ࡱ> %` Xbjbjٕ ([5558TXjjjj4kbxqxqxqxqxqooobbbbbbb$dhg)b]5wo)bxqxqYbxq5xqbbG;, 5Jxqlq Pf%j4XIP'Lb0b#Jg<gJg5JHoJt=ooo)b)booobee678 UNITED WAY OF SOUTHWEST VIRGINIA REQUEST for FUNDING for 2009 tc "REQUEST for FUNDING" 2008 Instructions tc "2002 Instructions " \l 2 GENERAL: This REQUEST for FUNDING will be used by all County Advisory Boards to determine allocations for 2009. Please download and complete this form following the directions on pages i-iii. Print the Signature Sheet, review and complete with original signatures. Prepare a separate Page 4, Part I-D, for each county in which funds are being requested. The information in each Page 4 must be specific for the county. Submit the completed application/budget file by APRIL 25, 2008 to applications@SWVAUnitedWay.org. Fill in all spaces. If the question does not apply to your agency, mark the space with NA. The completed Signature Sheet, Audit, Financial Statement and any required hard copy material is not mailed to the United Way office. Present this material to the United Way Liaison at the Day Tour. The local County Advisory Board may request a budget presentation separately if needed, but is usually part of the Day Tour. Use form as provided; altered applications will be returned. Below is the Allocations & Admissions Committee Chairperson for each County. Contact the person below with concerns, questions, or suggestions. COUNTYtc "COUNTY"COUNTY CHAIRPERSONADDRESStc "ADDRESS"PHONE/FAXtc "PHONE/FAX"Dickenson Wanda Perry RT 2 Box 268 Coeburn, VA 24230 (276) 835-9617RussellSteve Breeding P.O. Box 2046 Lebanon, VA 24266(276) 988-7921/ (276) 889-4589 (276) 988-7924 FaxScottGary E. Michael, M.DClinch River Health Services, Inc. Rt 1 Box 20 Dungannon, VA 24245(276) 467-2201/ (276) 467-2673 FaxWiseDan MinahanUnited Way of Wise County P.O. Box 1683 Wise, VA 24293 (276) 679-2007 i UNITED WAY OF SOUTHWEST VIRGINIA COUNTY ADVISORY BOARD APPLICATION FOR FUNDING PLEASE: Do not attach additional information such as brochures, etc. unless specifically requested to do so. BY SECTION: PART I-A: Use the table to list each program described in the application. Place the amount requested from each county under the county name and on the line for each program. CHECKLIST: Complete and submit. The completed Signature Sheet, Audit, Financial Statement and any required hard copy material is not mailed to the United Way office. Present this material to the United Way Liaison at the Day Tour. PART I-B: Complete and submit. The indicated Contact should be someone authorized to answer questions and make decisions relevant to United Way funding. Indicate your fiscal year. Regardless of your fiscal year or the disbursement schedule, United Way funds from this application cycle begins in January 2009. The original Signature Sheet must have original signatures. Briefly describe the agencys efforts for the next two years in regard to the mission/objectives/goals of the agency. PART I-C : GENERAL AGENCY INFORMATION - Focus on the program or service for which funds are requested. PART I-C is generic for all counties. PART I-D: This section is county specific and must be completed separately for each County in which funds are requested. Use a separate Page 4 for each county and list each program requesting funding from the county. PART I-E: CLIENT SERVICE/ALLOCATION SUMMARY - List the number of clients served and the allocation received from each county for 2007, 2008, and projected 2009. For questions 1 through 4, refer to FINANCIAL INFORMATION described below. PART II: MEMBER AGENCY AGREEMENT The Signature Sheet must be initialed, dated, and signed by the chief professional officer and the chief volunteer officer to indicate that the Member Agency Agreement was reviewed and the terms accepted. PART II: COUNTERTERRORISM COMPLIANCE CERTIFICATION - The Signature Sheet must be initialed, dated, and signed by the chief professional officer and the chief volunteer officer to indicate that the Counterterrorism Compliance Certification was reviewed and the terms accepted. ii PART II: FINANCIAL INFORMATION - Use the fiscal year for which you developed goals and objectives. Past Year: 2007 Current Year: 2008 Projected Year: 2009 PART II: FINANCIAL INFORMATION (cont) - Administrative Costs are those expenses that do not directly impact a client/consumer, but that are essential to the sound management of the organization. The following are examples of administrative costs. Audit and Form 990 preparation fees All fundraising expenses Attorney/legal fees Contractual fees, unless specifically program related Membership dues to business/civic clubs 100% of wages/benefits for Executive Director and all staff less any time spent on direct program duties as documented by a time study. Bookkeeper/accountant fees/wages Space/facilities/utilities cost for administrative areas/functions on a prorated basis Insurance Travel cost not directly related to a specific program Depreciation and amortization BUDGET FORM 1: This is for the entire agency and is required of all applicants. BUDGET FORM 2: This is required as the requested funds are for a specific service or program. Use a separate Budget Form 2 for each program when requesting funding for more than one program. BUDGET FORM 3: Used to address any discrepancies of revenues and expenses from Budget Form 1 and/or 2. The bottom section is used to report restricted funds or Board designated reserves. BUDGET PRESENTATION: Usually held during the Day Tour. The local Advisory Board may request a separate date for an expanded budget presentation The Agency representative must know the entire Application/Budget The representative should be familiar with the method/significance of calculating numbers specific to the county where the Application for Funding is submitted. iii UNITED WAY OF SOUTHWEST VIRGINIA REQUEST for FUNDING for 2009 Part I. Sec. A - Checklist  AGENCY_______________________________________________________________ tc "AGENCY_______________________________________________________________ " \l 5 Enter the amount requested for program and from each county to which this request is being submitted. ProgramDickenson tc "Dickenson " \l 3Russell tc "Russell " \l 3Scott tc "Scott " \l 3Wise tc "Wise " \l 3  CHECKLIST: This REQUEST for FUNDING has two parts. PART I is the application for funds to be dispersed in 2008 and must be completed in its entirety by all agencies. PART II is supporting documentation and is required only as defined below. Check off those documents that are attached to this request. ____ Part I, pages 1 through 5.  ____ List of current Board of Directors. Required for all incorporated agencies and others with a governing board.  ____ List of current volunteer officers. Required of all agencies. Check off those documents for presentation to the Liaison as required. ____ Financial statement. Required of all agencies.  ____ Formal CPA review. Required of all agencies whose total budget is > $25000 < $200000.  ____ Agency Audit. Required of all agencies whose total budget is greater than $199,999.  ____ IRS letter of exemption 501 (c) 3. Required of agencies requesting funds for the first time. NOTE: See MEMBER AGENCY AGREEMENT item 11.  ____ Part 2. The following forms are provided..  ____ MEMBER AGENCY AGREEMENT & Counterterrorism Compliance Certification. Must be reviewed and accepted by the Agencys Board of Directors.  ____ Signature Sheet. Required of all agencies. Present to Liaison as required.  ____ Budget Form # 1 - Agency. Required of all agencies.  ____ Budget Form(s) # 2 - Program. Required of all agencies for each specific program. One form for each specific program for which funds are being requested.  ____ Budget Form # 3 Supplemental Information. Section A required if the agencys projected revenues or expenditures for 2009 have increased or decreased by more that 25% from the 2008 budget. Section B required if the agency has reserve funds that exceed 25% of the 2008 proposed budget. - 1 - tc "- 1 - " \l 2 REQUEST for FUNDING for 2009 Part I: Sec.B Agency Profile tc "REQUEST for FUNDING Part I\: Sec.B Agency Profile " \l 2 =============================================== AGENCY:_______________________________________________________________________________ tc "AGENCY\:_______________________________________________________________________________ " \l 2  MAILING ADDRESS:______________________________________________________________________ tc "MAILING ADDRESS\:______________________________________________________________________ " \l 3  CITY, STATE, ZIP: ________________________________________________________________________________  TELEPHONE:________________________FAX: ________________________EMAIL: ________________________  CONTACT: _______________________________________________________________________________________ OFFICERS: Board President _____________________________________________________________________  Board Treasurer _____________________________________________________________________  Executive Director: ___________________________________________________________________  For Agency Fiscal Year ________________________________ to ________________________________________ Briefly describe your organizations mission and objectives for the next two years. Identify your funding priorities and describe the target population the organization serves.  This Application was considered and approved by our Board of Directors on _____Refer to Signature Sheet_______________. DATE ___Refer to Signature Sheet_____________________________ _______Refer to Signature Sheet_______________________ Chief Professional Officer Title Chief Volunteer Officer Title - 2 - REQUEST for FUNDING for 2009 Part I: Sec. C Program Information Use a separate sheet for each program.  AGENCY: _________________________________________________________________  PROGRAM: ________________________________________________________________ Describe the program(s) for which you are requesting funding in terms of need, target population, the number of clients on your waiting list and long-term outcome for those being served.  How are program(s) assessed for effectiveness to achieve the desired outcome?  How is the program(s) staffed? Include number of volunteer people and hours.   4) Do you charge fees ___Yes ___No. If Yes, explain fee basis.  5) Describe how you responded to Recommendation (if received) from United Way last year. Refer to the Letter of Award received by the agency in 2008.  - 3 - REQUEST for FUNDING for 2009 Part I: Sec. D County Specific Information Use additional sheets if more than 4 programs/services reported.  AGENCY: ________________________________________________________________ Mark the County for which this information is applicable. Complete this section separately for each county where funds are requested. Use separate sheets for each county. Dickenson tc "Dickenson " \l 3Russell tc "Russell " \l 3Scott tc "Scott " \l 3Wise tc "Wise " \l 3  For program(s) to be funded, describe the programs/services your agency currently provides, the number of total clients served, the number of County clients served and the percent that the County is of the total. Programs/ ServicesTotal number of clients served in 2007County number and percent of clients served in 2007Estimated total number of clients served in 2008County number and percent of clients served in 2008Estimated total number of clients served in 2009 County number and percent of clients served in 2009     Using County numbers only, describe the total number and type of unduplicated individual units of services (example: service hours, counseling sessions, meals served, trips, days of shelter), the total cost, and then the cost per one unit of service provided by the funded program(s) to the County residents. List by Unit of Service (or Program)Actual for 2007 Estimate for 2008 Projected for 2009 numberTotal costcost/1numberTotal costCost/1numberTotal costcost/1      - 4 - 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. - 5 - REQUEST for FUNDING Part I: Sec. J - Board members/Officers NAME, ADDRESS, TELEPHONETERM EXPIRATIONOFFICE  - 6 - 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.  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