GRANT APPLICATION FORM
Funding Period: July 1, 2015 – June 30, 2018
Updated 5/14/14
United Way of the Greater Chippewa Valley (UWGCV) is seeking proposals to support programs
addressing identified needs in the community action plans developed for Chippewa and Eau Claire
counties in the areas of Education, Income, Health, and Basic Needs. Only organizations that
received approval for their Intent to Apply Form may submit a grant application.
To complete the grant application form:
 Place your cursor in the appropriate text box and provide the information requested;
 Use Arial 10 font (or something comparable in font size) when answering the questions;
 Do not reformat the pages when printing or saving your documents because the text boxes
will expand in size to accommodate your responses; and
 Do not to exceed the number of words allowed for an answer (if specified) because the
extra text will not be reviewed.
Printed and electronic copies of the following paperwork must be completed and delivered no
later than 4:00 p.m. on Monday, June 30, 2014 to the United Way office:
Document
Application
Printed
One copy in Word
with original signatures
Budget
(Attachment A)
Attachments
B thru H
Separate Excel spreadsheet
for each year
Original or copy of each document
Electronic
One copy in Word and
another copy as a PDF
(preferably with signatures)
One file with Excel
spreadsheet for each year
PDF version of each document
If any required signatures are missing on the application, it is considered incomplete. These and
other application materials received after the deadline will not be eligible for review.
Electronic versions of those documents must be emailed to the United Way staff member
(listed below) in charge of the designated area to which application is being submitted:
Education
Income
Health
Basic Needs
Angela Weideman
Director of the Successful Children’s Network
Valerie Hogan
Director of the Financial Stability Partnership
Michael Hoadley
Director of the Community Health Initiative
Valerie Hogan
Director of the Financial Stability Partnership
[email protected]
[email protected]
[email protected]
[email protected]
In the subject line of the email, please type the area and the name or title of your program as
indicated on the application (Example: HEALTH – Lifestyle Makes a Difference). The electronic
versions must also be submitted by the deadline of 4:00 p.m. on Monday, June 30, 2014 in
order to be eligible for review.
All questions relative to the grant application process should be directed by phone (715-834-5043)
or email to the United Way staff member in charge of the designated area (listed above).
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Section 1: GENERAL INFORMATION ABOUT LEAD ORGANIZATION
1. Name of Lead Organization
2. Website of Lead Organization
3. Chief Executive Officer
Job Title
Address (City, State, Zip Code)
Phone
Email
4. Local Contact Person
Job Title
Address (City, State, Zip Code)
Phone
Email
2
5. Legal Status of Lead Organization
(Place an “X” in one of the boxes)
§501(c)(3) Organization
Public Agency
Educational Institution
Financial Institution
Other Tax-Exempt Organization
Other
Specify:
Name of Fiscal Agent
Legal Status of Fiscal Agent
(Place an “X” in one of the boxes)
§501(c)(3) Organization
Public Agency
Educational Institution
Financial Institution
Other Tax-Exempt Organization
Other
Specify:
6. Mission statement of your organization
Max: 200 words
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Section 2: PROGRAM INFORMATION
7. Name of Program
8. Website of Program
9. Contact Person Responsible for Program
Job Title
Address (City, State, Zip Code)
Phone
Email
10. Status of this program within your organization (Put an “X” in one of the boxes)
New program
Existing and ongoing program
Enhancement of an existing and ongoing program
11. Overview, purpose and description of your program
Max: 600 words
12. How does your program address an important need, problem or issue in Chippewa and/or Eau Claire
counties? Include information on how that need, problem or issue was identified and determined.
Max: 600 words
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13. What research and/or “best practices” support the need for your program and the approach being used?
Cite the reference for each resource and provide a brief description as well.
Max: 1,500 words
14. Organization’s qualifications (e.g., staff’s knowledge, competency, experience, and licensure) and any
historical data that demonstrate previous accomplishments (e.g., program capacity, longevity, awards,
community recognition, and success rate).
Max: 600 words
15. Geographic area served by your program (Put an “X” in one of the boxes)
Chippewa County
Eau Claire County
Both Chippewa and Eau Claire counties
If your program does not serve the entire county (or all of both counties), please include details about your
service area.
Max: 400 words
16. Describe target population your program serves in terms of gender, age, race/ethnicity, and income level.
Max: 600 words
17. Using the criteria established in the United Way action plans for each focus area, describe the target
population that will be served using the United Way funding requested. Note: Applications submitted to
Basic Needs should refer to the Basic Needs Funding Guidelines.
