United Way of Hernando County (UWHC) Community Investment Grant (CIG) Eligibility Form

Transcription

1 The CIG Eligibility Form must be completed by all applying organizations, even if you have received funding in the past. This form is due back to the United Way of Hernando County Office no later than 5:00 PM on November 29, 2017 (no exceptions). May be submitted via mail, fax, or dropped off. Organization Name: Date: Mark one initiative that applies to each program requesting United Way support: Health ] Education ] Financial Stability ] Basic Needs/Crisis Prevention HEALTH -Health education & public awareness -Healthy beginnings -Healthy eating and physical activity -Mental health services -Senior/elder support -Services for people with physical disabilities -Services for people with intellectual / developmental disabilities -Substance abuse services EDUCATION -Family engagement -Middle grade success and transitions -Out of school time -Reading, tutoring, mentoring support -School Readiness and access to high-quality early learning -Youth development FINANCIAL STABILITY -Financial education, coaching and service integration -Income supports (screening, enrollment, emergency assistance, etc.) -Job/workforce development and training -Veteran employment/financial support BASIC NEEDS/CRISIS PREVENTION -Emergency shelter care for people experiencing homelessness -Food security -Permanent supportive housing -Protection from neglect, abuse, exploitation -Transitional housing 1. Provide the name of Program(s) requesting United Way funding: 2. Provide the percentage of the total of those served which are Hernando County residents: 3. Date of most current 990: from to NA 4. Provide organization s administration/fundraising % by using the following formula from most current 990: Part IX, Line 25, Column C (M&G Expense) + Column D (Fundraising Expense) % Part VIII, Line 12, Column A (Total Revenue) (carryout two decimal points) 5. The organization applying for funding currently has their health & human services listed on United Way s Hernando and regularly updates any changes. YES ] NO 6. Does the Program requesting funding specifically serve the ALICE population? (Asset Limited, Income Constrained, Employed) YES ] NO ] UNSURE The following criteria must be met before program funding will be considered: The 501(c) 3 organization s program serves Hernando County residents. The organization must have an all-volunteer Board of Directors (i.e. President/ED is a non-voting member) Funded program(s) will need to provide measurable outcomes and community impact. Programs(s) requesting funding must be operational for at least one year prior to the CIG submission date. Duplication of program(s) in Hernando County will be considered by the CIG Committee. The organization must be listed on Hernando. The organization must have a budget approved by the Board of Directors annually. The organization s program(s) must have balanced budget(s) and be financially accountable. The organization s administrative/fundraising rate cannot exceed 25% in order to be considered. The organization must be able to explain expanded program(s), if applicable. The organization is expected to partner with United Way, incorporate United Way Branding, and is expected to abide by the terms as indicated in the UWHC Affiliation Agreement & USA Patriot Act (attached). The undersigned verify that their organization meets the required criteria for considered funding. Executive Director Print name Board Chair Print name Signature Signature United Way of Hernando County 4028 Commercial Way, Spring Hill, FL Ph: Fax: angie@unitedwayhernando.org

2 United Way of Hernando County, Inc. Community Investment Grant - Affiliation Agreement Affiliation Agreement I. Purpose It is the mutual objective of the United Way of Hernando County and its Partner Agencies that programs meeting the human service needs of Hernando County have adequate funding. UWHC s role in community development is to strategically invest resources obtained through the annual Community Investment Campaign with Agency impact programming. This agreement, or an updated version of it, is to be signed annually by both parties before allocations may be released. All funding is contingent upon the availability of funds and the performance of the Agency. All applying programs are evaluated on a zero based funding scale. Nothing in this document is to be construed as a guarantee of funding or its continuation. It is agreed that when the amount of funds awarded varies from the requested amount, the Partner Agency would be required to fill out the Revised Projection report for each program receiving financial support via e-cimpact prior to the new fiscal year. This agreement will not be fully executed until revisions are received and approved by United Way of Hernando County. II. Joint Responsibilities A. Be recognized as an organization exempt from federal income tax under IRS Section 501 (c) (3) Internal Revenue Code 1954, as amended, and as a publicly supported organization of the type described in Section 170(b) (1) (A) (vi). B. Be governed by a local volunteer board of directors that meet at least quarterly, with adequate provision for board rotation. C. Be registered with the Florida Department of Agriculture and Consumer Services ("DOACS"), pursuant to Chapter 496, FS (Solicitation of Contributions Act) D. Maintain adequate public liability insurance and appropriate directors and officer s insurance. III. United Way agrees to: E. Assess human service needs; and foster cooperation and coordination; and focus efforts on community-identified needs and seek collaborative solutions around health, education, financial stability, and basic needs/crisis prevention. F. Act as a responsible steward on behalf of United Way donors. G. Recognize and respect the autonomy of the agency, through its governing board, to determine its own policies and to manage its own program. H. Be responsible for the distribution of funds raised in its campaign. I. Represent and promote Agencies through collaborative efforts with a focus on UWHC funded programs.

