2022 Grant Application

Agency Name *

Tax ID# 501(c)3 *

Agency Address *

Phone # of Agency (For UW Brochure / Website) *

Name of Main Contact Person *

Email Address of Main Contact Person *

Total Agency Budget (for Current Fiscal Year) *

Please Provide a SHORT Narrative About Your Agency *

--------------- Grant Program Name (Program Applying for UW funds) --------------- *

Address of Program Site *

Program Description *

Please provide a description of the program for which you are requesting funding.

How Many Individuals will be Served in This Program (Numeric Only) *

Out of Total Served, How Many Individuals will be Served with the United Way Funding (Numeric Only) *

Did This Grant Program Receive UW funding last year? *

Yes

No

How Many Individuals were Served in This Program Last Year (Numeric Only) *

Total Grant Program Budget (This Would be the Total Amount Your Agency Budgets For This Program) (Numeric Only - No Dollar Sign) *

Total Grant Program Budget United Way Request (This Would be the Total Amount Your Agency is Requesting of United Way for this Program) (Numeric Only - No Dollar Sign) *Reminder: United Way of Bradford County annual agency grant program funding requests can not include grant writing fees. *

IF This is an Increase in Funding Request From Last Year, Please Provide Explanation For Need of Additional Funds

Program Impact & Priority Area: Choose ONE impact and priority area from the list below: *

------------Community Impact Program Outcomes 2020 Grant Program Results-------------
This information is collected to determine the outcomes of previous year grant dollars.

Indicate Grant Activities: (Action steps within a program that help achieve the programs goals and objectives.) Examples: sheltering homeless families, counseling for at-risk youth, or educating public on signs of child abuse

Indicate Grant Outputs: (Direct result of a program's activities.) Examples: numbers of meals provided, classes taught, brochures distributed or participants served

Indicate Grant Outcomes: (How the program changed the participants skills, knowledge, behavior, attitude or condition/value.) Examples: greater knowledge of nutritional needs, improved reading skills, effective response to conflict, getting a job, etc.

Indicate Grant Indicators & Data Source Used: (The number or percent of program participants who demonstrated the listed outcomes and the data source used for each.) Examples: 25% participants have a greater knowledge of nutritional need

------------------------ Success Story ------------------------

Include one client story from this program from the past 12 months. The United Way of Bradford County is committed to respecting individual’s privacy. This information will remain confidential unless authorized for use in marketing purposes.

Client Name

Services Provided

Can UW Use This Story for Marketing Purposes?

Yes

No

If Yes, Should UW Keep Client Anonymous?

Yes

No

The Board of Directors and staff of the applying agency have reviewed and approved this request prepared for the United Way of Bradford County. It fairly and accurately represents the needs of the program in serving the residents of the Bradford County Community. We understand this request will be considered with all requests for funding, and if funded, we agree to abide by all United Way policies.

Name of Preparer *

Phone Number of Preparer *

Email Address of Preparer *

Name of Board/Officer who can Verify / Certify this Application Information *

Phone Number of Board / Officer *

Email Address of Board / Officer *

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