2025 Agency Grant Application

Agency name:

Email address:

Physical address:

City:

State:

Zip:

Agency phone number:

Website address:

Agency primary contact/decision maker:

Primary contact phone number:

Primary contact email address:

Agency secondary contact:

Secondary contact phone number:

Secondary contact email address:

Board President:

Person preparing application:

Are you applying for funding for Project Program General Budget

Amount requested for 2025 from KAUW: $

Total 2025 budget for Agency:

How was the amount of your funding request determined?:

Signature of Agency Director/Executive Director/CEO

Date:

Signature of Board of Director President

Date:

All information is required for your agency to be considered for funding. Please complete each section of this application as it is specified below. Contact KAUW with any questions regarding completion of this form.
(All questions must have a response or application will not process. If a question does not apply, please enter NA.)

Section I: Who We Are

State the year agency was established:
State the year agency first partnered with KAUW:
Has your agency published a DEI (Diversity, Equality and Inclusion) policy statement? Yes No
How often are By-Laws reviewed?
Provide the date when your policies/by-laws were last reviewed or revised by your Board of Directors.

Section II: What We Do

What is your mission statement?
Describe the project, program, or services for which you are requesting funding. Only agencies and projects/programs that meet the mission of the KAUW will be considered.
How does this request specifically relate to the mission of the KAUW? The KAUW Mission Statement can be found at www.KAUW.orq.

Section III: Who is Served

What are the requirements to qualify for your services?
What is/are the addresses (include telephone number) in Henry and Stark Counties where services are provided?

Section IV: How is success measured?

What tracking information is used to measure success in the program?
Explain how the agency determines if your agency's goals are met.

Section V: Agency Partnership

How does your agency partner with United Way?
Does your agency display the United Way sign? Yes No (If not, this is a requirement, please request a UW window decal.)
Do your promotional materials clearly specify that your agency is in part funded by Kewanee Area United Way? Yes No
With what other community organizations does your agency collaborate?
Do agency activities utilize volunteers?

Section VI: : Funding Request and information

Source of Grant of Funding	Date Requested	Amount Received	Year(s) for which grant is applicable	Additional Information

Is KAUW funding used as part of match for other funding? Yes No

Does the agency have a reserve policy? Yes No
If yes, what is your reserve amount?
If no reserve policy exists, specify why it does not exist.
Did your previous year’s expenses exceed your available revenue? Yes No
If yes, how did your agency address the deficit?

Section VII: Agency Fundraising

List major agency fundraisers (AFA) that are scheduled for the upcoming year. (Please notify KAUW if these are scheduled during the Annual Campaign period, generally October-November. Refer to the Memorandum of Agreement for more information.)

Agency Fundraisers	Location	Date

Note: KAUW will post Fundraisers to KAUW’s website and Facebook platforms if possible.

Section VIII: Other needs/Issues

Have any increases/decreases in demand been noticed by your agency? Yes No

What is the percentage of change?
Why has the demand increased or decreased?
How is your agency addressing this change?

Section IX: Additional Data (Required)

Sections	Question 1	Answer	Question 2	Answer	Question 3	Answer	Question 4
Agency	Number of full-time employees?*		Number of part time employees?		Number of Volunteers?
Agency	Are services provided in Henry County?	Yes No	Are services provided in Stark County?*	Yes No
Who is Served?	Do all ages qualify for services?*	Yes No	If No; what ages Qualify?		Do all income levels qualify?	Yes No
	Is income a factor in providing services?* If yes, explain income qualifier in comments.	Yes No	If applicant cannot pay; are services provided free of charge?	Yes No	Percentage served that cannot pay for services?		What percentage of applicants don’t qualify for services?
	Comments:

Historical Comparative Data
Question: *(If services are not provided in Stark County use N/A)	2021	2022	2023	2024	Projected 2025
Amount Requested for the specified year?*
KAUW Grant awarded for the specified year?*					N/A
Did Expenses exceed available funds?*	Yes No	Yes No	Yes No	Yes No	N/A
Total Agency Budget for the specified year?*
Total Budget for Henry County by year?*
Total Unduplicated served in Henry County*					N/A
Total Budget for Stark County by year?*
Total Unduplicated served in Stark County*					N/A
Henry County-# denied services*					N/A
Stark County-# denied services*					N/A

ATTACHMENTS REQUIRED (DO NOT ATTACH OR SEND IF NOT REQUIRED) :

Required Yearly

Annual Budget broken down by program.
Current DEI policy.

Required every 3 years or if there has been a change in the previous 12 months:

Board of Directors and contact information.
A copy of the agency by-laws.
Copy of Tax-Exempt Documentation as a Non-profit entity if not previously included.
Annual Audit if completed in the last 12 months and performed by an independent auditing firm.

Note:- Support File extension(s) : .jpg, .png, .pdf, .docx, .xlsx

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Required Documents

The Memorandum of Agreement and Counter Terrorism Form has been made available and must be uploaded below when submitting the application. Please sign and date before uploading, a typed signature will not be accepted.

Memorandum of Agreement:

Counter Terrorism Form:

Notes

Applications not received by the due date will not be considered. All applications must be submitted online via the website. Please contact kewaneeareaunitedway@kewanee.com with any questions.
Each agency is expected to participate in the Annual Campaign as specified in the MOA.
As specified in the Memorandum of Agreement (MOA); a year-end report for the previous year is required by January 20th of each year. It should specify any variances of conditions from the application for the specified year. Do not send charts. This report should be one page unless there has been a very significant change in the agency. If the yearend report is not received by January 20th, delivery of funds may be delayed until this report is received. If applying for the first time for a grant through KAUW, this requirement is waived.

I certify on behalf of the Organization listed above that the foregoing is true.

AGENCY NAME:

ABCD (Area Board for Child Development)

Print Name:

Title:

Signature:

Date:

Verification Code

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