3 J. Honor the intent of the donor to the best of our abilities. K. Distribute donor designations twice within the following year of the campaign when raised. The amount paid is based on actual collections received. For funded partners, the amount is to be included in their monthly allocation, unless designated amount exceeds granted United Way dollars. L. Sporadically offer or share information on training opportunities, workshops, and additional resources in support of leadership and non-profit education. It is strongly encouraged to attend the local ADVANCING YOUR MISSION Workshops for Non-Profits. IV. Partner Agency (Agency) agrees to: M. Provide UWHC with the most current annual independent unaffiliated financial audit. - If an agency has total revenues of $99,999 or less, a compilation from an independent accountant in lieu of an independent financial audit can be provided. - If an Agency has total revenues between $100,000 and $499,999, a full disclosure review by an Independent Certified Public Accountant in lieu of an annual independent financial audit can be provided. - If an Agency has total revenues greater than $500,000, a certified independent financial audit must be provided. - Requests to waive these guidelines must be presented in writing to UWHC. N. Submit Quarterly Reports online through e-cimpact s designated format by deadlines. Information submitted must reflect true impact and accurate program accomplishments. Numbers are not to be inflated. If failed to submit on time, UWHC will not distribute allocation check(s) until report is received. O. Regularly attend Quarterly Agency Meetings or send a representative. Failure to participate may affect future funding. P. List program services on United Way s Hernando. Rules and regulations must be followed and a current profile is to be maintained. Q. Participate in annual United Way Community Investment Campaign. Participation includes but is not limited to: - Conducting an internal UWHC campaign - Presenting with United Way at annual workplace campaigns - Participate in Publix Appreciation Day, Annual Meetings, UWHC kick off events and other company appreciation events - All internal Workplace/Payroll Deduction Campaigns conducted directly through local corporations for your agency are prohibited. R. Report to UWHC any material changes in funded programs within five days of program change. For example, if the program is de-funded, discontinued loses matching funds, stops providing services to Hernando, etc. Any material change to funded programs may result in funding changes by UWHC.

4 S. Immediately notify UWHC regarding any organizational changes including staff, legal or financial matters or changes, which may affect the Agency s ability to operate and/or deliver services or may appear in the media. T. Promote its partnership with UWHC in media releases and public relations campaigns where UWHC dollars are a part of the program or services. The United Way of Hernando County logo must appear on all Agency communications including websites, community expo exhibits, newsletters and printed materials (letterhead, brochures, flyers, etc.) using approved branding and trademark standards. If funds are received from more than one United Way, there must be a geographical locator for UWHC, or a non-location specific United Way logo. U. Apprise UWHC staff of upcoming fundraising events. V. Identify itself to the Hernando County community, clients and corporations as a United Way Partner Agency or United Way Partner Program W. Use no UWHC funds for lobbying activities. X. Complete the USA Patriot Act Counterterrorism Compliance form. V. Termination An Agency s failure to comply with the provisions of this agreement may result in funding being revoked, terminated, or suspended. Continued failure to comply may result in a loss of good standing for Partner Agency status. The Board of Directors of the UWHC shall vote on termination and/or suspension of Agency status. The Agency will be provided with a written notice as to the reason(s) for the termination or suspension. An agency that is terminated may submit an application for recertification when the Agencies reopen for applications, unless instructed otherwise. VI. Liability To the extent provided by law, the Agency agrees to indemnify and hold harmless the UWHC from liability on account of any injuries, damages, omissions, commissions, actions, causes of actions, claims, suit judgments and damages accruing, including court costs and attorney s fees, as a result of services performed or not performed, or any negligent act by the Agency or funding granted or not granted by the UWHC or any action arising out of the affiliation and/or funding agreement.

5 "The USA Patriot Act Counterterrorism Compliance" form is for Agency REVIEW ONLY. DO NOT SUBMIT AT THIS TIME. USA PATRIOT ACT COUNTERTERRORISM COMPLIANCE In compliance with the spirit and intent of the USA PATRIOT ACT and other counterterrorism laws, United Way of Hernando County requests that each funded agency ( Organization ) certify that it is in compliance with the United Way of Hernando County and United Way Worldwide's ( UWW ) compliance program. Organization Name: FOR REVIEW ONLY Check the Appropriate Box to Indicate Your Compliance with Each of the Following: This Organization is not on any federal terrorism watch lists, including the list in Executive Order 13224, the master list of specially designated nationals and blocked persons maintained by the Treasury Department, and the list of Foreign Terrorist Organizations maintained by the State Department This Organization does not, will not and has not knowingly provided financial, technical, in-kind or other material support or resources* to any individual or entity that is a terrorist or terrorist organization, or that supports or funds terrorism. This Organization does not, will not and has not knowingly provided or collected funds or provided material support or resources with the intention that such funds or material support or resources be used to carry out acts of terrorism. This Organization does not, will not and has not knowingly provided financial or material support or resources to any entity that has knowingly concealed the source of funds used to carry out terrorism or to support Foreign Terrorist Organizations. This Organization does not re-grant to organizations, individuals, programs and/or projects outside of the United States of America without compliance with IRS guidelines. This Organization takes reasonable, affirmative steps to ensure that any funds or resources distributed or processed do not fund terrorism or terrorist organizations. This Organization takes reasonable steps to certify against fraud with respect to the provisions of financial, technical, in-kind or other material support or resources to terrorists and terrorist organizations. Comply Do Not Comply *In this form, material support and resources means currency or monetary instruments or financial securities, financial services, lodging, training, expert advice or assistance, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials. I certify on behalf of the Organization listed above that the foregoing is true. Print Name: FOR REVIEW ONLY Title: Signature: FOR REVIEW ONLY Date: