and Partner Agency APPLICATION and AGREEMENT

and Partner Agency APPLICATION and AGREEMENT For Funding Period January 1 December 31, 2018 Application and Agreement due: on or before Thursday, April 27th, 2017 Application Checklist: Partner Agency Name Signed Agreement and Application For Funding (page 6 to conclusion) Attachments A thru D A Most recent Audit (if revenue is greater than $100,000) those agencies having revenue less than $100,000 submit a financial statement and prior year s tax return B 501(C)3 IRS determination letter C IRS Form 990 D Oklahoma State Charitable Organization Registration from Secretary of State United Way of Pottawatomie County PO Box 697 23 E. 9 th Ste 333 Shawnee, OK 74802-0697 audrey@unitedwaypottco.org 1

AGREEMENT Between United Way of Pottawatomie County, Inc. And (Name of Partner Agency) For the Calendar Year January 1, 2018 through December 31, 2018 The United Way of Pottawatomie County, Inc. is a voluntary organization dedicated to strategically advancing our community s health and human service agenda in order to build a healthier community. We strive to accomplish our mission by uniting our residents and AGENCIES in efforts to plan, support, and deliver effective human service programs. In keeping with this mission, and to comply with the objectives of our pledging constituents, the following AGREEMENT is accepted and affirmed by the United Way and its AGENCIES: I. United Way agrees: A. To conduct annually a fundraising Campaign, and to provide an efficient and desirable means for the solicitation, collection, and receipt of funds for philanthropic, character-building and socialwelfare agencies and organizations; to solicit, collect, receive and apportion such funds among agencies and organizations. The Campaign shall be conducted among individuals and businesses in the United Way area at the lowest possible cost. B. To conduct sound budget controls and fiscal procedures. C. To provide logos and other materials needed by agencies for United Way identification, visibility, and marketing purposes. D. To make available to the AGENCY a copy of an annual audit of the financial records of the United Way prepared by a Certified Public Accountant. E. To maintain a Board of Directors that shall meet at least four times annually. F. To disburse to the AGENCY its annual allocation of United Way funds upon approval by the Board of Directors from the recommendation of the Allocation Committee as long as the funded program is in existence (within the year specified by this AGREEMENT). II. The AGENCY agrees: A. To obtain and maintain a charter as a non-profit charitable organization holding an exemption from federal income tax under the Internal Revenue Code: 501(C) 3 and an IRS Determination Letter. B. Agencies with annual budgets in excess of $100,000 must provide an audit conducted by an independent public accountant. C. To meet non-discrimination standards. D. To abide by the United Way s policies concerning supplemental fundraising, and non-coercion. E. To actually provide the services and programs in the manner in which they are presented to the United Way. F. To participate as an active AGENCY of the United Way by assuring that their Executive Director or assigned AGENCY representative will: 2

Participate in Campaign presentations if requested by the United Way Executive Director. Encourage support of the United Way through an annual in-house AGENCY employee Campaign facilitated by United Way staff or volunteers, unless the AGENCY does not have local employees or operates solely through the use of volunteers. Recognize that participation in other United Way special events is optional. G. To inform the United Way IMMEDIATELY, in writing, when it is learned that United Way funded programs cease to function. H. To ensure good communications and cooperative planning, the AGENCY agrees to keep United Way informed of any changes in programs and services, regardless of funding responsibilities. I. To have the financial records of the AGENCY reviewed annually, and the following financial information submitted to the United Way with this AGREEMENT: (1)For agencies with annual budgets in excess of $100,000, the prior year s audit completed by an independent public accountant. (2)For agencies with budgets of less than $100,000, a financial statement and the prior year s income tax return. A copy of the most current Form 990 must also be submitted annually. J. To keep the public informed as to its services and objectives, and to make known in every practicable manner that it is a recipient of United Way support. K. To display the insignia of the United Way prominently in its related offices, centers of operation and camps. AGENCY correspondence, news releases, and public presentations relating to the United Way s currently funded programs are to include the United Way insignia or a statement in the text recognizing the United Way of Pottawatomie County. L. To cooperate with other agencies, both public and private, and with the United Way in order to prevent duplication of effort and promote effective, efficient service. M To restrict Capital Campaign Kickoffs September 1 thru November 19 th each year. To comply with non-solicitation of employee groups in the work place year-round via payroll deduction. N. To cooperate with the Executive Director, the Board of Directors and all committees of the United Way, particularly the Drive Committee during all phases of the annual fundraising Campaign. O. To have a non-discriminatory employment policy in accordance with the laws of the state of Oklahoma, and the United States of America. III. Failure to Comply A. Failure by any AGENCY to comply with the terms of this AGREEMENT could result in decreased funding, termination of funding, or membership by the United Way. IV. Termination A. Either party may terminate this AGREEMENT without cause upon thirty days written notice to the other party. 3