Max: 600 words
18. Number of individuals served (anticipated) by your program
Age Group
Number of People Served
from Eau Claire County
0-5
6-11
12-24
25-34
35-44
45-54
55-64
65-74
75+
Total Served by County
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Number of People Served
from Chippewa County
Total Served
by Age Group
Section 3: PROGRAM GOALS, OUTCOMES & EVALUATION PLAN
DEFINITIONS:
A goal is the long-term, overall result that your program is trying to achieve.
A strategy is a plan or series of actions describing how your program will achieve its outcomes.
An outcome is a short-term, intermediate, or long-term result that is measurable and contributes to
achievement of your goal(s).
An indicator is a statistical measure that demonstrates progress toward achievement of an outcome.
A method is an approach or procedure used for measurement.
An instrument is a tool, data source or other resource used for collecting or obtaining information.
19. List the goal(s) of your program. At least one goal must be stated.
Max: 100 words per goal
Goal 1:
Goal 2:
Goal 3:
Goal 4:
20. Describe any strategies that will be used by your program to address the identified need(s) of people
residing in Chippewa and/or Eau Claire counties. At least one strategy must be stated.
Max: 600 words
OUTCOME MEASUREMENT:
21. Complete the table on the next page.
Max: 100 words per response


List the primary outcome(s) for your program, along with the outcome indicator(s) for each one. The
indicator should include the target number and/or percentage, as well as the identified timeframe. At
least one outcome and one indicator must be identified.
For each outcome and its indicator, describe the method and instrument that will be used to collect
the data and other information.
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Outcome
Outcome Indicator
1
1
Data Collection Method
Data Source
Collection Method:
Instrument:
2
Collection Method:
Instrument:
3
Collection Method:
Instrument:
2
1
Collection Method:
Instrument:
2
Collection Method:
Instrument:
3
Collection Method:
Instrument:
3
1
Collection Method:
Instrument:
2
Collection Method:
Instrument:
3
Collection Method:
Instrument:
4
1
Collection Method:
Instrument:
2
Collection Method:
Instrument:
3
Collection Method:
Instrument:
7
22. Describe how data will be tracked and analyzed to measure success in achieving your program’s
outcomes.
Max: 600 words
23. Describe your program’s evaluation plan during the first year to adjust and strengthen the overall work
plan for your program. Include information on how outcomes will be measured and benchmarks that will be
used to aid in evaluating whether or not the approach worked as intended.
Max: 750 words
24. Describe how your program will change or be different (if at all) in the second and third years of
operation.
Max: 600 words
25. How will you communicate the results of your program outside your organization?
Max: 600 words
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Section 4: PROGRAM STAFFING, WORK PLAN & TIMELINE
26. Describe how your program is (or will be) staffed with paid employees and volunteers.
Max: 600 words
27. Describe how staff and volunteers are (or will be) prepared and trained to implement the program.
Max: 600 words
28. Describe how staff and volunteers are (or will be) managed in your program.
Max: 600 words
29. Proposed work plan and timeline for the first year of your program. Identify activities and events (e.g.,
community awareness, recruitment, training, planning, fund-raising, implementation of program, collection of
data, etc.) and provide a brief description of each as needed.
Year 1
Activities and/or Events
July
Max: 150 words
August
Max: 150 words
September
Max: 150 words
October
Max: 150 words
November
Max: 150 words
December
Max: 150 words
January
Max: 150 words
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February
Max: 150 words
March
Max: 150 words
April
Max: 150 words
May
Max: 150 words
June
Max: 150 words
30. Anticipated differences or changes to staffing, the work plan, and the timeline in Year 2 (if funds are
requested)
Max: 600 words
31. Anticipated differences or changes to staffing, the work plan, and the timeline in Year 3 (if funds are
requested)
Max: 600 words
32. How will you utilize traditional and social media to communicate information about your program?
Examples of media include posters, websites, newsletters, Facebook, Twitter, blogs, newspaper articles,
radio and television interviews, etc.
Max: 600 words
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Section 5: PROGRAM FUNDING REQUEST & BUDGET
Funds requested from United Way of the Greater Chippewa Valley can vary from year to year. An
organization also has the option of applying for one, two or three years of funding.
33. Funding requested:
Year 1
July 1, 2015 – June 30, 2016
Year 2
July 1, 2016 – June 30, 2017
Year 3
July 1, 2017 – June 30, 2018
$
$
$
Note: Year 2 & 3 funding contingent upon program success documented in progress reports.
34. Proposed program budget for each year of funding requested.
Note: Complete Attachment A (annual spreadsheets designated by tabs).
35. List other organizations collaborating in your program and describe their role(s) and function(s), as well
as any funding (if provided).
