Interim Activity Report Form
Reports are due to United Way of 1000 Lakes by
Noon, Friday, April 15, 2016
+ This report covers year one of the two-year funding cycle 2015-2017.
+ Reports are NOT due in the second year – your application will serve this purpose
(unless not reapplying for funding).
+ Report sections include:
__ Cover Sheet
__ Organizational Information
__ Program Outcomes
__ Program Statistics
__ Fundraising Information
__ Program Budget / Actual (attach original budget and actual financial info)
+ Please submit a separate Interim Activity Report for each program that received
United Way of 1000 Lakes funds.
+ Submit Report Form and Budget Information electronically to Kimberly Brink Smith
at [email protected]
+ Questions, please contact Kimberly Brink Smith at 218-999-7570 or via email.
2016-2017 Calendar
Feb. 15
3rd Quarter Allocations
Feb. 24
Volunteer Award Nominations Due
March 24
Campaign Celebration & Awards at Timberlake Lodge
April 15
4th Quarter Allocations
April 15
Funding Interim Report due
May
Compliance Review; United Way Board of Directors Approval
June
Allocation Award letter and Affiliation Agreement sent to agencies
June 21
Day of Action
July 1
2016-17 Funding Year begins
July 15
1st Quarter Allocations
Sept. 10
United Way Campaign Kick-off
Oct. 15
2nd Quarter Allocations
Jan., 2017
Application for Funding available
Jan. 15, 2017
3rd Quarter Allocations
Year One Report Form Cover Sheet
Date:
Organization Information
Agency Name:
Address:
City, State, Zip:
Phone:
Report Period:
Focus Area:
Grant Amount:
Executive Director:
Title:
Phone:
Email:
Report Contact:
Title:
Phone:
Email:
Name of Program:
Population served and annual
estimated number of clients
served by this program in the
United Way of 1000 Lakes
service area:
A. Please attach a list of board members, include their term limits, community affiliation, phone,
email, address(s).
B. Please provide a current organization chart (attach).
C. Give a brief summary of factors, if any, affecting your agency/program over the last year, both
positive and negative, and describe how the agency is planning to address these influences.
Program Outcomes
A. List the program outcomes from the original proposal submitted January 2015.
2013 Outcomes
1.
2.
3.
B. Describe the progress made and results in achieving your outcomes in the past year. What
has gone well? What do you plan to do differently? Have you developed any new outcomes?
C. List your 2016 anticipated outcomes.
2014 Outcomes
1.
2.
3.
Program Client Statistics
Prior Year (2014)
From______to ______
Program Beneficiary Characteristics
(Clients/Patients/Recipients/Other)*
1. Program Beneficiaries
Total
Number of individuals served (unduplicated)
Number of families served (if applicable)
Number of services provided
2. Gender
Male
Female
Unknown
Total
3. Age Group
Child (Birth – 5)
School-Aged (6-18)
Adult (19 – 24)
Adult (25 – 64)
Senior (65+)
Other:
Total
4. Racial/Ethnic Background
African/African-American
American Indian
Asian/Asian-American
Caucasian
Latino/Hispanic
Other:
Total
5. Residence by community/zip code
AITKIN COUNTY:
55748 (Hill City)
55752 (Jacobson)
CASS COUNTY:
56626 (Bena)
56641 (Federal Dam)
ITASCA COUNTY:
55709 (Bovey); 55722 (Coleraine)
55716 (Calumet)
55744 (Grand Rapids)
55742 (Goodland)
55753 (Keewatin)
55764 (Marble)
55769 (Nashwauk)
55775 (Pengilly)
55784 (Swan River)
55786 (Taconite)
55793 (Warba)
56628 (Bigfork)
56631 (Bowstring)
56636 (Deer River)
56637 (Talmoon); 56657 (Marcell);
56659 (Max);
56680 (Spring Lake)
56639 (Effie)
56681 (Squaw Lake)
56688 (Wirt)
Total
Current Year (2015)
From_____to _____
Projected Year (2016)
From_____to _____
Program Service Statistics
Complete ONLY sections applicable to your program
Program Service Statisties
Prior Year (2015)
Current Year (2016)
From______to ______ From_____to _____
1.
Food Programs
Number of meals distributed
Pounds of food distributed
Number of referrals made
Other:
2.