United Way of Pottawatomie County, Inc. ADMISSIONS AND ALLOCATIONS POLICIES AND PROCEDURES POLICY: United Way of Pottawatomie County, Inc. maintains an open door policy concerning applications from agencies seeking affiliation and endorses the concept of funding projects within agencies. STRUCTURE: The Board of Directors is responsible for making decisions on agency admissions to United Way. The Board of Directors makes it s decision based on the recommendation from the Admissions & Allocation Committee. CRITERIA: To participate in the admissions review process, an agency must meet the following criteria: 1. Must be a non-profit agency as defined by the Internal Revenue Service in Title 501(c)[3] of it s code. 2. Must complete an annual 990 income tax return. (those organizations such as faith based groups that are not required to do so by the IRS must still complete the form and submit to the United Way. This document shows overhead/administration versus actual program costs). 3. Must provide an annual audit if your organization has revenue of $100,000 or greater. Those agencies having revenue less than $100,000 submit a financial statement and prior year s tax return. 4. Must provide services in the Pottawatomie, Seminole or Lincoln county service area. 5. Must establish that it is performing a needed service to the community not being provided by any other United Way agency. Must execute agency Agreement with United Way of Pottawatomie County, Inc. 6. Must agree to not launch Capital Campaign Kickoffs September 1 thru November 19 th. 7. Must agree to non-solicitation of employee groups in the work place year-round via payroll deduction. 8. Must have a financial support program that demonstrates community acceptance and agency stability. 9. Must agree to lend strength to United Way through support of its campaign and through publicity of its United Way affiliation. 10. Must provide a copy of your Oklahoma State Charitable Organization Registration from Secretary of State. PROCESS: Agencies seeking admission to United Way of Pottawatomie County must submit and return an application by the specified due date. During the admissions process, the Allocation Committee will schedule brief meetings with each applicant. Agencies will make formal presentations and respond to questions, and are encouraged to have board and staff representation for the presentation. At the conclusion of agency reviews, the Committee will identify applicants felt to be appropriate for United Way funding. The Committee will make specific individual agency allocation recommendations to the United Way Board of Directors. Those recommendations are based on total funds available, specific needs of individual agencies, and services provided by the agencies. Upon acceptance by the Board, agencies will be notified of their approval for funding as soon as possible. SUMMARY: The admissions and allocations process is designed to provide optimum accessibility to agencies pursuing United Way affiliation. The committee s assessments are critical and represent the first line of accountability for United Way to the community. The responsibility is made more difficult because of its competitive nature. Invariably, worthy agencies apply for more United Way support than available money will permit. Failure to be approved for funding or failure to obtain the requested level of funding through the process should in no way be construed as a criticism or indictment of an agency s program. 4

Approval of AGREEMENT Partner Agency At a meeting of the Board of Directors of (NAME OF AGENCY) held on (DATE) the board voted to request membership and/or continuing membership in the United Way of Pottawatomie County, and agreed to participate in accordance with the terms of this AGREEMENT. Signed for the AGENCY: Signature of Board President Signature of Executive Director Name of Board President Name of Executive Director Date United Way of Pottawatomie County, Inc. The applicant is accepted as a participating AGENCY of the United Way and the United Way agrees to fulfill its obligations as set forth in this AGREEMENT. Signed for the UNITED WAY: Signature of Board President Signature of Executive Director Nicole Sanchez Name of Board President Lindsay Dyer Name of Executive Director Date 5

I. APPLICATION FOR FUNDING FOR January 1 December 31, 2018 Agency: Executive Director: Address: City, State, Zip Code: Telephone: Fax: Email: Agency Mission: Project Name Total Amount Requested: Select a Community Impact Area for which you seek funding: (more than one may apply to your program) Signatures: Successful Children & Youth Independent & Active Seniors Strong & Safe Families Healthy Community Basic & Emergency Needs Executive Director Date: Board Chair Date: 6

II. Program Narrative Agency: Program: 1. Which community impact area(s) does the program address? How does this program fit into the mission of the organization? 2. How will the target issue be addressed? What are the program activities? What services are provided? When? How often? How? By whom? 3. Who are the intended beneficiaries of the program? Please describe the group in terms of their needs, strengths and barriers to providing services. How will the program improve their lives? How many people will benefit from the program? 4. Share your program s significant accomplishments over the last three years. Please discuss new trends and significant details learned by the organization in providing services? If this is a new program, what experience or expertise do you have to address the needs of these clients? 5. Are you willing to conduct an aggressive internal United Way campaign this fall? 6. What is your agency s administrative/fundraising expense percentage of the total budget for the past year? (Calculated from IRS Form 990) 7

