Grant Application Agency Name:* Tax ID# 501(c)3:* Upload 501c3 Letter from IRS*Max. file size: 32 MB.This is mandatory for a grant to be reviewed. Files must be less than 6 MB.Agency Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone # of Agency:*(For UW Brochure / Website)Name of Main Contact Person:* First Email Address of Contact Person:* DocumentsDocument Upload:*Max. file size: 32 MB.Upload Document Showing Current Board of Directors Roster. THIS DOCUMENT MUST INCLUDE TWO SIGNATURES: one from the preparer and one from a board officer/member. *Document Upload:*Max. file size: 32 MB.Upload Document Showing Current Local Advisory Board THIS DOCUMENT MUST INCLUDE TWO SIGNATURES: one from the preparer and one from a board officer/member. Document Upload:*Max. file size: 32 MB.Upload most recent Audit or IRS 990 (For Agencies that are not required to submit a 990 to the IRS, please attached your Reviewed Financial Statements) * Total Agency Budget (for Current Fiscal Year)*Please Provide a SHORT Narrative About Your Agency*--------------- Grant Program Name (Program Applying for UW funds) ---------------* Address of Program Site:* Program Description:* How Many Individuals will be Served in This Program (Numeric Only)*Out of Total Served, How Many Individuals will be Served with the United Way Funding (Numeric Only)*Did This Grant Program Receive UW funding last year?* Yes No How Many Individuals were Served in This Program Last Year (Numeric Only)*Total Grant Program Budget*(This Would be the Total Amount Your Agency Budgets For This Program) (Numeric Only - No Dollar Sign)Total Grant Program Budget United Way Request*(This Would be the Total Amount Your Agency is Requesting of United Way for this Program) (Numeric Only - No Dollar Sign) *Reminder: United Way of Bradford County annual agency grant program funding requests can not include grant writing fees. IF This is an Increase in Funding Request From Last Year, Please Provide Explanation For Need of Additional Funds Document Upload:*Max. file size: 32 MB.Upload document showing Agency Program Budget or Statement of Financial Activities/Position (balance sheet) Program Impact & Priority Area: Choose ONE impact and priority area from the list below:* Community Enrichment: Arts Community Enrichment: Animal Care Community Enrichment: Environmental Outreach Community Enrichment: Historical Education Community Enrichment: Libraries Educational & Emergency Needs: Crisis Services Educational & Emergency Needs: Emergency Assistance (food/clothing/shelter) Educational & Emergency Needs: Employment Opportunities Educational & Emergency Needs: Information & Referral Services Independence for Elderly & Disabled: Hospice Services Independence for Elderly & Disabled: Job Skills & Literacy Training Independence for Elderly & Disabled: Socialization Independence for Elderly & Disabled: Therapeutic Services Independence for Elderly & Disabled: Transportation Youth Development: Mentoring Programs Youth Development: Parenting Skills Youth Development: Physical & Mental Fitness (outside of school & sports programs) Youth Development: Positive Self-Image/Leadership Youth Development: Social / Recreational Activities ------------Community Impact Program Outcomes 2020 Grant Program Results------------- This information is collected to determine the outcomes of previous year grant dollars. Indicate Grant Activities: (Action steps within a program that help achieve the programs goals and objectives.) Examples: sheltering homeless families, counseling for at-risk youth, or educating public on signs of child abuse Indicate Grant Outcomes: (How the program changed the participants’ skills, knowledge, behavior, attitude or condition/value.) Examples: greater knowledge of nutritional needs, improved reading skills, effective response to conflict, getting a job, etc. Indicate Grant Outputs: (Direct result of a program's activities.) Examples: numbers of meals provided, classes taught, brochures distributed or participants served Indicate Grant Indicators & Data Source Used: (The number or percent of program participants who demonstrated the listed outcomes and the data source used for each.) Examples: 25% participants have a greater knowledge of nutritional need -----Success Story-----Include one client story from this program from the past 12 months. The United Way of Bradford County is committed to respecting individual’s privacy. This information will remain confidential unless authorized for use in marketing purposes.Client Name: Services Provided: Can UWAY Use This Story For Marketing Purposes? Yes No Should Client Be Kept Anonymous? Yes No If Possible, Please Upload a Candid Photograph for Purpose of Publication if Available that Effectively Shows the Success Story.Max. file size: 32 MB.If permission is provided from any individuals represented, we could incorporate in our brochure/website for marketing purposes. The Board of Directors and staff of the applying agency have reviewed and approved this request prepared for the United Way of Bradford County. It fairly and accurately represents the needs of the program in serving the residents of the Bradford County Community. We understand this request will be considered with all requests for funding, and if funded, we agree to abide by all United Way policies. Name of Preparer* First Last Phone Number of Preparer*Email Address of Preparer* Name of Board/Officer who can Verify / Certify this Application Information* Phone Number of Board / Officer*Email of of Board / Officer*
