Application for Community Response Grant

A Complete Application includes the Following:    Cover Sheet

Date of Application __________________________________

Organization Name __________________________________

Mailing Address ____________________________________

Contact Person _____________________________________

Phone Number _____________________________________

Email: ____________________________________________

Project Title _______________________________________

Dollar Amount Requested: ____________________________

Project Dates: ______________________________________

Project Budget Amount ______________________________

Annual Agency Departmental Operating Budget: __________

Other Sources of Revenue for the Project (please list confirmed and pending resources

___________________________________________________

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We, the undersigned, understand that a project report must be submitted to United Way within 30 days of the conclusion of the project.

Contact Person _____________________________________________Date _________

Chief Professional Officer ____________________________________Date _________

Board Chair _______________________________________________Date _________

   Project Budget – attach project budget in word, excel or pdf files

   Proposal (no more than 3 pages):  Your proposal must contain the following information clearly identified:

Brief history and explanation of mission of organization.

   Project description.

   The human service need in the community being addressed.

   Geographic area that will benefit from the project.

   Specific target population and estimate of the number of people affected.

   Expected outcomes of this project.

   Evaluation procedure – if applicable (description of the method for measuring expected outcomes.)

   Future funding sources for the project – if applicable.

   Implementation schedule for the project (specific dates).

   Plan for acknowledging United Way as a funding source.

   Commitment of agency support for United Way Campaign

   Verification of 501(c)(3) or Governmental Status