Collaborative Partner
Role(s) and Function(s)
Max: 100 words
Funding Dollars
(if provided)
$
Max: 100 words
$
Max: 100 words
$
Max: 100 words
$
Max: 100 words
$
36. If funding is received from UWGCV, how will this program be sustained after the grant period is over?
Max: 600 words
37. Has your program or the Lead Organization been part of a government-led investigation?
Yes
No
Note: Complete Attachment H if your answer is yes to this question.
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Section 6: PROGRAM & ITS RELATIONSHIP TO MISSION
38. How does this proposed program help your organization meet its mission?
Max: 600 words
39. How will you include or involve people in elected positions and other community leaders in your
program? Examples include the mayor, city council members, county board members, school board
members, chambers of commerce, boards of directors, legislators, special interest groups, coalitions, and
other individuals living in the community.
Max: 600 words
40. How does this proposed program help United Way of the Greater Chippewa Valley address its mission to
provide active leadership by bringing resources together to improve lives and create stronger communities?
Max: 600 words
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Section 7: SUBMISSION TO FOCUS AREA FOR REVIEW
41. Based upon the information you have provided in Sections 1-6 and the outcome(s) or service(s) you
select below, please choose the PRIMARY focus area that your program addresses:
EDUCATION
INCOME
HEALTH
BASIC NEEDS
42. In the focus areas below, PLEASE PLACE AN “X” IN THE BOX NEXT TO THE OUTCOME(S) AND/OR
SERVICE(S) YOUR PROGRAM WILL ADDRESS. You may select more than one outcome/service in any
of the four focus areas. Note: If funded, your program will be required to track results for each
outcome/service you select.
FOCUS AREA: EDUCATION
Target population: Children ages birth to five, in households below 200% of federal poverty guidelines.
Outcomes:
Children will enter school with age-appropriate development in the area of health and physical wellbeing.
Children will enter school with age-appropriate development in the area of social and emotional
development.
Children will enter school with age-appropriate development in the area of language and general
knowledge.
FOCUS AREA: INCOME
Target population: Middle and high school students, and adults through approximately age 45.
Outcomes:
Families who face financial challenges will have a steady source of income that allows them to meet
basic needs and increase disposable income.
Families will have effective personal money management skills. (If you select this outcome, please
select a target population below.)
Our program will provide financial coaching services for CVTC students, in cooperation with
United Way’s micro-grant program.
Our program will provide services to others.
Note: If you checked both boxes above, you must provide separate information for these
two populations:


Service statistics in Section 2 (Question 18)
Outcome measures in Section 3 (Question 21)
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FOCUS AREA: HEALTH
Outcomes:
Improve mental health services in the Chippewa Valley. Target population: Individuals and families
dealing with mental health issues, in households below 200% of federal poverty guidelines.
Alcohol misuse will decrease in the Chippewa Valley. Target population: People between the ages
of 12 and 34.
Decrease intimate partner violence (domestic violence) in the Chippewa Valley. Target population:
Adult victims of intimate partner violence (domestic violence) and their children.
Individuals in the Chippewa Valley will practice healthy behaviors to prevent and/or delay the onset
of obesity. Target population: People of all ages, with emphasis on individuals and families below
200% of federal poverty guidelines.
FOCUS AREA: BASIC NEEDS
Target population: Households that face economic challenges, living below 200% of federal poverty
guidelines, or people who face emergency situations.
Services:
Food – includes groceries and meals.
Shelter/Housing – includes sleeping, transitional, warming, and personal hygiene facilities, as well as
rental assistance. (Does not include energy assistance)
Clothing – includes all types of clothing.
Medical Care – includes basic health care and prescriptions.
Dental Care – includes basic dental care and prescriptions.
Programs that enhance access to the above services.
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Section 8: SIGNATURE PAGE
43. COMPLETE AND PRINT THIS PAGE, OBTAIN ORIGINAL SIGNATURES, AND DELIVER THE
SIGNED COPY WITH THE REST OF THE GRANT APPLICATION TO THE UNITED WAY OFFICE BY
4:00 P.M. ON MONDAY, JUNE 30, 2014. Note: Even though signatures were required on the Intent to
Apply Form, original signatures must be obtained again now that the full application is being submitted.
Organizations and individuals identified below have read and agree to abide by the following United Way
policies: Affiliation & Funding Requirements, Anti-Terrorism Policy, Annual Review Policy, Appeals Policy,
Designations Policy, Fund-Raising Policy, and Probation Policy. (See http://www.uwgcv.org/application.)
These same organizations and individuals agree to collaborate on the program identified as part of the grant
application process.
