Pre-Registration Due February 17 Financial Stability 2017-2020 Full Application Organization Information (0) General Information Organization Legal Name Organization Vision Statement Organization Mission Statement Annual Organization Operating Budget Organization Telephone Organization Fax Primary Address Organization Website Executive Director Full Name Executive Director Email Program Information (42,000 characters possible) General Program Information (8) Program Name Funding Request Primary Program Contact Is this a new or established program? Is this an evidence-based program? If so, please explain. Provide a brief program description. Please describe the program s key features and intended client benefits. How does the program align with the identified organization s mission and/or vision as stated within the organization information section? Describe the facility(ies) where program services are delivered, including the address(es). What, if any, added value does the location(s) brings to service delivery? Program Support (6) Describe the number of staff and the experience of those implementing this program.
Are volunteers used to support program services? If so, please explain the training volunteers receive, how the volunteers are utilized in service delivery, and the added value they bring to this program and its clients. Client Information (7) What data informs/supports the need for/development of this program for the intended target population? Describe the population this program serves/intends to serve. What are the requirements for a client to receive this program' services? Issue Area Specific Information (20) If applicable, what is the standardized curriculum/approach used for this program? Please explain why this curriculum/approach was chosen, and how it is used to support the key features and intended client benefits previously mentioned in the beginning of the application. If applicable, is this program innovative/what innovation is planned for this program? Please explain why this innovation is needed to further advance client outcomes. If addressing Priority 2, Strategy 1; describe what method (case management, etc) is used to help individuals obtain safe and affordable housing of choice. Within your description please describe the activities clients participate in in order to achieve the selected target outcomes. Where possible, demonstrate this program s effectiveness through quantitative data. (For example: aggregate entrance and exit data that aligns to the target outcomes/indicators.) If addressing Priority 2, Strategy 2; describe what method (case management, etc) is used to help individuals overcome barriers to employment. Within your description please describe the activities clients participate in in order to achieve the selected target outcomes. Where possible, demonstrate this program s effectiveness through quantitative data. (For example: aggregate entrance and exit data that aligns to the target outcomes/indicators.) If addressing Priority 2, Strategy 3; describe what method (case management, etc) is used to help individuals increase their money management skills. Within your description please describe the activities clients participate in in order to achieve the selected target outcomes. Where possible, demonstrate this program s effectiveness through quantitative data. (For example: aggregate entrance and exit data that aligns to the target outcomes/indicators.) If addressing Priority 3, Strategy 1; describe what method (case management, etc) is used to help seniors sustain safe and affordable housing. Within your description please describe the activities clients participate in in order to achieve the selected target outcomes. Where possible, demonstrate this program s effectiveness through quantitative data. (For example: aggregate entrance and exit data that aligns to the target outcomes/indicators.)
If addressing Priority 3, Strategy 2; describe what method (case management, etc) is used to help seniors effectively manage their money. Within your description please describe the activities clients participate in in order to achieve the selected target outcomes. To enhance the description, wherever possible please provide aggregate entrance and exit data that aligns to the target outcomes/indicators. Collaboration/Coordination (7) Collaborations for this grant s purposes means programs/initiatives who are in an active relationship in which the parties are mutually responsible for the success and well-being of the client. They are actively sharing data back and forth, and working seamlessly to advance the success of the client. In contrast, referrals are passive relationships that help connect client s, but programs are not integrated into the client s action plan, and data is not shared back and forth. Briefly describe the partnerships/collaborations this program utilizes to enhance client outcomes. This does not include referral relationships. What target client outcomes/indicators are the partners above responsible for and how is this information communicated back and forth between/among partners? In regards to referrals, please describe how this program effectively coordinates additional services for its clients where applicable. Program Information Provide start and end dates for the following program years. Current year Projected year Start Date: Start Date: Start Date: End Date: End Date: End Date:
Budget Information (10 : Includes form and narratives) (20,000 characters possible) PROGRAM BUDGET Code Line Item 4000 Contributions 4010 Foundations and Trusts 4200 Special Events 4300 Legacies and Bequests 4600 Contributed by Associated Organizations 4700 Allocated by Federated Fund-Raising Organizations 4701 Allocated by United Way of Central Illinois Donor Designated Funds by United Way of Central 4702 Illinois 4721 All Revenue from Other United Ways Allocated by Unassociated & Non-Federated 4800 Organizations 5000 Fees from Government Agencies 5500 Grants from Government Agencies 6000 Revenue from Membership Dues/Fees 6200 Program Service Fees & Incidental Revenue (Net) Sales of Materials & Service Fees & Incidental 6300 Revenue (Net) 6400 Sales to Public - Net 6500 Investment Income 6900 Miscellaneous Income Income Auto calculating line 7000 Salaries-Program Staff 7001 Salaries-Administrative 7100 Employee Benefits 7200 Payroll Taxes 8000 Professional Fees 8100 Supplies 8200 Telephone 8300 Postage and Shipping 8400 Occupancy (Building and Grounds) 8500 Equipment Expenses 8600 Printing and Publications 8700 Travel 8800 Conferences, Conventions, & Meetings 8813 Staff Education Expenses 8900 Specific Assistance to Individuals 9000 Membership Dues 9002 Payments to National Organizations 9100 Awards and Grants 9400 Miscellaneous Expenses 9800 Insurance Premiums Expenses Auto calculating line Most Recently Current (End of Proposed (
Revenues Over/Under Expenditures Auto calculating line
Budget and Allocation Request Narratives If miscellaneous income has been identified in the budget within any year, please explain and itemize. If miscellaneous expenses have been identified in the budget within any year, please explain and itemize. Explain all line items with any increase or decrease of 10 or more from one year to the next. Describe and itemize the following line items: 7000 and 7001 (Salaries, please no names), 8000 (Professional Fees), 8400 (Occupancy), 8500 (Equipment Expenses), 8800 (Conferences, Conventions, and Meetings), 8813 (Staff Education Expenses). If not previously addressed, what percent of funding is used for program evaluation, and to which line item is it attributed. Explain if this program is affected by other funding sources (i.e. match grants, government funding, etc.) Explain and provide a breakdown of how this program will use UW funding. If the full request cannot be awarded, please describe what will happen with 80 of the funding request. If the full request cannot be awarded, please describe what will happen with 60 of the funding request. If the full request cannot be awarded, please describe what will happen with 40 of the funding request.
