Partner Agency Funding Application

UNITED WAY OF GREENBRIER VALLEY

PARTNER AGENCY FUNDING APPLICATION

Due March 5th

PART I - AGENCY INFORMATION

Organization Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Use a 1 before your area code for U.S. numbers

Website

Number of Employees

Mission Statement

Project Name

Amount of Funds Requesting

Executive Director Name

Grant Writer Name

Email

Phone

Use a 1 before your area code for U.S. numbers

EIN

PART II - PROGRAM INFORMATION

Area of Focus

Health

Education

Basic Needs

Financial Stability

Counties being served through your project

Target Population:

Infants through teens

Adults

Seniors

Families

Please describe the target population served by the project

Project Description

Statement of Need

Total number of clients expected to be served by this project

Goals and Objectives

Identify up to 4 MEASURABLE goals and objectives for the program/service/project for which you are requesting funding.

Goals must be MEASURABLE and indicate the number of individuals/families to be served. Examples: # of meals per day/week/year to # of seniors; # of clients receiving emergency assistance; # of trainings to # of students plus frequency; # of individual scholarships to be awarded; etc.)

Name any partners and/or collaborators

PART III - BUDGET INFORMATION

Amount of funding request

Please upload your Annual Budget

Supported files:

MS Office: DOC, DOCX, DOCB, DOT, DOTX, XLS, XLSX, XLT, PDF, CSV

Please upload your Project Budget

Supported files:

MS Office: DOC, DOCX, DOCB, DOT, DOTX, XLS, XLSX, XLT, PDF, CSV

PART IV - REQUIRED DOCUMENTATION

Past Partner Agreement Assessment – If you were awarded a grant last year, how did your agency support the United Way this past year? Please provide detailed information in this space. If you were not funded by us last year, please enter N/A.

As a United Way Partner Agency, please indicate, below, the ways your agency will advocate, give, and volunteer.

Partner Advocate Action Plan

Post signage stating partnership

Accompany United Way staff and board on recruiting trips

Provide in-kind promotion of United Way in agency publication and/or publicity

Other

Partner Volunteerism

Empty Bowls

Chocolate Festival

Boot Drive

Other

DOCUMENT REQUIRED UPLOADS

Board of Directors

Supported files:

MS Office: DOC, DOCX, DOCB, DOT, DOTX, XLS, XLSX, XLT, PDF, CSV

IRS Letter of Determination

Supported files:

MS Office: DOC, DOCX, DOCB, DOT, DOTX, XLS, XLSX, XLT, PDF, CSV

Most recent 990

Supported files:

MS Office: DOC, DOCX, DOCB, DOT, DOTX, XLS, XLSX, XLT, PDF, CSV

Certification Statement

This agency operates in compliance with all applicable laws and regulations governing not-for-profit corporations, in the State of West Virginia. I understand that all requests for funding to the United Way of Greenbrier Valley must be complete upon submission, and by answering "Yes," I acknowledge that all required components of the application are included.

Yes