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Date: Click or tap to enter a date.

2019-2020 BOARD OF COUNTY COMMISSIONERS (BOCC) GRANT APPLICATIONPlease complete the following application for your grant request. Submit only the completed application and required attachments. All materials are due no later than 4:00 pm on November 28, 2018. NO LATE SUBMISSIONS will be accepted. Please direct questions concerning the grant application and submission to CarolAnn Popovich at [email protected] PAGE

Legal Name of ORGANIZATION: Click or tap here to enter text.(Should be the same as on IRS determination letter and as supplied on IRS Form 990)

Website: Click or tap here to enter text. EIN: Click or tap here to enter text.

Social Media: Click or tap here to enter text.

Agency Mission Statement: Click or tap here to enter text.

Physical Address: Click or tap here to enter text.

Mailing Address (if different from physical): Click or tap here to enter text.

CEO/Executive Director: Click or tap here to enter text. Email: Click or tap here to enter text.

Phone: Click or tap here to enter text.

Fax: Click or tap here to enter text.

Other: Click or tap here to enter text.

Grant Contact Person: Click or tap here to enter text. Email: Click or tap here to enter text.

Phone: Click or tap here to enter text.

Fax: Click or tap here to enter text.

Other: Click or tap here to enter text.

Agency Representative(s) who attended Mandatory Application Review Meeting : Click or tap here to enter text.

BOCC GRANT – PROGRAM GRANT REQUESTS (Note sections to complete for each program)

Program #1 – Name: Click or tap here to enter text.



1 BOCC Grant Application United Way of Charlotte County

SUBMITTING THE APPLICATION

Submission of the BOCC Grant Application and all required attachments is a two-part process. Both parts must be completed by 4:00pm on Wednesday, November 28, 2018. Late submissions will NOT be accepted.

Part OneAgency must submit paper copies of each of the following documents to the UWCC office:

15 paper copies of the BOCC Grant Application 15 paper copies of the Program Budget (The Program Budget Template provided by UWCC must be used to

complete this requirement.)

15 paper copies of the FINAL PROGRAM REPORT for the 2017-2018 grant cycle. 1 paper copy of the most recent Audited Financial Statements 1 paper copy verifying CURRENT 501(c)(3) tax-exempt status and public charities status

o IRS determination letter indicating 501(c)(3) tax-exempt status and public charities status

o Most recent 990 showing public charities status and public support 1 paper copy of Organization Chart 1 paper copy of Organization Budget 1 paper copy of Board of Directors List

Part Two Agency must submit an electronic copy of each of the following documents to Dropbox:

BOCC Grant Application BOCC Grant Program Budget (The Program Budget Template provided by UWCC must be used to complete

this requirement.)

FINAL PROGRAM REPORT for the 2017-2018 grant cycle. Most recent Audited Financial Statements CURRENT 501(c)(3) tax-exempt status and public charities status

o IRS determination letters indicating 501(c)(3) tax-exempt status and public charities status

o Most recent 990 showing public charities status and public support Organization Chart Organization Budget Board of Directors List

Provide the following supporting documents with the application: Strategic Plan for new program requests Letters of support from non-funded partners or stakeholders (if available)


CERTIFICATION AND AGREEMENTQUIRED ATTACHMENTSI CERTIFY, TO THE BEST OF MY KNOWLEDGE, THAT:

1. The 501-c3 tax-exempt status of Agency is still in effect;2. If a BOCC Grant is awarded, the proceeds of the grant will not be used for

anything other than the intended purposes stated within the grant applications. 3. If awarded the requested funding, the Lead Agency agrees to participate in quarterly

reporting by providing details regarding financial expenditures, programmatic oversight, and outcomes evaluation.

4. The accuracy of the information in this application and accompanying attachments is confirmed by the Lead Agency’s CEO/Executive Director.

Signatures confirming all have reviewed this application as submitted.

AGENCY CEO/EXECUTIVE DIRECTOR/DESIGNEE:

_________________________________________________________________________________________________________________ (SIGNATURE) (PRINTE NAME) Date



Population served: Click or tap here to enter text.

Total Program Budget: Click or tap here to enter text.

Total Funding Request: Click or tap here to enter text.

Program Status ☐ New Program ☐ Continuing Program (initial start date): Click or tap to enter a date.

Identify the United Way of Charlotte County Community Bold Goals that describe your program’s outcome focus (select all that apply):

☐ Financial Stability – We envision a community where financial stability is available for everyone.

