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UNITED WAY COMMUNITY IMPACT FUNDS
Thank you for your interest in applying for Community Impact Funds from United Way & Volunteer Services of Greater
Yankton. Our Board of Directors find this to be one of the most satisfying parts of their involvement with United Way,
investing in the success of our partners and learning more about the programs you provide to meet the critical human needs
in our community.
United Way Community Impact investments address priority outcomes in Education, Financial Stability and Health.
Please identify and break down your funding request based on which priority area you feel each program provided fits.
EDUCATION
FINANCIAL STABILITY
HEALTH






PROMOTING THE DEVELOPMENT
OF WORK AND LIFE SKILLS
INCREASING POSITIVE SOCIAL,
EMOTIONAL AND ACADEMIC
DEVELOPMENT
PREPARING YOUTH FOR SUCCESS
IN SCHOOL AND COMMUNITY

INCREASING SELF-SUFFICIENCY
PROVIDING BASIC NEEDS SUCH AS
FOOD, SAFETY AND SHELTER
PROVIDING SUPPORT DURING
TIMES OF CRISIS


SUPPORTING VULNERABLE
POPULATIONS
PROMOTING INDEPENDENCE
FOR INDIVIDUALS
PROVIDING ACCESS TO BASIC
AND PREVENTATIVE HEALTH
CARE SERVICE
United Way also focuses on measurable results within all funded programs and sharing that impact with the community more
effectively. Therefore, it is required that all programs clearly identify outcomes and goals for which you are seeking funding.
All applications received are scored using a worksheet developed by the United Way Allocations Committee and Board of
Directors. This worksheet scores applications in each of the following assessment areas:
NONPROFIT STATUS (10%)
Review Measures: RELEVANT MISSION STATEMENT, NONDISCRIMINATION POLICY, ESTABLISHED PERSONNEL POLICIES,
BOARD TRAINING & DIVERSITY, LOCAL PRESENCE, ACCREDITATION, LICENSE PROVIDED, EXPERTISE WORKING WITH THE
TARGET POPULATION, EVALUATION STANDARDS
FINANCIAL NEED (40%)
Review Measures: RESERVE POLICY REVIEWED, PERCENT OF THE DOLLARS SERVES CLIENTS DIRECTLY, REQUEST AS A
PERCENT OF TOTAL PROGRAM FUNDING, LOSS OR GAIN OF OTHER REVENUE SOURCES, DEVELOPMENT OF OTHER
FUNDING SOURCES, LEVERAGE OF OTHER FUNDS
IMPACT, COMMUNITY NEED & EVALUATION (40%)
Review Measures: PROGRAM OUTCOMES, PROGRAM GOALS AND OBJECTIVES, SUCCESS RATE STANDARDS, INDICATORS,
DELIVERY AND ACCESS OF TARGET POPULATION TO SERVICE, PROGRAM COST BREAKDOWN WITHIN UNITED WAY’S 3
PRIORITY AREAS, COMMUNITY NEEDS ASSESSMENT, SUPPORT DATA, PARTNERSHIPS IN COMMUNITY
PARTNER AGENCY PARTICIPATION (10%)
Review Measures: MARKETING SUPPORT, SUBMISSION OF REPORTS, LIAISON CORRESPONDENCE, PARTICIPATION IN AND
SUPPORT OF UNITED WAY EVENTS
Thank you again for your interest in partnering with United Way in meeting the needs of thousands of individuals in the
Greater Yankton area. Your work is deeply appreciated.
Please contact me at (605)665-6766 or at [email protected] regarding any questions.
Lauren Hanson, Executive Director, United Way & Volunteer Services of Greater Yankton
COMMUNITY IMPACT FUNDING APPLICATION
ORGANIZATION & FUNDING REQUEST INFORMATION
Organization Name:
Mission Statement:
Mailing Address:
Name of Yankton Contact:
Phone:
Email:
Federal TAX ID#:
Most recent United Way Venture Grant Awards: $
Description of program funded:
2017 Allocation Award Total:
2018 Funding Request:
If asking for more funding this year, please explain why?
Describe any significant changes (budget, programs, staff) that occurred last year?
NON-PROFIT STATUS
Any organization applying for funding from United Way & Volunteer Services of Greater Yankton must meet the following
requirements. Please initial to verify agreement.
1. Have operated one full year in the community before applying for partnership with United Way.
2. A copy of letter certifying your tax-exempt status under section 501c (3) of the internal revenue code must be
included with this application. If the most recent copy has been obtained from previous applications, there is no
need to resend.
3. Include constitution and updated bylaws. If the most recent copy has been obtained from previous applications,
there is no need to resend.
4. Include a copy of your organization’s policy of nondiscrimination and affirmative action. If the most recent copy
has been obtained from previous applications, there is no need to resend.
5. Include a copy of your organization’s personnel policies. If the most recent copy has been obtained from previous
applications, there is no need to resend.
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6. Include a copy of the 2016 Nonprofit Report for the South Dakota Secretary of State.
7. Include a copy of your most recent Form 990.
8. Be governed by an active volunteer Board of Directors, which serves without pay, meets with a quorum at least
quarterly and exercises effective administrative control. Please list members below:
OFFICERS
PHONE
OR EMAIL
YEARS
SERVED
TERM
COMPLETION
DATE
BOARD
MEMBERS
PHONE
OR EMAIL
YEARS
SERVED
TERM
COMPLETION
DATE
9. (a) Board Meeting day/time/place:
(b) Board Member term limits:
10. Describe the organization’s history, expertise and experience working with the target population, as well as experience
implementing the proposed programs and services. Please include all licensing and or accreditations related to serving
the target population.
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11. (a) Describe the organization’s leadership staff and key program staff. Include all employees who serve in a senior
leadership role within the organization and those key staff who contribute time toward programming. Include name, title
and experience.
(b) Do you measure employee performance, and if so, how and how often?
FINANCIAL & FUNDING INFORMATION
12. Complete the FINANCIAL INCOME AND EXPENSE FORM (Attachment A)
13. Include a copy of your most recent audit, review, or compilation of finances.
14. (a) Share your organization’s policy regarding reserves:
(b) How many months of operating capital do you currently have, including reserves:
(c) Please list specific reasons you are retaining financial reserves/savings:
15. Budget Year: (January-December/April-March)
16. Please list fundraising activities for 2016.
NAME OF FUNDRAISER
DATE OF FUNDRAISER
GROSS AMOUNT RAISED
$
$
$
$
17. What additional grants is your organization planning to pursue or are currently applying for?
GRANT/FOUNDATION NAME
FUNDING YEAR
AMOUNT REQUESTING
$
$
$
$
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IMPACT, COMMUNITY NEED & EVALUATION INFORMATION
18. Please list all PROGRAMS relative to your Community Impact Fund request. Identify how each program fits within United
Way’s funding priorities and describe the program’s OUTCOMES and GOALS.
PROGRAM NAME
UW FUNDING PRIORITY
FUNDING REQUEST from UW
Education, Financial Stability or Health
Funding needed for this program
$
PROGRAM DESCRIPTION
# OF CLIENTS in 2016
OTHER PROGRAM STATS
Unduplicated
Include important program #’s
OUTCOME achieved last year
INDICATOR
DATA & COLLECTION METHODS
What did the program participants achieve?
How do we know outcome was achieved?
How is data collected?
GOALS for next year
EST # OF CLIENTS in 2017
EST # OF CLIENTS in 2018
What will you hope to achieve?
Unduplicated
Unduplicated
PROGRAM NAME
UW FUNDING PRIORITY
FUNDING REQUEST from UW
Education, Financial Stability or Health
Funding needed for this program
$
PROGRAM DESCRIPTION
# OF CLIENTS in 2016
OTHER PROGRAM STATS
Unduplicated
Include important program #’s
OUTCOME achieved last year
INDICATOR
DATA & COLLECTION METHODS
What did the program participants achieve?
How do we know outcome was achieved?
How is data collected?
GOALS for next year
EST # OF CLIENTS in 2017
EST # OF CLIENTS in 2018
What will you hope to achieve?
Unduplicated
Unduplicated
PROGRAM NAME
UW FUNDING PRIORITY
FUNDING REQUEST from UW
Education, Financial Stability or Health
Funding needed for this program
$
PROGRAM DESCRIPTION
# OF CLIENTS in 2016
OTHER PROGRAM STATS
Unduplicated
Include important program #’s
OUTCOME achieved last year
INDICATOR
DATA & COLLECTION METHODS
What did the program participants achieve?
How do we know outcome was achieved?
How is data collected?
GOALS for next year
EST # OF CLIENTS in 2017
EST # OF CLIENTS in 2018
What will you hope to achieve?
Unduplicated
Unduplicated
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PROGRAM NAME
UW FUNDING PRIORITY
FUNDING REQUEST from UW
Education, Financial Stability or Health
Funding needed for this program
$
PROGRAM DESCRIPTION
# OF CLIENTS in 2016
OTHER PROGRAM STATS
Unduplicated
Include important program #’s
OUTCOME achieved last year
INDICATOR
DATA & COLLECTION METHODS
What did the program participants achieve?
How do we know outcome was achieved?
How is data collected?
GOALS for next year
EST # OF CLIENTS in 2017
EST # OF CLIENTS in 2018
What will you hope to achieve?
Unduplicated
Unduplicated
PROGRAM NAME
UW FUNDING PRIORITY
FUNDING REQUEST from UW
Education, Financial Stability or Health
Funding needed for this program
$
PROGRAM DESCRIPTION
# OF CLIENTS in 2016
OTHER PROGRAM STATS
Unduplicated
Include important program #’s
OUTCOME achieved last year
INDICATOR
DATA & COLLECTION METHODS
What did the program participants achieve?
How do we know outcome was achieved?
How is data collected?
GOALS for next year
EST # OF CLIENTS in 2017
EST # OF CLIENTS in 2018
What will you hope to achieve?
Unduplicated
Unduplicated
PROGRAM NAME
UW FUNDING PRIORITY
FUNDING REQUEST from UW
Education, Financial Stability or Health
Funding needed for this program
$
PROGRAM DESCRIPTION
# OF CLIENTS in 2016
OTHER PROGRAM STATS
Unduplicated
Include important program #’s
OUTCOME achieved last year
INDICATOR
DATA & COLLECTION METHODS
What did the program participants achieve?
How do we know outcome was achieved?
How is data collected?
GOALS for next year
EST # OF CLIENTS in 2017
EST # OF CLIENTS in 2018
What will you hope to achieve?
Unduplicated
Unduplicated
19. Do you measure overall client satisfaction, and if so, how and how often?
20. Provide a program success story based on one of the above OUTCOMES.
21. (a) Describe any program fees or dues associated with services provided.
(b) How are those rates determined?
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22. Client Demographics. Please indicate total number of UNDUPLICATED people served by your organization in 2016. Please
note, this application requires that you provide unduplicated client numbers. If not currently being counted, it is suggested
that collection methods be developed and implemented for the next fiscal year.
COUNTY, STATE
# OF
CLIENTS
%
AGE
# OF
CLIENTS
%
Youth, under 18
Adults, 18 +
ANNUAL HOUSEHOLD INCOME
Indicate guidelines used
# OF
CLIENTS
%
23. Describe why your organization and programming provided is necessary within our community? Please note, this
application requires that you provide existing agency data, waiting lists, current US Census data, or any other
dependable research and include citations.
24. Date of last Strategic Plan or Goal Session.
Please include most recent copy.
25. (a) Describe history of and current collaboration in the community with organizations or programs that offer similar
services or have a stake in the outcomes for your clients.
(b) Describe how the collaboration improves community systems, reduces duplication and fosters accurate data
collection.
PARTNER AGENCY EXPECTATIONS
As a United Way & Volunteer Services of Greater Yankton Partner Agency, we ask that the following expectations be met.
Please initial to verify agreement.
26. Complete the MARKETING SUPPORT FORM (Attachment B)
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27. Not conduct any fundraising drive (direct solicitation) during the period of September 1 until November 1. This
time period is reserved for the United Way Community Campaign. Failure to comply with United Way policy on
fund raising may result in a reduction or loss of funding.
28. Provide quarterly financial and program reports reviewed and approved by your Board of Directors.
29. Provide advance notice of Board Meetings and other organization information to United Way Board Liaison.
Liaison information will be distributed to all partner agencies as soon as possible.
30. Partner Agencies are required to support the United Way Community Campaign and to be actively promoting their
involvement with United Way to the community-at-large. Support of United Way is defined as:
 have representation at United Way events including Campaign Kick Off and Agency Meetings;
 using the United Way logo on organization’s public relations materials, including brochures, website, annual
reports, and displaying the logo prominently in their building;
 actively promoting United Way among the organization’s own constituents, including board members and
staff;
 running a successful United Way fund raising campaign to include staff and board members;
 and as requested by United Way on behalf of the campaign:
o speaking engagements or conducting tours of your organization to donors.
CERTIFICATION OF APPROVAL
I affirm that I have reviewed this funding request form and to the best of my knowledge the information furnish is true,
correct and complete.
Name of Board President:
Signature: ____________________________________________________________________ Date:
Name of Organization Director:
Signature: ____________________________________________________________________ Date:
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