7. Number of beneficiaries served in the last year (2016) in the Pottawatomie County area: Asher Maud Shawnee Bethel McLoud Tecumseh Dale Meeker Earlsboro Seminole Other Number of beneficiaries served in 2015 in the Pottawatomie County area Asher Maud Shawnee Bethel McLoud Tecumseh Dale Meeker Earlsboro Seminole Other Number of beneficiaries served in 2014 in the Pottawatomie County area Asher Maud Shawnee Bethel McLoud Tecumseh Dale Meeker Earlsboro Seminole Other 8. Which best describes the purpose of your agency? 1 Life Sustaining The means of livelihood 2 Life Enabling To provide with the means, knowledge or opportunity for personal improvement 3 Life Enhancing To improve the quality of life 9. Will you support United Way Days of Caring August 16 th, 17 th, and 18 th, 2017? 10. Will you acknowledge that you are a United Way Partner Agency in all forms of publicity? Check all that will apply: Newspaper Web Page Radio/T.V. Newsletter Brochure Letterhead 11. Do you provide 211 dialing information to clients that contact your organization with resource and referral questions and are you listed in the 211 database? 8

www.heartlineoklahoma.org 12. Do you utilize the Pottawatomie County Charity Tracker online database for case management or some other tracking system? Please describe. 13. Do you network with other local agencies via Charity Tracker or some other tracking system to manage client intake and mobilize resources? Please describe. 14. How is your organization advancing education, income and health to create building blocks for a good quality of life for the clients you serve? 15. Please estimate what percent of the clients you serve would be considered low to moderate income? (low-income is 50% of the area median income and moderate income is 50-80% of the area median income go to www.huduser.org to find MFI ) 16. Tell us a Great Story!!!! How a person(s) life was changed via your program. 17. Provide specific detailed information such as a transaction detail of accounts for United Way of Pottawatomie County dollars expensed during the time period 1-1-2016 to 12-31-2016. 9

III. OUTCOME MEASUREMENT FRAMEWORK AND RESULTS Agency: Program: Desired Outcome(s) From Logic Model Indicator(s) # & % of Measured Outcome Results Reported Last Year Measured Outcome Results Reported Since that Time Comments What are the expected benefits or changes in lives of people because of the activities you do? Initial What are the observable, measurable characteristics or changes that represent achievement of an outcome? Measured indicators representing achievement of outcomes Measured indicators representing achievement of outcomes Brief description/explanation Comparing results reported last year to current results Intermediate Long Term 10

IV. OUTCOME MEASUREMENT PROCESS Agency: Program: Collection and Management of Outcome Data Which staff members are involved in collecting and managing the data described in the Outcome Measurement Framework? Who is responsible for this step? Describe the methods used to collect and analyze the data. Analysis and Interpretation What do the results tell you about the impact of your program? Do the results suggest possible changes or improvements that may need to be made to your program? What are the factors beyond your control that may have influenced these results? Use of Outcome Findings Who are the key recipients of this information? When will they receive the information, and in what form? Who is responsible for this step? 11

V. PROGRAM FINANCIAL Revenues Program Request Budget for Entire Agency Contributions Fundraising Legacies and bequests Government fees or grants Membership dues Program service fees Sales/materials or services Sales to public Investment income Miscellaneous revenue This United Way Total Revenues Salaries Expenses Program Request Budget for Entire Agency Professional fees Supplies Occupancy/rent Equipment Travel Miscellaneous expense Total Expenses Surplus or deficit This program request is what percent of total Agency Budget 12

Budget Narrative Using the chart of accounts, please provide us with a one-page summary of the program revenues and expenses. Provide a summary of proposed budgets for the program for which funds are being requested. Please describe indirect and direct program cost, money allocated for the program from other funding sources and a timeline for fundraising activities. Please discuss direct and indirect cost, providing an explanation for determining the amount of indirect cost charged to the program. Chart of Accounts Description Contributions report any monies given by individuals. Fundraising Report funds raised from agency s special events such as dinners, golf tournaments, raffles, etc. Legacies and Bequests report funds given by donors estates or wills. Government Grants report funds received from any unit of government. Membership Fees report fees paid by clients. Program Service Fees report fees paid by client or on behalf of client by nongovernmental third party (i.e. insurance companies) for services rendered by the agency. Sales/Materials report funds generated from sales of materials (books, information, etc) to clients. Sales to Public report funds generated from sales to general public, not clients. Investment Income report interest, dividends and all other investment income. Miscellaneous Income report any other sources of income not included in the above categories. This United Way report funds requested from United Way of Pottawatomie County. 13

Expenses Salaries report wage costs for full and part time employees; all persons for whom the agency is responsible for social security taxes. Include professional and clerical. Include costs for all related expenses (fringe benefits) purchased for agency employees. Professional Fees report fees paid for consultants who are not employees of the agency who are engaged as independent contractors for specific services on a fee for service or contractual basis. Supplies report costs of materials or other supplies including postage and shipping, food and beverage, office supplies and janitorial services. Occupancy/Rent report costs associated with agency s occupancy, buildings and offices such as rent, utilities, telephone. Equipment - report costs from equipment items, rental/repair. Travel reports costs associated with travel including airfare, hotel, meals, and conference registration fees. Miscellaneous Expense report all other expenses not included in the categories above. 14

Board of Directors (please current list of your Board of Directors) Name: Address: City:State: Zip: Phone: Position Term Expires: How often did your Board of Directors meet during the last 12 months? 15

Attachments A. Most recent Audit (if revenue is greater than $100,000) Those agencies having revenue less than $100,000 submit a financial statement and prior year s tax return B. 501(C)3 IRS determination letter C. IRS Form 990 D. Oklahoma State Charitable Organization Registration from Secretary of State 16