Community Impact Grant Application 2023 | United Way of Southwest Minnesota

Organization Name:

Program Name:

Organization Operates as:

Organization Federal Tax Identification Number:

Organization Website:

Organization Mission Statement:

Street Address:

City:

State:

Zip Code:

Do you have a separate mailing address?

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip Code:

CEO's First Name:

Community Impact Grant Workshop Requirement

CEO's Last Name:

Fiscal Sponsor Information

CEO's Title:

What organization is serving as your fiscal sponsor?

CEO's Email Address:

What is your fiscal sponsor's federal tax identification number?

CEO's Phone Number:

Fiscal Sponsor Contact's First Name:

Do board/advisory committee members sign a conflict of interest statement?

Fiscal Sponsor Contact's Last Name:

Does the board/advisory committee meet at least quarterly, establishing policy and providing supervision of operations and finances?

Fiscal Sponsor Contact's Email Address:

Grant Contact's First Name:

Does the board/advisory committee annually approve, and at least quarterly review, the organization's financial statements, including actual revenue and expense as compared to budget?

Fiscal Sponsor Contact's Phone Number:

Grant Contact's Last Name:

Does the organization do an annual independent audit and/or financial review that conforms to general accounting standards?

Fiscal Sponsor's Mailing Address:

Grant Contact's Email Address:

Do all board members receive and review the audit/financial review annually?

Fiscal Sponsor's Mailing City:

Grant Contact's Phone Number:

Did the most recent audit/financial review state any qualifications?

Fiscal Sponsor's Mailing State:

Please explain:

Fiscal Sponsor's Mailing Zip Code:

Program Purpose Statement:

What is the primary UWSWMN Community Impact Priority Area that your program will address?

How does your program align to that area? Include any specific bullet points that your program is targeting. (30 to 200 words suggested)

Individuals Served

Lincoln County:

Lyon County:

Murray County:

Yellow Medicine County:

Cottonwood County:

Lac Qui Parle County:

Nobles County:

Redwood County:

How has your program been effected by COVID-19 (include need for it, delivery of it, etc.)?

What are the local community/client needs or problems that will be addressed by this program? Why is this issue important? (30 to 250 words suggested)

What research, local statistics or evidence demonstrates this need and/or potential community benefit? (25 to 250 words suggested)

How will your program tackle this community need? (25 to 200 words suggested)

What are your goals and objectives for this program? (25 to 200 words suggested)

How would funding from UWSWMN help you address this community need and achieve your stated goals and objectives? Please include specifics about what funds will be used for. (25 to 300 words suggested)

How will you define and measure success? (25 to 300 words suggested)

Describe your program’s relationship(s) with other organizations working with similar programs. Do you collaborate with them? If so, how? If not, why not?

If this is an ongoing program, please provide an example of how this program is/has made a difference in a local client’s life:

Have you received funding for this program from UWSWMN in the past two years?

Please describe how you indicated you would define and measure success in your most recently funded UWSWMN Community Impact Grant application?

What progress did you make towards meeting those goals and objectives?

Please indicate how your program/organization demonstrates your ongoing support of UWSWMN. Select all that apply.

IF YOU ARE NOT A CURRENT UWSWMN Community Partner, upload your ORGANIZATION'S current IRS tax determination letter regarding your status as a 501(c)(3) organization, a public school or a unit of government:

Upload your FISCAL SPONSOR'S current IRS tax determination letter regarding your status as a 501(c)(3) organization, a public school or a unit of government:

Upload a confirmation letter from your FISCAL SPONSOR stating they agree to serve as fiscal sponsor for this program from July 1, 2021 – June 30, 2022 and verifying that they understand their responsibilities when serving in this capacity:

Please upload your ORGANIZATION'S current board list, including terms and leadership positions:

If you have an advisory committee for this PROGRAM, please upload your current committee list including terms and leadership positions:

Upload your PROGRAM'S current fiscal year budget compared to year-to-date actual income and expense information. Be certain to indicate time frame covered.

Upload your PROGRAM'S PROPOSED budget for the grant time frame of July 1, 2021 - June 30, 2022, including activities proposed in this application. Be certain to break out other sources of funding for proposed program activities, noting whether approved, pending or declined.

Please upload your ORGANIZATION'S most recent balance sheet, indicating effective date:

Please upload the first two pages of your ORGANIZATION'S most recently filed Federal Form 990 or equivalent:

Please upload your ORGANIZATION'S most recent audited or reviewed financial statements:

Please include anything additional that you feel is necessary to adequately review your request:

Anti-Discrimination Statement:

Anti-Terrorism Compliance:

Funding Terms and Conditions:

Signature:

Title: