ࡱ> %` dbjbjٕ y'JJJJbbbd6,,,,lDK!388888???|2~2~2~2~2~2~2$3h?629b  ?  2JJ88i'2@ @ @  (J, 8b8|2@  |2@ @ vbt8, 0, XHh"20!3^60 6,t6bt?=l@ $???220 ???!3    DKDKDK{(DKDKDK(jrJJJJJJ REQUEST for FUNDING for 2009  Part I: Sec. E  Client Service/Allocation Summary ALL COUNTIES * Complete using only United Way monies. ALLOCATION FROM CLIENTS SERVED 2007 $ ACTUAL 2007 PROJECTEDCLIENTS 2008 $ BUDGET 2008 % INCREASE (DECREASE) $ - 06 to 07 Projected CLIENTS 2009  $ Requested 2009  % INCREASE (DECREASE) $ - 07 to 08 DICKENSON*** RUSSELLtc "RUSSELL"*** SCOTT*** WISEtc "WISE"***TOTAL tc "TOTAL " \l 2 UWSWVA   ALL OTHER UNITED WAYSUPPMENTAL FUNDRAISING   How much of your budget is covered by United Way allocations?  $_______________________ ________________% of Total Budget How much of your budget is spent on administrative and general cost?  $_______________________ ________________% of Total Budget How much of your budget is spent directly on client services/programs?  $_______________________ ________________% of Total Budget  Does your organization have a reserve or contingency fund? Yes___No___ If yes, refer to Budget Form # 3 Supplemental Information: Item B. - 15 - REQUEST for FUNDING Part I: Sec. J - Board members/Officers NAME, ADDRESS, TELEPHONETERM EXPIRATIONOFFICE  - 16 - UNITED WAY OF SOUTHWEST VIRGINIA REQUEST for FUNDING for 2009 Part II: MEMBER AGENCY AGREEMENT tc "REQUEST for FUNDING Part II\: MEMBER AGENCY AGREEMENT " \l 5 =================================================== For the purpose of sharing in the funds to be raised by the United Way of Southwest Virginia and the local County Advisory Boards, this organization agrees: To maintain responsible management, with a qualified Board of unpaid Directors or Administrative Body, which shall meet on a regular basis during the year. 2. To cooperate with other social agencies in preventing duplication of effort and in promoting effective services, and efficiency and economy of administration. 3. To advise the United Way and Advisory Board of planned large fundraising campaigns or new programs during the year. 4. To keep complete books of account open to inspection by authorized people. 5. That, in the event of the termination of agency services, allocated United Way funds shall revert to the United Way for reallocation to a functioning agency. 6. To provide services to all persons without discrimination because of race, religion, age, national origin, sex, or disability status. 7. To refrain from major fundraising in September and October. 8. To publicize fact that agency is a member of the United Way and use logo on published material. 9. To cooperate during campaign time with agency tours, presentations, requests for publicity, and staff/ Board solicitation during the campaign. 10. To accept final funding of approved agency budget based on the percentage of actual collections by the United Way. The percentage of actual collections equals the percentage of dispersion by the United Way and the Advisory Board. 11. To notify the United Way of Southwest Virginia immediately upon any change in the agencys tax exempt status under IRS code 501 ( c ) 3. This agreement should be properly signed and accompany the application for funding.  ______________________________ _____Refer to Signature Sheet_______ AGENCY DATE ______Refer to Signature Sheet_______ ____Refer to Signature Sheet_______ CHIEF PROFESSIONAL OFFICER CHIEF VOLUNTEER OFFICER COUNTERTERRORISM COMPLIANCE MEASURES In compliance with the USA PATRIOT Act and other counterterrorism laws, the United Way of Southwest Virginia requires that each agency certify the following:  "I hereby certify on behalf of ___________________________________________ [name of grantee] that all United Way funds and donations will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes and executive orders."  Print Name: ______________________________ Title: _____________________________  Signature: ___Refer to Signature Sheet_______ Title: _____________________________ SIGNATURE SHEET  Agency Name: _______________________________________________________________  Name of Chief Professional Officer: __________________________________ Initials: _______  Name of Chief Volunteer Officer: ____________________________________ Initials: ______ The purpose of this page is to facilitate the compliance of a Governing Body review of this United Way Application, its contents entirely, the terms of agreements and issues of compliance, by providing one page for signature. Three areas are covered in this application and are as follows. 