Client Demographic Report (5: Includes form and narrative) (1,000 characters possible) Clients Served Clients served by program # of total clients served identified to IRS as single # of total clients served identified to IRS as head of household/dependent Fiscal (End of ( Individual Client Information: Female Male Transgender Gender Fiscal (End of ( Age 00-04 s (Infant) 05-09 s (Child) 10-14 s (Pre-teen) 15-19 s (Teen) 20-34 s (Young Adult) 35-54 s (Adult) 55-64 s (Mature Adult) 65-74 s (Senior) 75-84 s (Senior +) 85+ s (Elderly) Fiscal (End of ( Ethnicity Black / African American Asian White / Caucasian Fiscal (End of (
Hispanic / Latino Native Americans Pacific Islander Multi-Racial Others Single and *Family Unit Information: Location Sangamon County Menard County Fiscal (End of ( Family Size of client being served 1 (Single) 2 3 4 5 6 7 8+ Fiscal (End of ( Menard County Unit Information: Single Income ( of MNFI: $28,607) 0-50 ($0-$14,303.50) 50-80 ($14,303.51-$22,885.60) At least 80, but less than 120 ($22,885.61-$34,328.40) Equal to or greater than 120 ($34,328.41+) Fiscal (End of (
Family Income ( of MFI: $73,516) 0-50 ($0-$36,758) 50-80 ($36,758.01-$58,812.80) At least 80, but less than 120 ($58,812.81-$88,219.19) Equal to or greater than 120 ($88,219.20+) Fiscal (End of ( Sangamon County Unit Information: Single Income ( of MNFI: $34,491) 0-50 ($0-$17,245.50) 50-80 ($17,245.51-$27,592.80) At least 80, but less than 120 ($27,592.81-$41,389.19) Equal to or greater than 120 ($41,389.20+) Fiscal (End of ( Family Income ( of MFI: $72,772) 0-50 ($0-$36,386) 50-80 ($36,386.01-$58,217.60) At least 80, but less than 120 ($58,217.61-$87,326.40) Equal to or greater than 120 ($87,326.41+) 0-50 Fiscal (End of ( Other Client Information: Other Services Clients are Receiving SSDI (Social Security Disability Insurance) SSI (Supplemental Security Income) Fiscal (End of (
SNAP (Supplemental Nutrition Assistance Program) Medicaid Affordable Care Act Subsidies Other Demographic Narratives If applicable, explain why there is unknown demographic data for this program
LOGIC MODEL Data FORMS GO HERE! (7) (Programs will be asked to provide past, current, and proposed outcome and output data as available)
Logic Model Questions (30) (22,000 characters possible) List and explain this program s inputs. (i.e. the resources, people (no names), skills, knowledge and tools being used to deliver services) List and explain this program s activities. (i.e. the services a program provides for its clients to accomplish their goals. (For example mentoring sessions, conducting job training classes, presentations, meeting with clients, etc.) Explain any additional OUTPUTS identified (beyond the suggested outputs) and their importance to program delivery. Explain any additional outcomes/indicators identified (beyond the suggested outcomes/indicators) and their importance to program delivery. What tool(s) are used to evaluate this program and client progress, and what data do they collect? How often, and where, is data collected? Who is charged with reporting client and programmatic results based off of data evaluation? Optional (5,000 characters possible) Provide a success story that details the effectiveness of this program s services. If needed, use this space to further explain a programmatic aspect which is of value, but went under addressed in other sections of the application. Attachment Section Upload the tools used to evaluate this program. Please upload all relevant coordination/collaboration agreements that your program uses to achieve programmatic success. Upload any relevant awards or certification this program has received or organizational awards/certifications that enhance the value of this program specifically. Upload a programmatic flow chart/process map and or other visual representation that shows how this program operates. Optional Optional