United Way of Coastal Georgia 2019 Funding Application for Through the Community Investment Fund, United Way invests in local organizations and programs that deliver measurable results in the areas of Education, Income, and Health, as well as those that strengthen our regional safety net. To be eligible to receive United Way of Coastal Georgia community funds, your program must clearly fit under at least one of United Way s three impact areas: Education, Income and Health. In addition, your sponsoring agency must meet all of the following criteria: Be a not-for-profit 501(c) (3) organization that is conducting a health and human service program which is meeting the needs of the people residing in Glynn and McIntosh counties Have an active board of directors that meets with a quorum at least quarterly Have stated mission and bylaws File a Form 990 annually with the Internal Revenue Service An annual external audit or financial review (Per the application on pages 2 & 3 of the application) 2019 Funding Schedule October 8, 2018 November 16, 2018 January 11, 2019 February 15, 2019 February 1-28, 2019 March 1, 2019 March 5 & 7, 2019 March 12, 2019 July 1, 2019 Agency application training and release Application due for applying programs Agency Mid-Year Reports due Applying organizations Year End Income Statement and completed 2017 actual numbers referenced in Section E: Program Data Chart of the application DUE Agency site visits Agency Video Due Agency/Program Presentation (1/2 day) Agency/Program Presentation (1/2 day) 2019 Funding Cycle begins Page 1 of 19
PART I: 2019 United Way Proposal Checklist The packet must be submitted in the exact order of the checklist. If a document is not applicable please answer N/A. PART II: Agency Overview Section A: Organization Contact Information Section B: Organization Summary Section C: Organization Chart PART III: PROGRAM PROPOSAL (Please complete a program proposal section for each program for which you are applying, please see attachment) Section D: Program Information Section E: Data Chart Section F: Logic Model for 2019 (By applying for funding you are agreeing to collect data and evaluate 3 outcomes) Section G: Evaluation Plan for 2019 PART IV: FINANCIALS Section H: Program Budget Section I: Agency Financials PART V: GOVERNANCE Section J: Governance Section K: Governance Addendum (If applicable) Section L: Financial Addendum (If applicable) Section M: Affidavit of Certification & Authorization Signatures Page 2 of 19
ATTACHMENTS Attachment: Current Charity Registration with Georgia Secretary of State Attachment: Current Corporation Registration with Georgia Secretary of State Attachment: Board of Directors Roster (Include place of employment and contact information) Board of Directors Meetings (Include percentage of directors that attended all scheduled meetings and quorums) Audit or Compiled Financial Statement i. Agencies with annual revenue of $250,000 or more in 2017 are required to submit an audit report including accrual basis financial statements prepared in conformance with generally accepted accounting principles (GAAP) or another comprehensive basis of accounting and audited in accordance with generally accepted auditing standards (GAAS). ii. Agencies with annual revenue between $100,000 and $249,999 in 2017 must have an independent financial review of agency financial statements, in accordance with Statements on Standards for Accountability and Review Services issued by the American Institute of Certified Public Accountants. iii. Agencies with annual revenue of less than $100,000 in 2017 must submit an accrual basis compilation (non-disclosure) report prepared by an independent CPA. (If your 2016 Audit/Review is not complete, please enclose your most recent audit and provide an explanation of when the one requested will be completed) Attachment: Most recent IRS Form 990 (Completed and filed) (Please submit a signed copy to UW with application. Submitted 990 to United Way must match the FY year of the submitted audit or reviewed Financials) Please use the checklist to verify the completeness of each component of your application. Name of Person Completing Checklist Signature of Person Completing Checklist Date Page 3 of 19
PART II: AGENCY OVERVIEW Section A: Organization Contact Information Name of Applying Mailing Address: Physical Address: City: Phone Number: Website address: State: Executive Director of Organization Name: Title: Phone : Email: Local Point of Contact: (If different than Executive Director or Program Coordinator) Name: Title: Phone: Email: Chairperson, Board of Directors Name: Title: Phone: Email: Fax: Fax: Page 4 of 19
PART II: AGENCY OVERVIEW Section B: Organization Summary Describe your organization in bullet-point format. Please include the following: date founded, mission, services provided, clients served, number of locations and/or sites, type of metrics used in measuring the impact you have on the community (Specifically, what are you measuring and how?). (300 words or less) Page 5 of 19
Section C: Organization Chart Please insert organization chart. Page 6 of 19
PART III: PROGRAM PROPOSAL Please complete the Section A: Program Information for each applying program. Program Name: Amount of funding requested from UWCGA for the 2019 funding period Section D: Program Information $Click here to enter text. Program Coordinator/Manager (if different from Executive Director): Name: Title: Click here to enter text. Phone: Click here to enter text. Best Contact Number: Email: Click here to enter text. Please select the ONE United Way impact area that best aligns with your program: Education: Increase the number of students enrolled in school and prepared to move to the next grade level via programs such as mentoring, tutoring, anti-bullying, summer programs, after school programs, etc. Income: Increase opportunities for a good quality of life by reducing the % of people living in poverty via program such as job training, interviewing skills, GED programs, removing transportation barriers, budgeting, affordable housing, etc. Health: Providing services, support and resources to improve the health, safety and wellness of individuals and families including infant mortality, teen pregnancy, childhood obesity, anti-drug, mental, emotional and behavioral health treatment. PROGRAM DESCRIPTION: Briefly describe the specific program for which you are requesting funding in the space provided below. Include the mission of your program, date program was formed, number of offices or sites for program, service area by: (When program was formed, list counties served by program) Click here to enter text. PROGRAM QUESTIONS: 1. Specifically, how will United Way funds be used, for what purpose, general expenses or direct program expenses? 