1 Program Funding Request Form

1 Program Funding Request Form (Note: A separate Program Funding Request Form must be filled out for each program) Agency Name: Program Name: Program Physical Address: Program Contact Person: 1. Program Funding History & Request Summary: Dollar Amount Received (from UWSWMOSEK) in 2015 Dollar Amount Requested (from UWSWMOSEK) for 2016 $$ Difference from 2015 Allocation Received and 2016 Requested Total Program Expenses for 2015 Total Program Expenses Budgeted for 2016 2015 UWSWMOSEK Allocation Received % of Overall Program Expenses (Amount Received divided by Total Expenses) 2016 UWSWMOSEK Requested % of Overall Program Expenses (Amount Requested divided by Total Expense Budgeted) 2. Number of unduplicated clients served by this program (actual from prior fiscal year): Infants/Toddlers (Birth-3 Years) Children (4-12 Years) Teens (13-17 years) Young Adults (18-22) Adults Seniors (65+) Total Clients Served: 3. Provide a brief description of the program. 2 4. What are the days and hours of program operations? 5. What United Way Community Impact Area does the program align with? (Include Percentage)  Education Helping children and youth achieve their potential by succeeding in school, graduating, _______% finding work and becoming productive adults.  Income Supporting financial independence through employment, job training, money management, _______% owning or renting a home and saving for the future.  Health Promoting healthy choices and behaviors that improve well being. _______% 6. What Community Level Outcome(s) are you addressing with the program? (Circle or highlight applicable outcomes; logic model and measurement system must reflect outcome(s) chosen) Education Income Health Children and youth are ready for school, starting with the skills they need to succeed. Families sustain employment. Infants have healthy beginnings. Children’s reading skills are on track by fourth grade Families build savings and assets. Community members choose healthy eating. Youth transition successfully to and from middle school. Living wage employment opportunities are available. Community members choose physical activity. Youth graduate high school on time. Families have manageable expenses. The community supports healthy choices. Youth are working or in advanced education by age 21. Families have access to affordable housing. The community has access to healthcare. 3 7. Briefly describe your target population. 8. Describe the need that exists in the community for your program’s services. Please cite your data sources. (Some recommended sources include The County Rankings Report, Kids Count, US Census) 9. Which counties are served by this program? (Check all that apply) Jasper Newton Crawford Cherokee Barton  Other Counties 10. What are the client eligibility requirements? 11. Are clients charged fees for program services? YES NO If no, please skip to question 14. 12. What is the percentage of clients paying fees? 13. Do you have a sliding fee scale? YES NO If yes, please attach a copy of your sliding fee schedule to this form. 4 14. Is there a waiting list for services? YES NO Average number of clients on the waiting list: Average wait time per client: 15. Who serves as a referral source for the program? 16. Do volunteers work directly with the program? YES NO If YES, thinking only about UNPAID volunteers working directly with the program (Jan 1 2015-Current Date): (Do not include board members attending board and/or committee meetings.) Number of Volunteers: Number of Volunteer Hours: 17. What changes if any will occur within your program if your funding request is not met? 5 Geographic Service Area: Please indicate the total number of unduplicated clients served by this program who reside in each of the following locations. Missouri Kansas Oklahoma Barton County Lawrence County Bourbon County Craig County Lamar   Aurora   Fort Scott   Vinita   Liberal   Freistatt   Cherokee County Delaware County Barry County Halltown   Baxter Springs   Afton   Butterfield   Marionville   Columbus   Grove   Cassville   Miller   Galena   Jay   Exeter   Mount Vernon   Riverton   Ottawa County Monett   Stotts City   Crawford County Commerce   Purdy   Newton County Arma   Miami   Wheaton   Diamond   Girard   Picher   Butterfield   Granby   Cherokee   Quapaw   Cassville   Joplin (64804   Frontenac   Other OK Counties Dade County Neosho   Mulberry     Arcola   Seneca   Pittsburg     Everton   Vernon County Labette County     Dadeville   Brounaugh Chetopa       Greenfield   Nevada Oswego     Lockwood   Sheldon   Parsons Arcola   Walker    Montgomery County Everton   Other MO Counties Coffeyville Dadeville     Independence Greenfield       Neosho County Lockwood       Chanute   Greene County     Erie Republic       Thayer   Springfield     Other KS Counties  Strafford         Walnut Grove         Willard         Republic   Jasper County Carl Junction   Carthage   Carterville   Duenweg   Duquesne   Jasper   Joplin 64801   Joplin (64804)   Sarcoxie   Webb City   McDonald County Anderson   Goodman Noel Pineville   Program Logic Model Inputs	Activities	Outputs	Outcomes *Outcomes must be quantified by including numerical targets for change. Example: 90% of youth will graduate on time.			Measurement Systems
What are the resources needed to operate your program?	What does the program do with the inputs?	How many times did you do the activities and for whom? (This year – what will you track in this area?)	Initial Outcome	Intermediate Outcome	Long Term Outcome	How will you measure your outcomes?

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PROGRAM BUDGET FORM

(Total Budget for Program)


Name of Program:

Budget figures should coincide with fiscal calendar year (calendar or July-June). Be sure to describe any budget items that many need clarification in the Budget Narrative Section below.

REVENUE	2015 Budget	2016 Proposed Budget
Requested from United Way SWMO & SEK
Contributions Unrestricted
Contributions Restricted
Fund Raising (Gross)
Contributed by Associated Organization
Government Income
Program Generated Support
Grants
Other Earned Income
Total Revenue

EXPENSES	2015 Budget	2016 Proposed Budget
Salaries
Payroll Taxes
Employee Benefits
Supplies/Equipment
Telephone/Telecommunications
Postage & Shipping
Equipment Rental & Maintenance
Printing/Publications
Travel
Certifications/License Fees
Training/Conferences/Meetings
Program Related Insurance
Occupancy/Utilities
Specific Assistance for Individuals
Depreciation
Fundraising Expense
Payments to Affiliated Organization
Other Expenses
Total Expense
Revenue minus Expense

Budget Narrative: (Include in your budget narrative a list of all local corporate gifts to your agency over $1000.)