United Way of the Quad Cities AreaFY21 Community Impact Plan Application

1. Pre-application Questions (Yes/No)

* 1. Are you either a 501(c)(3) nonprofit organization or a 170(a) public institution

2. Will your organization have been incorporated and actively conducting business for at least two years by December 13th, 2019?

3. Can you maintain in your organization's budget and programming a demarcation between religious activities and non-religious activities so that United Way is not funding religious programming?

4. Is your organization managed under the supervision of a voluntary board of trustees or other administrative committee that determines the policy and meets at least four times a year?

5. Will United Way funds be used only to serve residents of Scott County, Iowa, and Rock Island County, Illinois?

6. Does your organization maintain accounting records which are either:(a) in conformity with the current Standards of Accounting and Financial Reporting for Voluntary Health and Welfare Organizations (for nonprofits), or (b) in conformity with standards set by either the Government Finance Officers Association (GFOA) or Government Accounting Standards Board (GASB) (for 170(b) entities)?

7. Does your organization meet one of the following two requirements?(a) Agencies with annual budgets up to $249,999: Does your organization

prepare an annual financial review conducted by a CPA? or(b) Agencies with annual budgets $250,000 or higher: Does your organization

prepare a CPA-prepared independent annual audit?

8. Answer “YES” to the following question if any of the following conditions is true of your organization. Otherwise, answer “NO”:

(a) Your organization has gross receipts between $50,000 to $199,999 and files a Form 990-EZ.

(b) Your organization has gross receipts more than $200,000 and files a full Form 990.

(c) You are a 170(b) organization and are not required to file a 990 tax form.

2. Agency Profile

* Applicant Organization:

* FEIN:

MAILING ADDRESS

* Street

* City

* State

* Phone Number:

EXECUTIVE DIRECTOR/PRESIDENT/CEO INFORMATION

* Name of Executive Director/President/CEO:

* Email Address:

* Phone Number:

* Name of Board Chair/President:

PRIMARY CONTACT INFORMATION

* Name of Primary Contact Person:

* Primary Contact Phone Number:

* Primary Contact Email Address:

* Year Organization was Established/Incorporated:

* Mission Statement of Organization:

* Please provide an overview of your organization and its work. (300 words max)

FISCAL INFORMATION

* What is the annual budget of your organization?* In what month does your fiscal year begin?* In what month do you normally complete your annual audit/review?* In what month do you normally file your 990?

* Would you like to share any additional information about your agency that helps to strengthen your request (for example: management practices, volunteer management, diversification of funds, governance, leverage of funds, etc.)? (300 words max)

3. Strategy ApplicationApplicants complete to following section for each Strategy they apply under.

SELECT YOUR STRATEGY

* A. What amount in funding are you requesting from United Way for your work in this Strategy (FY21 numbers only)?

* B. What is the total budget for this your work in this Strategy (FY21 numbers only)?

* C. What services will your organization and/or partnership provide and how will these services produce results in the Strategy for which you’re applying? How do you propose to spend the requested United Way of the Quad Cities funds to implement these services? (500 words max)

* D. What evidence-based or best-practice models are your services based on? (200 words max)

* E. Which population/community/race/ethnic group(s) does this funding request benefit? Does your agency impact different racial or ethnic groups in different ways? How does your agency work to reduce or eliminate disparities between different racial and ethnic groups? (200 words max)

* F. Which other organizations do you collaborate with in support of the work you’re applying for funding for? Please describe the nature of the collaboration (i.e.: formal vs. informal) and list the specific contributions of each partner to your strategy. In what ways do the contributions of these partners expand the depth and/or breadth of the impact of these services? (200 words max)

* G. United Way of the Quad Cities has established seven BOLD GOALS (link) to measure our impact in the community. Which of these BOLD GOALS does your

strategy directly address? Explain how your work in this strategy will help the community achieve each goal you have selected. (200 words max)

* H. How will you adjust your plans if your request is not fully funded? (200 words max)

Applicants complete to following section for each Performance Measure they select under each Strategy.

SELECT YOUR PERFORMANCE MEASURE(S)

For each program measure chosen, the applicant will have to answer the following questions:

* 1. NUMBER SERVED: How many individuals will United Way’s investment allow you to serve in your proposed strategy (FY21 numbers only)?

* 2A. OUTCOME POPULATION: Of the total number served (your response to Question 1, above), with how many of these individuals will you attempt to achieve the Performance Measure (FY21 numbers only)?

NOTE: In many, but not in all cases, your answers to Question 1 and Question 2A will be the same, but there are exceptions. For example, a high school completion program may serve 100 high school students, but only the 25 seniors in the program would be eligible to graduate in FY21.)

* 2B. TARGET: How many (what number) of the individuals you indicated in Question 2A do you propose will succeed in achieving the Performance Measure (FY21 numbers only)?

* 2C. TARGET: What percent of the individuals you indicated in Question 2A do you propose will succeed in achieving the Performance Measure (FY21 numbers only)?

NOTE: This number will be your answer to 2B divided by your answer to 2A.

NOTE: Question 2 is worded differently for each individual Performance Measure. Be sure to check the version of Question 2 for each Performance Measure you select.

* 3. What tool will you use to measure this impact? How will you implement it? In what way does it determine that the impact has been achieved? (300 words max)

* 4. Please provide us with past data (your own or that of the program you are modeling your work on) that demonstrates the possible impact of your strategy. (300 words max)

* 5. Describe how your organization uses outcomes data to evaluate the effectiveness of your services and to make adjustments to those services when necessary. (200 words max)

4. Application Attachments:* Upload 501(c)(3) determination letter {501(c)(3) organizations only}

* Upload full proposed FY18 organization budget (in the organization’s own format)

* Upload most recent audit or financial review

* Upload most recent 990 (990 EZ or 990 core) form {501(c)(3) organizations only}

* Anti-Terrorism Compliance Form

* Roster of current board members with the member’s business or affiliation

Upload signed Letters of Collaboration (optional)