<p> United Way of Mahaska County Community Investment Grant Application 2016 </p><p>Agency ______</p><p>Program Name ______</p><p>Amount Requested______</p><p>Program Classification: (Check One) </p><p> Education</p><p> Income/Financial Stability</p><p> Health</p><p>Mailing Address______</p><p>City, State, Zip ______</p><p>Contact Name ______</p><p>Contact E-Mail ______</p><p>Contact Telephone______</p><p>FEIN #______</p><p>Agency Website URL: http: //www.______</p><p>Brief Description of the program requesting funding______</p><p>______</p><p>______Agency Director Signature President of the Agency Board Signature All forms are due no later than Noon on Monday, January 11th, 2016. Late submissions will not be accepted. (p. 1) ______Date Date</p><p>All forms are due no later than Noon on Monday, January 11th, 2016. Late submissions will not be accepted. (p. 2) AGENCY DEMOGRAPHICS</p><p>If you are part of a regional service provision organization, the information requested should represent your LOCAL office services.</p><p>1. What is your agency’s mission?</p><p>2. Is the Director’s performance evaluated annually? If not, why? ___ Yes ___ No, every: ______</p><p>3. Do you have an annual audit? If no audit, why? ___ Yes ___ No, we are audited every: ______</p><p>Is your audit internal or external? ______If only internal, who performs the audit? Please attach one copy of your most recent audit, unless provided to UWMC staff at an earlier date. Please indicate the approximate date received by UWMC.</p><p>4. Is your annual report filed with the Secretary of State? ___ Yes ___ No</p><p>5. Do you file a Form 990 with the IRS? ___ Yes ___ No Please attach one copy of your most recent 990.</p><p>6. Which communities does your agency serve in Mahaska County?</p><p>7. How many total clients did your agency serve in 2015? (Can be duplicated, Mahaska </p><p>County only)</p><p>8. Does your organization have a strategic plan? (If so, please attach a copy)</p><p>PROGRAM DEMOGRAPHICS</p><p>1. What is the program mission or objective? (should be different from agency’s mission)</p><p>2. Why are you requesting funding for this program?</p><p>3. Staff- Number of full-time or part-time employees running this program, names and </p><p> position title(s).</p><p>4. What is the total number of unduplicated clients this program served in the last fiscal year </p><p> in Mahaska County? What is your cost per client?</p><p>5. Describe the population to be served with this program (demographics, eligibility, etc.), and </p><p> your experiences working with this population.</p><p>All forms are due no later than Noon on Monday, January 11th, 2016. Late submissions will not be accepted. (p. 3) 6. Using local data describe the scope of the need for this program in the community.</p><p>7. Explain why your program increases the level/likelihood of optimal self-sufficiency of the </p><p> clients served, and how your program addresses a long-term solution verses a short-term </p><p> fix.</p><p>8. Please describe the methods used to evaluate the effectiveness of this program and explain </p><p> how the results demonstrate that effectiveness. (include what outcome measurement tools you </p><p> are using)</p><p>9. Do you conduct customer/client satisfaction surveys for this program? If so, please </p><p> summarize last year’s results and attach a sample survey.</p><p>10.Prospective donors want to know how their gifts to United Way affect the lives of the </p><p> individuals your agency serves. Please share one or two “success” stories that are unique </p><p> to this program to help us illustrate the impact of your services. Our donors what to know </p><p> specifically how you are changing people’s lives.</p><p>11.In one short sentence, summarize what this program does for our community. This will be </p><p> used in our brochure and other documents.</p><p>12.List specific services or items that can be provided to clients or community members </p><p> through your program at each of the following denominations. For example, for $50, we </p><p> can provide 2 hours of counseling, etc.</p><p>$25 $50 $100 $500 $1,000</p><p>MEASURING SUCCESSFUL OUTCOMES</p><p>Note: We are attempting to answer the question “How successful is your program in impacting the lives of your clients?” In order to do so, we’d like you to define what “success” means to you. If your goal is to educate, it would require some of kind of survey to show that knowledge has grown. If the goal is to feed people, “success” might mean decreasing instances of food insecurity. You set the measure of success, talk about how you are/will track success, and what goals you have regarding the rate of success. If you haven’t been tracking metrics specific to positive outcomes, please provide your plan for measuring success in the future. </p><p>1. Describe what a successful outcome looks like for a client of your program.</p><p>All forms are due no later than Noon on Monday, January 11th, 2016. Late submissions will not be accepted. (p. 4) 2. Describe how you measure those successful outcomes. If you don’t have a system in place </p><p> currently, how to you plan on measuring those outcomes in the future.</p><p>3. How effective is your program? (How many outcomes would you categorize as </p><p> successful/total number of clients served)</p><p>4. What goals do you have for the program? Please include at least one goal regarding the rate</p><p> of successful outcomes.</p><p>EFFICIENT RESOURCE MANAGEMENT/COLLABORATION</p><p>1. Describe how volunteers are currently used in the program, if applicable. For example, how </p><p> many volunteers were utilized in 2015? How many hours did they contribute? (Be specific) If</p><p> volunteers cannot be used, please describe why this is not possible.</p><p>2. List other agencies/programs in your service area that address this program need, and </p><p> explain your role in coordinating activities and collaborations with these programs or </p><p> agencies to ensure efficient delivery of services or a continuum of care? (Be specific)</p><p>3. How do you market the services of this program to other agencies and the population you </p><p> plan to serve? If you do not market the services, why?</p><p>4. If you have sought funds from other sources for this program during the past two years and</p><p> are awaiting an answer or were denied, please identify the source and amount requested. If </p><p> no other funding was sought, please write N/A. </p><p>Source 2014 2015 $ Requested Denied/unknown $ Requested Denied/unknown Example: MCCF $4,000 Denied</p><p>5. Explain the reason for continuing the program at current levels, or expanding services, </p><p> adding new locations and other proposed changes, if applicable.</p><p>6. Describe your organization’s contingency plans to sustain this program, if UWMC funding </p><p> is not given. </p><p>7. UWMC wants to see a community where we’re all working together to support the greater </p><p> good. How have you collaborated with other organizations to either enhance your own </p><p> programming or support the programming of others?</p><p>All forms are due no later than Noon on Monday, January 11th, 2016. Late submissions will not be accepted. (p. 5) PROGRAM FUNDRAISING PLAN </p><p>Name & Type of Activity Date Fundraising Anticipated Use of Proceeds</p><p>Net Income Fundraising</p><p>2015 Net Income</p><p>2016</p><p>Tota $0,000.00 $0,000.00</p><p> l</p><p>All forms are due no later than Noon on Monday, January 11th, 2016. Late submissions will not be accepted. (p. 6)</p>