KERR COUNTY UNITED WAY Phone: Earl Garrett St. Fax: P.O. Box GRANT APPLICATION
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1 KERR COUNTY UNITED WAY Phone: Earl Garrett St. Fax: P.O. Box Kerrville, TX GRANT APPLICATION APPLICATION DEADLINE: noon on April 2nd. INTERVIEWS: MONDAY - MAY 14 th & TUESDAY - MAY 15 th Please call to deliver applications. Information requested is for KERR COUNTY only. INSTRUCTIONS A complete application consists of 1 original and 14 copies. Applications must have the following documents attached. Please do NOT attach these instructions to your application. List of current board members with addresses & phone numbers. Most recent Income Statement. An audited statement is preferred. Year-End Profit and Loss Statement Current Year s Budget & Proposed Budget for next year New applicants must provide their IRS 501c3 certification letter. $40.00 application fee made payable to Kerr County United Way 1. MAKE COPIES ON THE FRONT & BACK. 2. NUMBER ALL PAGES & SEPARATE APPLICATIONS WITH A DIVIDER OF SOME SORT. 3. DO NOT STAPLE DOCUMENTS HOLE PUNCH ALL DOCUMENTS. Thank you very much. We look forward to serving you. Please do not hesitate to contact us if you have any questions.
2 KERR COUNTY UNITED WAY GRANT APPLICATION AGENCY: DIRECTOR: AGENCY PHONE: DIRECTOR S CELL: AGENCY MAILING ADDRESS: CITY, STATE, ZIP: PHYSICAL ADDRESS: CITY, STATE, ZIP: 1. What is the agency s mission statement? 2. What programs/services did your agency provide this year? 3. How are your agency programs/services assessed for effectiveness and how do you measure your program s outcome? 4. What counties does your agency serve? 5. Target population served (age, gender, special interest, etc.): 6. Number of unduplicated individuals served in: Kerr County: 2016: 2017: Other Counties: 7. How many employees are paid by your agency? Full-time: Part-time: 8. How many employees are paid from other sources? 9. How many volunteers work with your agency? 10. What is the size of your present Board? 11. When and where does the Board meet? 12. What supplementary fundraising activities does the agency conduct?
3 13. Is an independent audit performed of your agency s records? Yes / No 14. Who performs this audit? 15. Do you charge fees for any of your programs or services? Yes / No 16. What percentage of your services are free? % 17. Costs of services? 18. Amount of funds received from United Way last year: $ 19. Funds requesting from United Way: $ 20. Describe how these funds will be used. Please be specific. PARTICIPATION AGREEMENT We agree to allow Kerr County United Way the right to inspect and audit this agency s books and financial records, if it is deemed necessary. We agree to participate actively in the ANNUAL FUNDRAISING CAMPAIGN, and to support Kerr County United Way s efforts throughout the year, including but not limited to: Identify the agency as a United Way participating agency on letterhead, if, possible, and in all publicity and educational efforts in the community. Have the agency s staff/board members/volunteers and/or workers actively participate in the annual United Way Presentations and its ANNUAL FUNDRAISINGCAMPAIGN. Encourage the agency, Board of Directors, staff, and volunteers pledge to Kerr County United Way. Attach three (3) client stories that are representative of people helped in the past year. Please change their names and give stories that can be printed and/or placed in social media. NON-DISCRIMINATION POLICIES We do not exclude anyone from service because of race, ethnic origin, religion, or gender and there is no segregation of persons served on the basis of race, ethnic origin, religion, or gender. With regard to hiring, assignment, promotion or other conditions of staff employment we do not discriminate on the basis of race, ethnic origin, religion, or gender. This agency has a written plan for positive action to achieve equal employment opportunity for all persons in the filling of its staff positions including elements such as contacts with various organizations in the community, including minority group organizations, regarding the agency s employment needs, recruitment advertisements in minority group news media where advertising in the general media is used to fill jobs, identifying the agency as an equal employment opportunity employer in recruitment advertisements, and the use for job referral purposes of only those employment agencies that do not discriminate on the basis of race, ethnic origin, religion, or gender in making referrals. We do not discriminate on the basis of race, ethnic origin, religion, or gender in membership on the agency s governing body. The practices of this organization conform to the non-discrimination policy stated above.
4 AGENCY ADMINISTRATIVE COSTS Please provide a computation of your agency s percentage of total support and revenue spent on administrative costs. The calculation method to determine administrative costs is as follows: MANAGEMENT & GENERAL EXPENSES 1. IRS Form 990 Part IX - Line 25 Column C $ FUNDRAISING EXPENSES 2. IRS Form 990 Part IX - Line 25 - Column D $ TOTAL EXPENSES 3. Sum of Line 1 and Line 2 $ TOTAL REVENUE 4. IRS Form Part VIII - Line 12 Column A $ PERCENTAGE OF REVENUE SPENT ON ADMINISTRATION 5. Divide Line 3 by Line 4 %
5 REVENUE AND EXPENSES Figures for should be PROJECTED. Round out to the nearest dollar. You may add or delete categories as needed OR you may attach your own Excel spreadsheet, if desired. REVENUE Kerr County United Way 2. From other United Ways 3. Contributions/Donations 4. Special Events 5. Legacies & Bequests 6. Other Organizations 7. Government Agencies 8. Program Fees 9. Net Incidental Revenue 10. Sales of Materials 11. Investment Income 12. Other Revenue 13. TOTAL REVENUE EXPENSES 14. Salaries: 14.a. Full-time 14.b. Part-time 15. Employee Benefits 16. Payroll Taxes, etc. 17. Professional Fees 18. Program Supplies/Expenses 19. Marketing Expenses 20. Office Supplies/Expenses 21. Telephone/Internet 22. Postage & Shipping 23. Rent 24. Equipment Rental & Maintenance 25. Printing & Publication 26. Travel 27. Conferences & Conventions 28. Meetings Specific Assistance to Individuals 29. Subscription/Membership Dues 30. Other Expenses 31. TOTAL EXPENSES NET OPERATING INCOME $ $ $ Agency Director s Signature Date:
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