2. Will you use United Way funds as match funding for a new or existing grant or other funding source? Yes No If yes please provide details: Page 7 of 19
3. Do you charge a fee for the program service? Yes No 4. If yes, how much? 5. How/When do you collect the fee? 6. If participant is unable to pay fees do you provide financial assistance? Yes No If yes, how do you determine need? What documentation is required to show need? 7. Do you have a waiting list? Yes No If yes, give the number and duration. 8. List the evidence of need for your program (include local data as well as state and/or national data if applicable) a. Click here to enter text. 9. What are the relevant data sources used for your program to evaluate its planning and decision making? a. Click here to enter text. b. Click here to enter text. c. Click here to enter text. 10. How do you inform your target population of the availability of your program? 11. Staffing: a. Total # of full time staff in the program: b. Increase or decrease during the year: c. Total # of part-time staff in the program: 12. Volunteers: a. Total # of volunteers in the program: b. Total hours served by volunteers (in what time frame...year?) 13. Do you perform background checks on your employees and volunteers? Yes No Please explain the process you use, how you run checks and at what level? 14. How is this program meaningfully collaborating with other community partners to provide its services in an effective manner? Provide the name of the partner, shared services, hours served, and monetary contributions. Click here to enter text. Collaboration: Two or more organizations working together to produce, create something, or fill a need in the community. Partner Organization Shared Service(s) Specifically how do you collaborate, include hours served if applicable. Monetary Contributions Page 8 of 19
15. List your top 5 accomplishments during the year for this program: 1. Click here to enter text. 2. Click here to enter text. 3. Click here to enter text. 4. Click here to enter text. 5. Click here to enter text. 16. List your top 5 challenges during the past year for this program: 1. Click here to enter text. 2. Click here to enter text. 3. Click here to enter text. 4. Click here to enter text. 5. Click here to enter text. 17. Goals for the upcoming year for this program: 1. Click here to enter text. 2. Click here to enter text. 3. Click here to enter text. 4. Click here to enter text. 5. Click here to enter text. 18. Please provide the gross cost based on per individual or unit served. (This must match the Data Chart in Section E) Click here to enter text. Page 9 of 19
PART III: PROGRAM PROPOSAL Program Name: Section E: Program Data Chart Please provide the number of unduplicated clients served for each time frame and county 2017 Actual Glynn County 2017 Actual McIntosh County 2018 Jan. - Oct. Actual: Glynn County 2018 Jan. Oct. Actual: McIntosh County 2018 Total Projected: Glynn County 2018 Total Projected: McIntosh County 2019 Projected Total Glynn County 2019 Projected Total McIntosh County Total Number of Participants Gender Males Females Unknown Gender Families if you do not track individuals Ethnicity African American Asian Caucasian Hispanic Unknown Age Infants/Toddlers (Birth to 4 years) School Age Children (5 to 12 years) Teens (13 to 18) Young Adults (19-25) Adults (26 to 54) Seniors (55+) Unknown Organizations will be required to submit actual data information for the 2018 year by February 15, 2019. Page 10 of 19
PART III: PROGRAM PROPOSAL Program Name: Program Goal: Target Population: Section F: Logic Model INPUTS ACTIVITIES OUTPUTS IMPACT (OUTCOMES) Page 11 of 19
PART III: PROGRAM PROPOSAL Section G: Evaluation Plan Program Name: Click here to enter text. Impact/Outcome 1 as listed in the logic model: Indicator: (include the number and/or percent) Data collection tool(s): Sampling plan, if applicable: Data collection timeline: Impact/Outcome 2 as listed in the logic model: Indicator: (include the number and/or percent) Data collection tool(s): Sampling plan, if applicable: Data collection timeline: Impact/Outcome 3 as listed in the logic model: Indicator: (include the number and/or percent) Data collection tool(s): Sampling plan, if applicable: Data collection timeline: (Add an additional page(s) with individual Outcome Numbers for any additional information your agency wishes to express that is pertinent to the Outcome of any particular Activity wherein funding is requested. Please use the same format as that listed above, including Indicator, Collection Tools, Sampling, and Timeline.) Page 12 of 19
Part IV: FINANCIALS Section H: PROGRAM Budget **These numbers apply to the PROGRAM only and not the organization** 1. Please list the revenue sources for your program: REVENUE TABLE 2017 Actual Program Revenue 2018 Program Budget (include changes to date) 2019 Proposed Program Budget A. Federal Funding Public B. State Funding (Public) C. Private Funding (Including United Way) D. Other Program Funding/Revenue TOTAL REVENUE (A+B+C+D) 2. Please list the top three to five funding sources of this program over the past two years: 1. 2. 3. 4. 5. Page 13 of 19
