Agency Information
Agency Name*
Agency EIN (Employer Identification Number)*
Has your agency/program been funded by United Way of East TN Highlands within the last 2 years?*
- Yes
- No
- Unsure
Agency Executive Director Name*
Agency Mailing Address*
City / State / Zip*
Agency Phone Number*
Fax Number
Executive Director Email Address*
Date Agency Established*
Month
Day
Year
What is your fiscal year?*
Do you have insurance(s)? If so, what type(s)?*
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 Name*
Agency Program Contact Email*
Agency Program Contact Phone*
Please submit (1) ONE PDF copy of your most recent year's audited financials. Audit Review accepted for agencies with less than $100,000.00 in gross receipts.*
Accepted file types: pdf, Max. file size: 100 MB.
Please submit (1) ONE PDF copy of your most recently filed IRS Form 990 or Form 990EZ. If you are a government organization, please submit the filler PDF found on www.unitedwayetnh.org/applyforfunding.*
Accepted file types: pdf, Max. file size: 100 MB.
Please submit (1) ONE PDF copy of your Audit and Management Letter from your most recently completed fiscal year.*
Accepted file types: pdf, Max. file size: 100 MB.
Please submit (1) ONE PDF copy of your 501(c)3 status letter from the IRS. If you are a government organization, please submit the filler PDF found on www.unitedwayetnh.org/applyforfunding.*
Accepted file types: pdf, Max. file size: 100 MB.
Please submit (1) ONE PDF copy of your current Board Roster with addresses and telephone numbers (please make sure that your officers and their titles are clearly marked on your roster).
Accepted file types: pdf, Max. file size: 100 MB.
Please submit (1) ONE PDF copy of your agency's organizational chart.*
Accepted file types: pdf, Max. file size: 100 MB.
Please submit (1) ONE PDF copy of your current Charitable Solicitation Renewal. If you are a government organization, please submit the filler PDF found on www.unitedwayetnh.org/applyforfunding.*
Accepted file types: pdf, Max. file size: 100 MB.

Agency Overview
List agency Mission Statement.*
Describe the population group that your agency's services address.*
List the top priorities of the population you are serving and describe your agency's efforts of addressing them.*
List the local gaps in services for the population group you are serving and describe your agency's efforts of addressing them.*
List up to 3 significant challenges/opportunities that exist for your agency in the next 1-3 years?*
List up to 3 major capital projects or expenditures you're planning for in the next 2 fiscal years ($10,000+). If none, please put N/A.*
Average number of yearly agency volunteers*

For your most recent fiscal year, please provide the number of individuals (unduplicated) your agency served in each county (do not count individuals in more than one county).
Carter County*
Johnson County*
Washington County*
Southern Sullivan County (Piney Flats & Fall Branch)*

2021 Allocations Committee Recommendations Progress Update
If last year's allocations committee provided any recommendations for your program funding last year, please list the recommendation that they provided to you and how you have responded to it accordingly. If no funding or recommendations were given, please put N/A.*

2022-23 Funding Application
What is the name or title of the program that you are requesting funds for?*
What amount of funding are you requesting for this program?*
Please submit one (1) PDF copy of your Program Budget Form.*
Accepted file types: pdf, Max. file size: 100 MB.
This file is downloadable at www.unitedwayetnh.org/applyforfunding (copy & paste URL if needed). Please upload as a PDF.
Do you have other sources of funding in place for this program? If so, what are they? Please list with the estimated percentage of total program funding that each source represents.*
Describe your program.*
Describe how you staff this program, including the use of volunteers.*
Describe the overall need in your service area for this program.*
Describe the program target population to be served (age, sex, socio-economic level, special needs, etc.).*
List the requested funding amount per county covered by this program.*
*These numbers should match in your budget sheet*
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.*
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 partner with other agencies/organizations to serve your target population in the community? If so, please list and describe your partnership(s) and the benefit(s) associated with them.*

Program Evaluation
What metrics do you use to measure this program's effectiveness and what tools (i.e. software) and methods are you using to accomplish this?*
Program Cost Analysis - Individuals Served
Total Program Cost*
FY 2022 Proposed FY 2021 Budgeted FY 2020 Actual
Total Number of Unduplicated Individuals Served*
FY 2022 Proposed FY 2021 Budgeted FY 2020 Actual
Cost per Unduplicated Individual (Total Program Cost divided by Total Number of Individuals Served)*
FY 2022 Proposed FY 2021 Budgeted FY 2020 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.
What is your unit of service? (meals, rides, nights of shelter, etc.)
Total Program Cost
FY 2022 Proposed FY 2021 Budgeted FY 2020 Actual
Total Number of Units Provided
FY 2022 Proposed FY 2021 Budgeted FY 2020 Actual
Cost per Unit (Total Program Cost divided by Total Number of Units Provided)
FY 2022 Proposed FY 2021 Budgeted FY 2020 Actual

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. To offer opportunities 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 by hosting a workplace campaign within your agency.

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. (Ex. United Way of East TN Highlands logo on your agency website, program specific materials, social media posts, etc.)

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 accepted 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 (via the Program Budget Form). Failure to provide semi-annual financial statements by the due date will 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 by the due date will result in loss of future funding for your agency program.

7. To carry out the programs of the agency in such a manner that will best meet the needs of the community and 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, which is typically the third week of June).

10. To be represented by an executive level staff or board member at the following events:
 United Way Impact Awards (April)
 All Quarterly Executive Director Meetings
 If service area covers Carter County, Carter County Golf Tournament August.

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 United Way campaign objectives and fund Agency Programs that are making significant community 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 annually 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

2022-23 Agency Program Funding Application

Step 1 of 7

Agency Information

Agency Overview

For your most recent fiscal year, please provide the number of individuals (unduplicated) your agency served in each county (do not count individuals in more than one county).

2021 Allocations Committee Recommendations Progress Update

2022-23 Funding Application

Program Evaluation

Program Cost Analysis - Individuals Served

Program Cost Analysis - Units of Service (Optional)