2008 Solano-Napa United Way Health Fund Grants Request for Proposal and Application Form

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1 2008 Solano-Napa United Way Health Fund Grants Request for Proposal and Application Form ABOUT The Solano-Napa United Way Health Fund was created in partnership by the United Way of the Bay Area and Solano Community Foundation. The Health Fund was created to serve the health needs of residents in Solano and Napa Counties. The fund is held by Solano Community Foundation, working with United Way and an advisory committee of community leaders, health practitioners, and others. Our goal is to increase access and availability of culturally appropriate direct health services for Solano and Napa residents who are currently above age 45. The target group includes individuals age who represent the future senior population boom, as well as individuals who are currently seniors (65 and up). CONTEXT United Way of the Bay Area, in partnership with Solano Community Foundation, conducted a study to find out the current status of 45 to 64 year old residents in Solano and Napa Counties, entitled The Coming Wave: Solano and Napa Counties Brace for Elderly Population Boom (available at The report s major findings included the following: By 2030, the Solano and Napa senior population will skyrocket (182% increase in Solano; 99% increase in Napa); In 2000, one-third of Napa and Solano residents age had incomes below 300% FPL ($42,450 for a family of 3), which means that they will likely remain poor as they become seniors; The numbers of Latinos, African Americans and Asians will grow among seniors, requiring services to meet their language and cultural needs. CHALLENGE The growth of the elderly population will put a larger and larger burden on the health care system and local economy, which may not have sufficient community services or tax base to support it. Communities, service providers, local governments and planning bodies should look now at how they can improve the current health and well-being of 45 to 64 year olds, before current issues are exacerbated with time. IMPACT In an effort to address current health needs of residents ages 45 and up in Solano and Napa Counties, the Solano Napa United Way Health Fund will be awarding grants to 501(c)(3) nonprofit organizations that focus on improving the lives of these individuals. Grant awards will range from $5,000 - $30,000. General program requirements include the following: Proposed projects must address one or more of the following three areas (taken from recommendations of The Coming Wave report): 1

2 o Increase number of service providers and/or improve accessibility to existing preventative care for older adults, especially for low-income adults and those without insurance; o Increase number of service providers and/or improve accessibility to existing outpatient and in-home care of chronic diseases, especially for those who do not have insurance; o Increase service providers ability to understand and transform their services to accommodate cultural differences such as language, community and tradition. Grants should be focused on providing program capacity for organizations serving the target population (individuals age 45 and up who have health issues). Grants may be used for direct services to individuals, technical assistance, start-up costs for a pilot project, planning and/or capacity building. These funds may also be used as a local match to leverage other sources of funds. Applicants who demonstrate collaboration will be preferred (please include a letter of support from collaborating agencies, outlining the agency s role in the collaborative and signed by their executive director). Services must be provided within Solano and/or Napa Counties. All grantees must be 501(c)(3) nonprofit agencies. APPLICATION PROCESS The application form is attached to this document. All applications must be received on or before 5:00 PM on August 15, Application PROPOSAL AND BUDGET must be submitted electronically to Supporting documents can be ed or submitted by mail at: United Way of the Bay Area Solano Napa Health Fund 401 Amador Street Vallejo, Ca Questions about the grant process may be posted at the following website, and will be answered for all participants to view: To gain access the site, you will need to contact After the grants are chosen and awarded, grantees will receive full payment at the beginning of the grant period. Grantees will also be required to submit a final report at the conclusion of the grant period. 2

3 SOLANO NAPA HEALTH FUND GRANT APPLICATION Contact Information Date: Organization Name: EIN Mailing Address: Executive Director: Program/Project Name: Program/Project Contact Name and Title: Contact Telephone: Contact Fax: Address: Website: If your Organization has a fiscal sponsor, please complete your fiscal sponsor information: Fiscal Sponsor Name: EIN Mailing Address: Executive Director: Program/Project Contact Name and Title: Contact Telephone: Contact Fax: Address: Website: 3

4 IRS 501(c)(3) determination letter REQUIRED ATTACHMENTS IRS Form 990 (same fiscal year as audit/financial statements) Financial Audit, Financial Review or Financial Statements depending on organization s budget size, as described below: Audit of most recent Financial Statements, including revenue and expense detail by an outside CPA (if organization's annual budget is $250,000 or more and organization has been operating for more than one year). Review of most recent Financial Statements including revenue and expense detail by an outside CPA and signed by the Board President and Executive Director (if organization does not conduct an annual audit and its annual budget is less than $250,000 and greater than $100,000, or if organization has been operating for less than one year). Unaudited, unreviewed Financial Statements (if organization does not conduct an annual audit and its annual budget is less than $100,000). Letter/statement signed by board president indicating board concurrence with UWBA Nondiscrimination policy: whereby the organization actively seeks to hire and promote individuals, recruit volunteers and provide services to individuals without regard to race, creed, color, gender, sexual orientation, disability, marital status, veteran status, national origin, age or physical disability Demographics Form Proposal Narrative Program/Project Budget (Format Attached) Organization s current annual budget or Program s Fiscal Sponsor s current annual budget Signed Fiscal Sponsor/Collaborative Relationship Agreement, if applicable 4