Safety – Domestic Violence/Sexual Assault/Crisis Shelter
Number of shelter/safe housing nights (note how this is computed)
Number of times provided legal advocacy or court assistance
Number of crisis calls handled
Number of Orders of Protection
Number of Restraining Orders
Number of clients transitioned out of an unsafe environment
Number or clients received crisis counseling
Other:
3.
Legal Assistance Programs
Number of housing cases handled
Number of benefits cases handled
Number of domestic violence related cases handled
Number of family law cases handled
Number of mediation or alternative dispute resolution cases handled
Number of parental education seminars conducted
Number of cases with positive outcome for client
Other:
4.
Social Services/Case Management/Resource Assistance
Number of referrals made
Number of case mgmt or counseling sessions (in person/by phone)
Number of clients connected to housing options
Number of clients connected to educational options
Number of clients connected to employment options
Number of clients received financial assistance for food, clothing
Number of clients received financial assistance for rent, utilities
Number of clients received assistance for transportation
Number of clients received assistance for daily living/chores
Number of clients able to stay connected to the community
Other:
5.
Educational, Recreational, and Social Activities
Number of clients participated in educational mentored outings
Number of clients participated in recreational mentored outings
Number of clients participated in social activity events/outings
Number of clients participated educational tutoring/mentoring
Number of youth participated in scouting
Number of adults trained to work with/mentor/tutor youth
Number of adults worked with youth
Other:
Projected Year (2016)
From_____to _____
Fundraising Information
Gifts: Please submit up to three examples of services provided by the program that a weekly contribution of $X
dollars would make possible (i.e., $6.00 per week for one year shelters and feeds a family of 4 for 4 days). This
information will be essential for marketing during United Way Campaign.
1.
2.
3.
Impact Story: Please provide a true story stating the impact your services have had on an individual or family that
can be used during the United Way of1000 Lakes campaign. The story must be 150 words or less, recent and local to
our service area; names can be changed for confidentiality. Stories become United Way property and will likely be
used in fundraising efforts. You must have a signed release in your records if using real names. (Please send a copy
via e-mail to: [email protected])
High-quality, high-resolution digital photographs available for promotional purposes?
Yes
No
High-quality, high-resolution video available for promotional purposes?
Yes
No
* Signed releases in your records are required for all submitted photos.
Fundraising: Please provide information for major fundraising activities during the organization’s most recently
completed fiscal year and any events/activities in the upcoming fiscal year (special events, product sales,
membership drives, direct mail solicitation, etc.). United Way wishes to support agency activities and events
throughout the year by attending and promoting through online communications.
Event / Activity
Date / Time Frame
Net Profit
PROGRAM BUDGET
PROGRAM TITLE:
SUPPORT & REVENUE
Allocation from this United Way
Allocation from United Youth for United Way
Allocation from other United Ways
Individual Contributions
Special Events
Contributed by Associated Organizations
Fees & Grants From Government Agencies
Fees & Grants From Non-Government Agencies
8. Membership Dues
9. Program Service Fees
10. Sales of Materials
11. Investment Income
12. Miscellaneous Revenue (itemize if over $1,000)
13. TOTAL SUPPORT & REVENUE (add 1-12)
EXPENSES
Requested Amount
Prior Year (2014)
Current Year (2015)
From______to ______
From_____to _____
Projected (2016)
From_____to _____
1.
2.
3.
4.
5.
6.
7.
Requested Amount
Prior Year (2014)
From______to ______
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
Gross Salaries
Employee Benefits
Total Staff Compensation (add 14-15)
Payroll Taxes
Professional Fees
Office Supplies
Phone
Postage & Shipping
Occupancy
Rental & Maintenance of Equipment
Printing & Publications
Travel
Conferences, Conventions & Meetings
Awards/Grants/Scholarships
Membership Dues
Miscellaneous (itemize this item if over $500)
Special Event Expenses
Payments to Affiliated Organizations
Additional Costs (not covered above, list below)
Other_______________________________
Other_______________________________
Other_______________________________
33. Monies Allocated to Reserve Fund
34. TOTAL EXPENSES (add 16-32)
SURPLUS/(DEFICIT) (Line 12 minus Line 34)
Current Year (2015)
From_____to _____
Projected (2016)
From_____to _____