2021 Online Grant Application - United Way of East TN Highlands

Agency Information
Agency Name
Agency Executive Director
Mailing Address
City / State / Zip
Phone Number
Fax Number
Email Address
Date Organization Established
What is your fiscal year?
What types of insurance do you have?
Name of Board Chair/President
How many members serve on your Board of Directors?
What percentage of your Board of Directors donate to your agency?
Agency Program Contact
Please submit (1) ONE PDF copy of your financial information (audit and tax return)
Drop files here or

Max. file size: 16 MB.
Please submit (1) ONE PDF copy of all supplementary information
Drop files here or

Accepted file types: pdf, Max. file size: 16 MB.
Copy of 501(c)3 Status letter from IRS, current Board Roster with addresses and telephone numbers (please make sure that your officers are clearly marked on your roster), audit and management letter from most recently completed fiscal year & a copy of most recently filed IRS Form 990 or form 990EZ

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Agency Overview
Describe the mission of your organization.
Indicate the population group that your agency's services address.
Describe in detail your agency's efforts to address the top priorities of your population group.
Describe in detail your agency's efforts to address the gaps in services for your population group.
What significant challenges/opportunities exist for your agency in the next 1-3 years?
Do you plan any major capital projects or expenditures in the next 2 fiscal years ($10,000+)?
Describe your agency's organizational structure (board, staff and volunteer roles and responsibilities).

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For 2019 - 2020, please provide the number of individuals (unduplicated) your agency served in each location. (Do not count individuals in more than one location)
Carter County
Johnson County
Washington County
Southern Sullivan County (Piney Flats & Fall Branch)

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2020 Allocations Committee Recommendations Progress Update
Please type the recommendation, followed by the response.
If last year's allocations committee provided any recommendations to your program funding last year, please list the recommendation that they provided to you and how you have responded to it accordingly.

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2021-22 Funding Application
What is the name or title of the program?
What amount of funding is requested for this program?
Describe the program in 250 words or less
Describe how you staff this program, including the use of volunteers
Identify who and how many you expect to serve in the coming year
Describe the overall need in your service area for this program.
Describe the target population to be addressed (age, sex, socio-economic level, special needs, etc.)
Describe the service area (geographic) covered by this program.
Describe the beneficial long-term outcomes for the persons you serve through this program.
Describe the program activities and how they lead to achieving the outcomes noted above.
Do you have other sources of funding in place for this program? If so, what are they?
Discuss how you handle waiting lists and other demands for services that cannot be immediately met.
How do you market/communicate your agency's program(s) to the community?
Do you coordinate with other agencies/organizations in the community? If so, how?

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Program Evaluation
What metrics do you use to measure this program's efectiveness and what tools (i.e. software) and methods are you using to accomplish this?

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Program Cost Analysis - Individuals Served
Total Program Cost
FY 2021 Proposed FY 2020 Budgeted FY 2019 Actual
Total Number of Individuals Served
FY 2021 Proposed FY 2020 Budgeted FY 2019 Actual
Cost per person (Total Program Cost divided by Total Number of Individuals Served
FY 2021 Proposed FY 2020 Budgeted FY 2019 Actual
Program Cost Analysis - Units of Service (Optional)
You may submit information for both individuals served and units provided if it is to your advantage, but you are only required to submit information for individuals served.
Total Program Cost
FY 2021 Proposed FY 2020 Budgeted FY 2019 Actual
Total Number of Units Provided
FY 2021 Proposed FY 2020 Budgeted FY 2019 Actual
Cost per Unit (Total Program Cost divided by Total Number of Units Provided)
FY 2021 Proposed FY 2020 Budgeted FY 2019 Actual

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Proposed Program Output, Objectives, Measurements & Outcomes
2022 Proposed Output (Units of Service)
2022 Proposed Objectives (How many units of service delivered?)
2022 Proposed Measurements (How do you know?)
2022 Proposed Outcome (What difference did it make?)

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Consent
I agree to the Statement of Agreement
As a participating agency of the United Way of East TN Highlands we accept the following principles and conditions:

A. BOTH UNITED WAY OF EAST TN HIGHLANDS AND THE PARTNER AGENCY AGREE

1. To maintain an active, rotating volunteer structure which assumes and fulfills the responsibility of managing its affairs within the scope and spirit of respective by-laws and this agreement.

2. Offer opportunity for participation in programs, services, policy designation and staff employment to persons regardless of race, religion, age, sex, national origin, sexual orientation, and disability.

3. To strive to increase the public's understanding and appreciation of and participation in human services programs.

4. To consult and work together on matters of common interest in an effort to achieve the best interest of the community as a whole.

B. THE AGENCY AGREES

1. To maintain a positive and supportive relationship with United Way and the United Way Staff in all communications and throughout the community.

2. To support and assist in the United Way of East TN Highlands annual fundraising campaign.

3. To engage in an effective year-round public relations program in which the objectives, services and accomplishments of the Agency, and the United Way of East TN Highlands support of such services, are adequately publicized.

4. To have a complete audit of its financial affairs made each year and to furnish the most recent copy to the United Way of East TN Highlands with their application for funding (audit review for agencies with less than $100,000.00 in gross receipts).

5. To provide semi-annual financial statements to United Way of East TN Highlands (e.g. Profit & Loss and Balance Sheets). Failure to provide semi-annual financial statements in a timely manner could result in loss of funding for your agency program.

6. To provide a semi-annual report to the United Way of East TN Highlands indicating the number of clients served and the impact results of the program being funded. (format to be provided). Failure to provide semi-annual reports in a timely manner could result in loss of funding for your agency program.

7. To carry out the programs of the agency in such a manner as will best meet the needs of the community and will be consistent with standards of service, efficiency and economy.

8. After being given full consideration and hearing, to accept the apportionment of funds made to it by the Allocations Committee and approved by the United Way of East TN Highlands Board of Directors.

9. To submit a minimum of one Week of Caring volunteer project request by the end of April to be completed in the month of June (preferably during the Week of Caring).

10. The agency should also be represented by staff executive leadership at the
following events:
 All United Way Impact Awards (April)
 All Quarterly Executive Director Meetings
 If service area covers Carter County, Golf Tournament August 13, 2021

C. THE UNITED WAY OF EAST TN HIGHLANDS AGREES

1. To provide resources to strengthen partner agencies.

2. To respect the agency's prerogative of determining its own policies and programs within the community.

3. To use its best efforts to achieve the campaign objectives and fund Agency Programs that are making significant impact in the categories of Health, Education, and Financial Stability.

4. To act as responsible stewards of funds publicly contributed to the United Way by fully informing contributors of the allocations and use of the funds.

5. To submit all its financial records for an audit by an independent public accountant.
Electronic Signature of Agency Executive Director / CEO (Please type your name below)
Today's Date
MM slash DD slash YYYY

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2021-22 Online Agency Program Funding Application

Step 1 of 9

Agency Information

Agency Overview

For 2019 - 2020, please provide the number of individuals (unduplicated) your agency served in each location. (Do not count individuals in more than one location)

2020 Allocations Committee Recommendations Progress Update

2021-22 Funding Application

Program Evaluation

Program Cost Analysis - Individuals Served

Program Cost Analysis - Units of Service (Optional)

Proposed Program Output, Objectives, Measurements & Outcomes