5 DEMOGRAPHICS Please list the number of program participants served in the previous fiscal year (if verifiable participation numbers are unavailable, please estimate). 1. Indicate the total number of participants served by this program: Individuals Families Organizations 2. Indicate the total number of participants at each age: years Unknown 3. Indicate the total number of participants with each ethnicity: African American or Black Native Hawaiian/Other Pacific Islander American Indian and Alaskan Native Other Asian Multi-racial Hispanic or Latino Unknown/Do Not Collect 4. Indicate the total number of participants of each gender: Female Male Other Unknown/Do Not Collect Of the individuals listed above, how many are transgender? MTF (Male to Female) Other FTM (Female to Male) Unknown/Do Not Collect 5. Indicate the total number of participants with each sexual orientation: Bisexual Lesbian Gay Unknown/Do Not Collect Heterosexual 6. Indicate the total number of participants at each income level: < $19,350 (below 100% of the Federal Poverty Level (FPL)) $19,351-38,700 (between 100%-199% FPL) $38,701- $58,050 (between 200%-299% FPL) $58,051- $77,400 (between 300%-399% FPL) > $77,401 (at or above 400% FPL) Unknown/Do Not Collect/Not Applicable 7. Indicate the total number of participants belonging to the following populations: Foster Youth Immigrants Unemployed Disabled PROPOSAL DESCRIPTION 5

6 The Solano-Napa Health Fund will grant awards to organizations that address the health challenges and needs of individuals age 45 and up. As you complete the following proposal, we strongly encourage you to review The Coming Wave report and its suggested action items and recommendations (see: Solano_ExecSumm_UW21c.pdf) 1. ACTIVITIES AND OUTCOMES CHART: Please use the following chart to list the goal(s) of your program, specific activities you propose to accomplish, the outputs that you will achieve and the outcomes that will result. You may expand the chart as needed. Note: Outputs are the immediate deliverables or services provided to participants. Outcomes are the lasting change or intermediate- and long-term goals achieved by participants. EXAMPLE: Goal: To increase individuals ability to manage their diabetes and improve their health. Activities: Volunteer medical staff will perform diabetes screenings and give out free blood glucose monitors to community members at churches, at health fairs and in senior centers. Staff will follow up with 100 individuals every 3 months to check on their health status. Outputs: The project will screen 500 individuals and distribute 100 free blood glucose monitors. Outcomes: At the end of 1 year, 75 individuals age 45 and up in Solano County will report improved diabetes management. 1. Goals Activities Outputs (short-term) Outcomes (long-term) 2. 6

7 2. PROPOSAL NARRATIVE. Please answer the following questions in 2-5 pages: A. Your organization: Please briefly describe your agency s history, mission and purpose. B. Need for your project and alignment with Fund goals: Please describe the community health need that your project is addressing and how your project is in alignment with one or more of the goals of the Solano Napa Health Fund. C. Goals and Objectives: Outline the proposed goals and objectives of this project. Objectives should state the strategic impact you hope to realize. Please include information on the number of people served during the grant period as well as the qualitative strategic impact of your work on the target population, service delivery system and/or the larger community. D. Activities and Indicators: Describe the major activities you will undertake to meet each of the proposed objectives and list the specific, measurable indicators (characteristics or changes) you will measure that represent achievement toward each outcome as a result of your activities. E. Outcomes: Outline the outcome(s) (changes or impact) you project to achieve during the grant period. What long-term measurable impact does your program have on the target population, larger community or service delivery system? How do your outcomes relate to the recommendations outlined in The Coming Wave report? How does your program address the challenges and needs of the current 45 and up population, as well as their future needs as they enter retirement age? F. Evaluation Plan: Please explain how you intend to measure the outcomes and impact of your work. G. Award Intent: Please state the amount you are requesting and indicate how your organization plans to utilize an awarded grant (e.g., staff, materials, etc). List any other commitments you expect from other funding sources to cover the full cost of the program. H. Partnership and Collaboration: Please list the major collaborative partners that will contribute to your program. Describe how each partner will contribute to the outcomes or long-term impact. These may include public, private or nonprofit organizations. I. Sustainability Plan: Summarize how you intend to sustain the program to meet your longterm outcomes answered above.

8 PROPOSAL BUDGET Please fill out shaded columns ( Total Project Budget and Proposed Use of Health Fund Dollars ) below to describe how the funds will be spent. This form is aligned with the report your organization produces each year for the IRS form 990, and (if your proposal is chosen) will be re-sent to you to complete as a financial report at the conclusion of the grant period. Revenue Government grants Foundation grants Individual donations Earned income Other income Total Revenue Total Project Budget Actual Program Budget Proposed Use of Health Fund Dollars Actual Use of Health Fund Dollars Expenses Compensation of officers, directors, etc. Other salaries and wages Pension plan contributions Other employee benefits Payroll taxes Professional fundraising fees Accounting fees Legal fees Supplies and minor equipment Purchase of major equipment Telephone and telecommunications Postage and shipping Rent and occupancy Equipment rental and maintenance Printing and publications Travel Conferences, conventions, Total Project Budget PERSONNEL Actual Program Budget PROFESSIONAL FEES PROGRAM AND OPERATING Proposed Use of Health Fund Dollars Actual Use of Health Fund Dollars

9 and meetings Interest Depreciation, depletion, etc. Other expenses not covered above (itemize): Total Expenses

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