3. Please list expenses for your program (without overhead costs): EXPENSE TABLE 2017 Actual Program Expenses 2018 Program Budgeted Expense (include any changes to date) 2019 Proposed Program Budgeted Expenses A. Personnel Expenses B. Operational Expenses (rent, utilities, insurance, technology, etc.) C. Direct Client Support (financial support, client supplies, event fees and etc.) D. Other Expenses: E. Other Expenses TOTAL EXPENSES (A+B+C+D+E) Page 14 of 19
Part IV: FINANCIALS Section I: AGENCY Financials **These numbers apply to the organization as a whole and are not program specific** ORGANIZATION QUESTIONS: General 1. Do all directors and Officers sign an Ethics Statement? Yes No 2. Does the Board regularly review the Financial Statement Presented in comparative format of actual vs. budget and prior year? Yes No 3. Does the Finance Committee of the Board recommend the auditor hire And sign the scope of engagement? Yes No 4. Does the Finance Committee perform an Annual Risk Assessment? Yes No 5. Do all Board Members and Officers have an organization chart and delegated responsibility and authority levels? Yes No Operational and Financial 1. Are there written policies and procedures in the following areas: - Cash and Deposits Yes No - Purchase and Payroll Authorization Yes No - Recording of Accounting Entries Yes No - Closing Procedures of Agency Financials Yes No - Reconciliation of Bank Accounts Yes No 2. In each of the five areas, is there appropriate Segregation of Duties and Authorization Levels? - Cash and Deposits Yes No - Purchase and Payroll Authorization Yes No - Recording of Accounting Entries Yes No - Closing Procedures of Agency Financials Yes No Reconciliation of Bank Accounts Yes No Page 15 of 19
PART V: GOVERNANCE Section J: Governance 1. Do you have any national and/or state affiliations, accreditations, ratings or certifications? Yes No If yes, please list and describe: Click here to enter text. 2. When was the last time your Board of Directors reviewed the organization s mission and supporting strategies? Click here to enter text. 3. Does your organization have a strategic plan? Yes No a. If yes when was the last time it was updated and how often is it reviewed? Click here to enter text. b. How is the strategic plan used in implementing decisions and actions within the organization? Click here to enter text. 6. When was the last time the Board of Directors reviewed the organization bylaws and other governing documents? Click here to enter text. 7. Describe how new board members are oriented to their board roles and responsibilities (Please use bullet-point format including frequency, process, content, etc.). Click here to enter text. 8. Did the Board of Directors meet at least four times during the last fiscal year with a quorum and maintain written minutes for each board meeting? If no, explain. Yes No 9. Do the organizational bylaws set a certain number of consecutive terms that can be held by a board member or provide for a limit on the number of consecutive years served? What are the term limits? Click here to enter text. 10. When did the board conduct a review of the completed IRS Form 990 and all attachments? If the board did not conduct a timely review of the completed IRS Form 990, explain why not. Click here to enter text. 11. Is your organization governed at local, regional, state or national level? (Check all that apply) Local Regional State National If your organization is not governed locally please complete the Governance and Financial Addendum. Page 16 of 19
Section K: Governance Addendum Non-profit governance focuses primarily on the fiduciary responsibility that a board of trustees or directors has with respect to the exercise of authority. 1. Describe the organizational structure, decision making and roles and responsibilities of the regional/state/national organization versus the local organization? (Please be specific on local, regional, state and national roles and responsibilities) Click here to enter text. 2. Who is your governing body? If it s not local what decision making authority does your local organization possess? Click here to enter text. 3. If the local board does not make all the decisions for the local organization is it Advisory in nature or is it for community input and marketing only? Click here to enter text. 4. What decisions can the local organization board make? Click here to enter text. Section L: Financial Addendum 1. Does money flow from the local organization TO a regional/state or national organization? 2. What is the amount and purpose of this money movement? Purchase services such as, but not limited to, group purchasing, financial, insurance and other specialty services? Be specific. Regional/state/national organization financial support? Support the programs of the regional/state/national organization? Other purposes If you selected other please explain. Click here to enter text. 3. Does money flow FROM the regional/state/national organization to the local? a. What is the amount and purpose of this money movement? Click here to enter text. b. Support of the local organization and/or making up for a cash shortfall? Click here to enter text. c. Other purposes? Click here to enter text. 4. Do all financial resources raised in the community stay local? Page 17 of 19
5. Who is accountable for your program budget- local, regional, sate, national Page 18 of 19
Section M: Affidavit of Certification & Authorization Signatures Each of the undersigned does hereby certify that all of the foregoing information and statements submitted in this application and its attachments and supporting documents are true and correct to the best of his/her knowledge, and that all responses to the questions are full and complete, omitting no material information. Each of the undersigned further agrees that United Way of Coastal Georgia can contact other individuals and organizations for pertinent information about the applicant s program or application and related documentation. Executive Director (Print Name) Executive Director Signature Date Board Chair (Print Name) Board Chair Signature Date Page 19 of 19