Community Initiative. Grant Request Form. Please check that the completed application has the following:

Transcription

1 Community Initiative Grant Request Form Please check that the completed application has the following: An audited financial statement or annual financial review. A list of names and contact numbers for the organization s Board of Directors or individuals responsible for the program. Organization name at the top of each page. Completed answers are under one-hundred-words per question unless otherwise specified. Eight copies of completed application are submitted. United Way Oxford s Community Initiative Fund Application Page 1 of 11

2 GRANT REQUEST FORM INSTRUCTIONS United Way Oxford values new program initiatives directed at emerging community issues and encourages organizations with such programs to apply for funding. This grant request form is designed to be a generic form for both large and small organizations. United Way recognizes that small and developing organizations may be unable to answer all of the following questions. In these instances, an N/A in the space provided is acceptable. The following application is composed of three sections and two appendices: Section A: Administrative Information Section B: Program Information Section C: Accountability Statement Appendix A: Statements of Total Organization Revenues and Expenditures Appendix B: Projected Program Revenues and Expenditures This application form contains eight pages. Please ensure that all questions are answered and that the pages are securely attached when submitted. PLEASE NOTE: All applications must be completed on the United Way Oxford form as written here (i.e. unless otherwise specified, alterations to the format of the request form or its appendices will NOT be accepted). Clear point form answers are acceptable. Applications will be accepted on an ongoing basis, dependant on funds. All applications must be delivered to United Way Oxford. Applications that are incomplete, faxed or ed will NOT be accepted. Please contact United Way Oxford with any questions or concerns: 65 Springbank Ave. N. Woodstock, Ontario N4S 8V8 (519) info@unitedwayoxford.ca United Way Oxford s Community Initiative Fund Application Page 2 of 11

3 CRITERIA FOR SELECTING PROJECT PROPOSALS ELIGIBILITY CRITERIA The application must meet the following eligibility criteria: Application is fully completed For reasons of Accountability, at least one agency in a collaborative submission must provide evidence that there is an active Board of Directors/Steering Committee Organization must be non-profit, and operating in a non-discriminatory manner Applicant or sponsoring agency is incorporated, has been in existence for more than one year, has a charitable registration number and is located in Oxford County The project must be held in Oxford County and be utilized by Oxford County residents INELIGIBILITY CRITERIA The funders will not fund: For-profit organizations or ventures Organizations that have explicit links with any political party Organizations where the service component is conditional upon participation in the religious activities of the organization Capital costs such as the purchase of large equipment; construction, or reconstruction Deficit financing Projects targeted at provincial/national organizations unless a chapter/branch exists to serve only the residents of Oxford County Organizations whose primary purpose is to raise funds to distribute in the community United Way Oxford s Community Initiative Fund Application Page 3 of 11

4 SECTION A: ADMINISTRATIVE INFORMATION Organization name: Registered Canadian charity status number: Address of organization: Organization telephone number and fax number: Phone: ( ) Fax: ( ) Organization web address and Name of Program: Grant Amount Requested: Name/position Lead volunteer Lead staff (Executive Director) Contact person Re: Application Telephone number address Signature Date signed United Way Oxford s Community Initiative Fund Application Page 4 of 11

5 Organization Staff Specifics: Current Year Number of paid full-time equivalents: Number of volunteers: Number of volunteer hours required: Following Year Change (+/--) Please provide a brief description of the organization, its origin, and its mission statement in two hundred words or less: If this organization has been in operation for more than one year, United Way Oxford requires an audited financial review. If the gross income of this organization is less than $5000 an annual financial statement is acceptable. ALL APPLICANTS MUST SUBMIT A CURRENT FINANCIAL STATEMENT PLEASE COMPLETE APPENDIX A. United Way Oxford s Community Initiative Fund Application Page 5 of 11