1. The United Way Application for 2009.  This Application was considered and approved by our Board of Directors on _______________________.  DATE Initials: _______  Initials: _______ 2. The Member Agency Agreement.  This agreement was reviewed and accepted by the Board of Directors on ________________. DATE  Initials: _______  Initials: _______ 3. Counterterrorism Compliance Measures.  This statement was reviewed and accepted by the Board of Directors on ________________. DATE  Initials: _______  Initials: _______  ______________________________________________________ __________________________________________________ Chief Professional Officer Title Chief Volunteer Officer Title  Date of original signatures: ___________________ REQUEST for FUNDING for 2009 Part II: Budget Form # 1 - Agency tc "REQUEST for FUNDING Part II\: Budget Form # 1 - Agency " \l 2  Agency _________________________________ tc "Agency _________________________________ " \l 5Fiscal 07 ActualFiscal 08 Revised% Increase or (Decrease) 07 to 08Fiscal 09 Proposed% Increase or (Decrease) 08 to 09Support and Revenue1. Allocation from all Southwest Virginia Counties 2. Contributions3. Restricted Contributions and Bequests4. Revenue Grants from Government Agencies5. Revenue from other United Ways6. Membership Dues7. Program Service Fees8. Sales of Materials/ Special Funds9. Transfers from Endowment Funds10. Miscellaneous Revenues/ Investment Income11. Total Support and Revenue (Lines 1 - 10)Expenses12. Employee Compensation and Related Expense13. Operating Expenses14. Professional Fees15. Travel and Staff Training16. Specific Assistance to Individuals17. Membership Dues/ Affiliated Organizations18. Other Expenses (see below)**19. Miscellaneous20. Transfers to Endowments/ Other Funds21. Total Expenses for Budget Period (Lines 12-20)22. Depreciation of Buildings and Equipment23. Major Property and Equipment Acquisition24. Total Expenses (Lines 21-23)25. Cost per client (Line 21 divided by # of clients)26. Total Surplus or (Deficit) (Line 11 minus Line 24)**Note here what items are included in Other Category: ________________________________________________________________________________________________________________________________ NOTE: Depreciation should only be included in the line provided above. REQUEST for FUNDING for 2009 Part II: Budget Form # 2 - Program tc "REQUEST for FUNDING Part II\: Budget Form # 2 - Program " \l 2  Agency ________________________________________ tc "Agency ________________________________________ " \l 5  Program _______________________________________ Use a separate sheet for each program.Fiscal 07 ActualFiscal 08 Revised% Increase or (Decrease) 07 to 08Fiscal 09 Proposed% Increase or (Decrease) 08 to 09Support and Revenue (Program Specific)1. UW Allocation from all Southwest Virginia Counties2. Revenue from other United Ways3. Other contributions and gifts4. Revenue Grants from Government Agencies5.Program service fees6.Other revenues (List on lines 6-10) 7.8.9.10.11. Total Support and Revenue (Lines 1 - 10)Expenses12. Employee Compensation and Related Expense13. Operating and administrative Expenses14. Professional Fees15. Specific assistance to individuals16. Other expenses (List on lines 16-20) 17. 18. 19. 20. 21. Total Expenses for Budget Period (Lines 12-20)22. Cost per client (Line 21 divided by # of clients)23. Total Surplus or (Deficit) (Line 11 minus Line 21) REQUEST for FUNDING for 2009 Part II: Budget Form # 3 Supplemental Information tc "REQUEST for FUNDING Part II\: Budget Form # 3 Supplemental Information " \l 2 RECONCILIATION REPORT tc "RECONCILLATION REPORT " \l 5 Complete the following report if the agencys projected revenues (from Agency Budget Form #1: Line 11) or expenditures (from Agency Budget Form # 1: Line 23) for 2009 have increased or decreased by more than 25% from the 2008 budget. Line item revenue(s) differing by more than 25% and reason for the difference.  Line item expenditure(s) differing by more than 25% and reason for the difference.  EXPLAINATION OF RESERVE FUNDS tc "EXPLAINATION OF RESERVE FUNDS " \l 5 Complete the following report if the agency has reserve funds that exceed 25% of the agencys 2009 budget.  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