon-Fri 9-5 Expected # of Susq Co served
01/01/09 – 12/31/09 specify persons or households

Actual # of Susq Co served *01/01/08-9/30/08
specify persons or households

E.g. Class Store

6th graders at Elk Lake Clients that walk in

90 950

86 982

If you need more space, please attach an additional page. * Note: Expected numbers for 01/01/10 – 12/31/10 and actual numbers served for the period of 10/01/08 – 12/31/08, 01/01/09 – 12/31/09 and 01/01/10 – 12/31/10 will be requested separately. 8. What will be the requirements to receive program services?

9. List amounts charged for this service or attach a fee schedule (client, activity, month, annual), if applicable.

10. If you charge a fee, what percentage of individuals must pay full price or sliding fee? What percentage is covered under PA Access, private insurance or by other means?

11. How will you measure outcomes/success?

12. What will be the number of annual staff hours assigned to this program?

13. How many volunteer hours will be assigned to this program? 6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net

Telephone (570) 278-3868

Page 5

Program Budget from January 1, 2009 – December 31, 2009:
(A new budget will be requested for January 1, 2010 – December 31, 2010) Program Operating Support & Revenue (Income) 1. Client fees, memberships 2. Investment income 3. Fund raising 4. Donation, gifts, etc 5. Government grants 6. Tax Dollars 7. Other income____________ *Total support & revenue Program Expenses 1. Direct service payroll 2. Administrative payroll 3. Employee benefits 4. Contract / Professional fees 5. Office Supplies 6. Marketing 7. Program supplies 8. Dues / Memberships 9. Fund Drives 10. Collection Fees 11. Rent, utilities etc 12. Transportation 13. Licenses 14. Assistance to clients 15. Other expenses_____________

_________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________

_________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________

*Total operating expenses

*Note: Total Support & Revenue must equal Total Operating Expenses

Telephone (570) 278-3868

6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net

United Way of Susquehanna County
2009-2010 Organization Agreement

Organization Name & Address:

The Board of Directors of the United Way of Susquehanna County and the above named Organization hereby agree to the following terms and conditions: 1. The named Organization acknowledges it has: a. an unpaid active Board of Directors that meets at least 4 times per year; b. a formally adopted non-discrimination policy; c. tax-exempt status by the Internal Revenue Service as a Charitable Organization 501(c)3. 2. The named Organization is strongly encouraged to actively support the United Way and display the United Way logo on its website, stationary and other relative materials and will partner with the United Way in a timely and effective manner. (The United Way will provide artwork, posters and signs.) 3. The United Way of Susquehanna County reserves the right to reduce or eliminate the named Organization’s allocation.

Date: _______________________________ _________________________________________ Organization’s Authorized Board Member __________________________________________ Title _______________________________ Date ______________________________________ President, United Way of Susquehanna County

Telephone (570) 278-3868

6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net

Telephone (570) 278-3868

6 Locust St., Montrose, PA 18801 Fax (570) 278-7605 E-mail: unitedway@epix.net


				
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