2010 Investment Process LOI Online Application Questions
Online Application Questions 2010 Program Investment Process
LETTER OF INTENT
ORGANIZATION INFORMATION Organization Legal Name: Organization Mailing Address: (Street or Post Office Box) (City, State & Zip) Organization Phone: (xxx) xxx-xxxx
Organization Fax: (xxx) xxx-xxxx
Organization Website: Executive Director/CEO: (Name) Executive Director/CEO Phone: (xxx) xxx-xxxx Board Chair: (Name) Program Contact: (Name) Program Contact Phone: (xxx) xxx-xxxx Organization EIN:
Executive Director/CEO Email: (Email) Board Chair Affiliation: (Work Place) Program Contact Title: (Position) Program Contact Email: (Email) Date IRS 501(c)(3) status determined: (MM-DD-YYYY)
Organization Mission Statement: (50 words or less) PROGRAM INFORMATION – PART 1 Program Name: 2010 UWCO Funding Requested $
2010 Total Program Budget $
2010 Total Agency Budget $
UWCO Impact Area: Select One: Primary Community Result Addressed by Program: Select One:
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PROGRAM INFORMATION – PART 2 Is this an existing program? Yes No If yes, how long has the program been in operation? (25 words or less) Is this a collaborative proposal? Yes No If yes, list collaborative partners, their roles, and resources committed to the program: (250 words or less) Program Summary: (100 words or less) Has organization previously received UWCO funding (check all that apply)? Ongoing program investment Donor designation Initiative Funding No Other (Describe in 25 words or less) The agency executive and board chair have reviewed the Letter of Intent materials and they affirm that the information provided is accurate and provides full and fair disclosure. Yes PROGRAM INFORMATION – PART 3 What is the intent of the program? (100 words or less) How does the program contribute to the achievement of the community result? (50 words or less) What community need or condition does the program address? (100 words or less) What data clearly document the need or condition described above? (300 words or less) What UWCO strategy does the program use? (Please select from the list in UWCO’s resource documents). (50 words or less)
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Does the program respond to a UWCO priority consideration for the community result? Yes
No
If yes, what is the priority consideration? Describe how the program addresses it. (200 words or less) What is the intervention target for the program? (50 words or less) What are the specific characteristics of the intervention target? (200 words or less) PROGRAM INFORMATION – PART 4 Describe the primary program activities. (500 words or less) What inputs (staff, supplies, facilities, volunteers, other) will the program use to deliver the proposed activities? (250 words or less) Which of UWCO’s specified performance measures for this strategy will the program track? (Please select from the list in UWCO’s resource documents). (100 words or less) What is the unit of service for the program? (25 words or less) What amount of service will the program deliver in 2009 and 2010? Units of Service Persons/Intervention Targets Served
Projected - 2009 (enter number) (enter number)
Projected - 2010 (enter number) (enter number)
PROGRAM INFORMATION – PART 5 What results have the program achieved in past? How have those results been tracked and measured? How have results been used to improve the program? (200 words or less) How does the program collaborate and/or integrate with other services, organizations and systems to achieve results? (250 words or less) 4
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Describe the organization’s capacity (staff expertise, financial resources, etc.) to effectively and efficiently deliver the program and achieve and track the stated performance measures. (250 words or less) Other (250 words or less) PROGRAM BUDGET 2009 Budget
2010 Budget
2009
2010
SUPPORT/REVENUE Contributions Foundations/Trusts Special Events Legacies and Bequests Federated fund-raising orgs Other United Ways Fees and Grants from Govt Agencies Membership Dues Program Service Fees Investment Income Misc. (Specify)__________________________ Transfer from restricted funds UWCO Program Funding UWCO Special Grant/Initiative TOTAL SUPPORT/REVENUE EXPENSES Salaries Retirement Health Insurance Life Insurance Other Payroll Taxes Professional Fees Supplies Telephone Postage & Shipping Total Occupancy Equipment rental & maintenance Printing & Publication EXPENSES (continued) Travel 5
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Conferences, conventions Specific Assistance to Individuals Membership dues Misc. (Specify)__________________________ Dues or Support to National Depreciation TOTAL DIRECT EXPENSES INDIRECT EXPENSES TOTAL EXPENSES TOTALS SURPLUS/DEFICIT Units of Service Unit Description Cost per Unit
2009
2010
PROGRAM BUDGET NARRATIVE Revenue Assumptions and Explanations (250 words or less) Expense Assumptions and Explanations (250 words or less) Indirect Expenses Explanation (250 words or less)
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