☐ Education – We envision a community where at least 70% of Charlotte County 3rd grade students are reading at grade level or beyond by June 2022.

☐ Health and Wellness – We envision a community where ALL children, adults and senior citizens have access to services that improve their well-being, and therefore the overall health of Charlotte County.

SECTION ONE: Program Overview (applicant must adhere to word limits)

1. Identify the unique needs that the program addresses. Discuss how the community would be enriched by this program. Provide supporting data. (250 words or less)

2. Identify what success looks like for this program. (150 words or less)

3. Identify how this program addresses poverty through the Community Bold Goal(s) that you selected on page 4. (150 words or less)


BOCC GRANT: Program #1

BOCC GRANT: Program #1 – Bold Goals

BOCC GRANT: Program #1 – Program Details

4. Describe the long-term vision for this program – beyond this funding year. (100 words or less)


SECTION TWO: Program Development Plan

Program Name Click or tap here to enter text.

PopulationIdentify the number of unduplicated clients to be served. If duplicated clients are important to include, please define the duplicate client.

Unduplicated client is defined as an individual or family that is counted only once, no matter how many direct services, per program, they receive during a funding year.

The number of unduplicated clients you anticipate serving. (NOT the number eligible)

The number of duplicated clients you anticipate serving. (if applicable – please define)

For current funded programs only and If applicable, describe how this population has changed.

Timeline Identify when the activities associated with the program will occur during this funding cycle. (You may attach a calendar or timeline of events)

StaffingIdentify number of paid and unpaid individuals (volunteers) who will assist this program during this funding cycle.

Staff for this program (not the agency):

Number of Paid Staff:

Projected number of Unpaid Staff (Volunteers):


BOCC GRANT: Program #1 – Program Details continued

Potential Partners: Describe potential partnerships (funded or non-funded), and other stakeholders who would care about this program, its work and therefore, would have a vested interest in supporting it.


SECTION THREE: Program Outcomes

Based on your response to the Program Outcomes, a planning session with UWCC may be necessary. If this is the case, the UWCC will schedule a consultation time to assist the crafting of Program Evaluation Plan.

List one to three outcomes goals (impact) for the program. Outcomes, not more than three, should be specific, quantifiable, measurable, and ATTAINABLE. Identify the measures to be used to manage and determine success for each outcome goal.

GOAL # 1

Outcome

Activity for Outcome

Outcome Evaluation Plan

Discuss quantified measures to determine success.(identify measurement tools to be used)

Discuss how the client will be benefited.

GOAL # 2

Outcome







GOAL # 3

Outcome






SECTION FOUR: Program Financials & Governance

Funding Request Continued Program Funding New Program Request

Total Program Budget: $ Amount Requested: $

% of Total Program Budget Requested: $

What is the program’s cost per client?

What are your other sources of funding and/or support for this program?

Describe fundraising efforts for this program?

Does your agency have an endowment, quasi-endowment or permanent restricted funds? If yes, please list the current amount and purpose for each.

Explain any pending investigations, litigation or licensing violations against the agency of which you are aware.

Describe any changes to your organizations 501c3 status OR operations during this past year or in the coming year.



For current funded programs only: Score your partnership with the United Way of Charlotte County.

1. Were your quarterly reports submitted in a timely manner?

☐ Yes ☐ No

2. Did you participate in UWCC events? (e.g. Day of Caring)

☐ Yes ☐ No

3. Is the UWCC logo prominent in program literature?

☐ Yes ☐ No

4. Is the UWCC mentioned in program press releases?

☐ Yes ☐ No

5. Did you participate in the offered application review meetings?

☐ Yes ☐ No

Score your agency on your UWCC partnership: 1. ☐ Poor 2. ☐ Needs Improvement 3. ☐ Satisfactory 4. ☐ Very Good 5. ☐ Excellent

If 1 or 2, please discuss:


BOCC GRANT: Program #1 – Program Culture (Current funded programs only)




GOAL # 1

Outcome



Discuss quantified measures to determine success. (identify measurement tools to be used)


GOAL # 2

Outcome







GOAL # 3

Outcome








☐ Yes ☐ No


☐ Yes ☐ No


☐ Yes ☐ No


☐ Yes ☐ No


☐ Yes ☐ No








GOAL # 1

Outcome





GOAL # 2

Outcome



BOCC GRANT: Program #3– Program Details continued




GOAL # 3

Outcome








☐ Yes ☐ No


☐ Yes ☐ No


☐ Yes ☐ No


☐ Yes ☐ No


☐ Yes ☐ No





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