LEAD ORGANIZATION
Name of Organization
Contact Person
Job Title
Signature: ______________________________________________________________ Date: _________
Email:
___________________________________________
Phone: ____________________________
FISCAL AGENT (This could be the Lead Organization or a Collaborative Organization)
Name of Organization
Contact Person
Job Title
Signature: ______________________________________________________________ Date: _________
Email:
___________________________________________
Phone: ____________________________
COLLABORATIVE ORGANIZATION
Name of Organization
Contact Person
Job Title
Signature: ______________________________________________________________ Date: _________
Email:
___________________________________________
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Phone: ____________________________
COLLABORATIVE ORGANIZATION
Name of Organization
Contact Person
Job Title
Signature: ______________________________________________________________ Date: _________
Email:
___________________________________________
Phone: ____________________________
COLLABORATIVE ORGANIZATION
Name of Organization
Contact Person
Job Title
Signature: ______________________________________________________________ Date: _________
Email:
___________________________________________
Phone: ____________________________
COLLABORATIVE ORGANIZATION
Name of Organization
Contact Person
Job Title
Signature: ______________________________________________________________ Date: _________
COLLABORATIVE ORGANIZATION
Name of Organization
Contact Person
Job Title
Signature: ______________________________________________________________ Date: _________
Email:
___________________________________________
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Phone: ____________________________
ATTACHMENTS
The following attachments are required from the Lead Organization, along with your application:
_____ Attachment A: Budget
Projected program budget and usage of United Way grant dollars, using the
spreadsheet supplied by United Way.
_____ Attachment B:
Program Profit and Loss Statement
Include budget vs. actual for the most recently completed fiscal year.
_____ Attachment C:
Organizational Profit and Loss Statement
Include budget vs. actual for the most recently completed fiscal year.
_____ Attachment D:
Organizational Financial Statements
Audited, reviewed, or compiled organizational financial statements. These financial
statements should include: the balance sheet and profit & loss statements for the
last two most recently completed fiscal years. If possible, also include a cash flow
statement for the most recently completed fiscal year.
i. For tax-exempt organizations under §501(c) of the Internal Revenue Code,
please provide the following, based on revenues reported on your most recently
filed IRS 990 form:
 Annual Revenues < $200,000: The above financial statements that have
been reviewed and approved by the board treasurer and chairperson (verify
with signatures);
 Annual Revenues > $200,000: A formal “review” of the above financial
statements is required from an independent accountant.
 If your organization received over $400,000 in contributions: You must
submit audited financial statements and the opinion of an independent
accountant.
ii. For organizations that are not tax-exempt, please provide the following, based on
revenues reported on your most recently filed tax return:
 Annual Revenues < $200,000: The above financial statements that have
been reviewed and approved by your chief executive officer (verify with a
signature);
 Annual Revenues > $200,000: A formal “review” of the above financial
statements is required from an independent accountant.

_____ Attachment E:
Federal Tax Return
For the most recently completed fiscal year (e.g., 990, 1040, etc.).
_____ Attachment F:
Organizational Chart
Reflect the following structures and how they relate to each other:
 Board and committee structure,
 Departmental structure, and
 Supervisory structure, including position titles
(specific names are not necessary).
If your local office is a subsidiary of a parent organization, please submit the above
for both your local office and your parent organization to illustrate the relationship
between the two.
_____ Attachment G:
Board Members
List each board member and indicate whether or not she/he is an officer, which of
your committees that person participates on, her/his employment affiliation, and
contact information.
_____ Attachment H:
Narrative Regarding Government-led Investigation (Response to Question 37)
Include why the investigation happened, findings from the investigation, whether or
not the agency/program has been put on corrective action or probation, and what
the agency is doing to correct the issue. Also include timeframes for each part of
the process.
Note: If the Fiscal Agent is NOT the same as the Lead Organization, the Fiscal Agent must ALSO provide
Attachments C, D and E.
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CHECKLIST
Please print this page and put an “X” next to each of the items that your program is submitting for review.
Printed copies of all documents must be delivered to the United Way office by 4:00 p.m. on June 30, 2014.
_____ Grant Application (Sections 1 thru 8)
_____ Signature Page must be completed and signed by a representative from the
Lead Organization, Fiscal Agent, and ALL Collaborative Partners
_____ Attachment A:
Budget
_____ Attachment B:
Program Profit and Loss Statement
_____ Attachment C:
Organizational Profit and Loss Statement
_____ Attachment D:
Organizational Financial Statements
_____ Attachment E:
Federal Tax Return
_____ Attachment F:
Organizational Chart
_____ Attachment G:
Board Members
_____ Attachment H:
Narrative Regarding Government-led Investigation (Response to Question 37)
Note: If the Fiscal Agent is NOT the same as the Lead Organization, the Fiscal Agent must ALSO provide:
_____ Attachment C:
Organizational Profit and Loss Statement
_____ Attachment D:
Organizational Financial Statements
_____ Attachment E:
Federal Tax Return
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