6 SECTION B: PROGRAM INFORMATION Program name: Provide a brief description of program i.e. goals and activities in two hundred words or less: Check the category of needs that this program will apply to; provide a brief explanation of the program s importance in Oxford County, and the adverse effects of not having this program in Oxford County. Please check all applicable categories : Reducing Violence Supporting Seniors Mental Health Services Supporting Persons with Disabilities Helping Families and Individuals in Crisis Assisting Youth Tackling Poverty Volunteer Leadership / Information Services Transportation IMPORTANCE ADVERSE EFFECTS i) Is this program unique within Oxford County? yes no ii) If not, why is this program necessary? United Way Oxford s Community Initiative Fund Application Page 6 of 11

7 Geographical area served (Please check all applicable spaces and provide numbers if possible): City of Woodstock Town of Ingersoll Town of Tillsonburg Blandford & Blenheim Township East Zorra-Tavistock Township Norwich Township South West Oxford Township Zorra Township Participant base/ target population served: What are the goals of this program? Describe the planned activities intended to achieve anticipated results? How will your organization define a unit of service? United Way Oxford s Community Initiative Fund Application Page 7 of 11

8 Year (projected) Cost of program (budget) Program Participant Specifics: Number of Cost per participants participant Example: Number of children receiving breakfast at school Number of units of service Cost per unit of service Example: Number of breakfasts served Number of paid full-time equivalents: (projected) How will participant feedback be gathered? Program Staff Specifics: Number of volunteers: Number of volunteer hours required: How will the project be evaluated upon completion? Is future financial sustainability a concern? If so, how will it be addressed? List partnerships, collaborations, and associations with other organizations and individuals to facilitate this program and their qualifications: More rows may be added if necessary. Name of contact Name of agency/ organization and mailing address Telephone number Fax number A COMPLETE BUDGET STATEMENT IS REQUIRED BY ALL APPLICANTS FOR THIS PROGRAM PLEASE COMPLETE APPENDIX B United Way Oxford s Community Initiative Fund Application Page 8 of 11

9 SECTION C: ACCOUNTABILITY STATEMENT Complete this section only once. Agency Name (Please Print) Registered Charitable Number The undersigned affirms to the best of their knowledge, the information contained in this application is true and complete, and that the responsible governing body approved this request on, and is aware of and concurs with the foregoing information. (Date) Further, if the proposed grant is made, the undersigned agrees to use the funds only for the purpose granted and to provide any reports or information that may be requested by the United Way Oxford. The undersigned also agrees to recognize the United Way Oxford as a funding source and to include United Way Oxford s logo on relative material. Upon approval, the undersigned agrees to sign a detailed Letter of Agreement which outlines full expectations. Board President / Chair (Please Print) Executive Director (Please Print) Signature of Board President / Chair Signature of Executive Director Date submitted to United Way Oxford: United Way Oxford s Community Initiative Fund Application Page 9 of 11

10 APPENDIX A: STATEMENT OF TOTAL AGENCY REVENUES AND EXPENDITURES Revenue Current Budget Current Actual Following Year Budget % Change United Way Allocation Fees For Services Fundraising Government Funding: Federal Provincial Municipal Trillium Funding Other (Specify) Total Agency Revenue Expenses Capital Expenditures Salaries and Benefits (Administration and Programs) Office and Administration Costs Fundraising Expenses Other (Specify) Total Agency Expenses Agency Surplus or (Deficit) Explanation Of Major Changes: United Way Oxford s Community Initiative Fund Application Page 10 of 11

11 APPENDIX B: PROJECTED PROGRAM REVENUES AND EXPENDITURES Name of Program: Revenue Projected Budget United Way Allocation Fees For Program/Services Fundraising Government Funding: Federal Provincial Municipal Trillium Funding Other (Specify) Total Program Revenue Expenses Capital Expenditures Salaries and Benefits (Administration and Programs) Direct Office and Administration Program Costs Fundraising Expenses Other (Specify) Total Program Expenses Program Surplus or (Deficit) United Way Oxford s Community Initiative Fund Application Page 11 of 11