Community Investment Grant Application Community Investment Criteria for 2023 Funding Period Loading… Taking too long? Reload document | Open in new tab Community Investment Application A checklist is provided for your use at the end of the application. All attached files should have the organization name in the file name with title of document! Examples: RCHELPSPEOPLE Inc FY 2015 990, RCHELPS Inc Strategic Plan. A shortened organization title is acceptable and/or recognizable acronym such as MECAA or SCHAS. An organization will NOT be considered for funding if they do not: Meet the qualifications described in Process Description and Rating Criteria document, OR Submit a full, completed application package by 5:00 p.m. on December 5th.If an organization is unable to submit a requested document(s); the organization should provide an explanation as to why it is unable to submit the document(s) in the “Additional Comments” located at the end of the application section. Vision Statement: RCUW will be the organization the community turns to when seeking lasting community change. We will be recognized as a catalyst for making a significant and measurable difference in our community. We will mobilize and enable partner agencies to achieve our mission and will be nationally recognized as a leading rural United Way in the area of community outreach. Mission Statement: RCUW mobilizes the caring power of our community • To create long-lasting change that improves people’s lives, and • To provide for the basic human needs of those needing assistance. Health, Education, Financial Stability – Roane County United Way’s (RCUW) goal is to help more members of our community achieve: healthier lifestyles; enhanced levels of education and job qualification; and financial stability. All applications must relate to one of these areas.Application Deadline: December 5th, by 5:00 pmCommunity Investment funds are provided for delivery of a single service, NOT a program. Please note Section 1 – 6 contains required information. Any item marked with * is a required field and must be completed for submission.Section 1 – Contact Information:Organization Name: (Must Match IRS Form 990)* Organization Name Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Website IRS Tax ID Number*(Format XX-XXXXXXX)Year Organization FoundedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Contact Name First Last Contact PhoneDoes your organization use another organization for fiscal managment or administration? If yes, please provide the contact information.* No Yes Contact Name First Last Contact PhonePlease indicate where grant awards should be mailed:* Organization listed above Other (List Fiscal Agent Name and Adress) Fiscal Agent Name and Address Name Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the Organization an audited federal and/or state government entity?* No Yes Section 2 -Amount Requested and Certification – Recommend creating a PDF of the completed application with signatures. The completed application as a PDF and a separate PDF of the signature page only is acceptable.Please read the instructions belowService Title(s):Total Award Amount Requesting for all services:Compliance Agreement*1. In compliance with the USA PATRIOT ACT and other counterterrorism laws, we certify that all RCUW funds will be used in compliance with all applicable anti-terrorist financing and asset control laws, statutes, and executive orders. 2. We certify that an active and responsible governing body directs the organization named in this application whose members have no material conflict of interest and who all serve without compensation; that publicity and promotional activities are based on actual programs and operations; and that the organization is chartered or incorporated under the State of TN. We certify that the information provided for this application is true and accurate and either has been or will be shared with the entire Board: SelectAgreeDisagreeOrganization Executive Signature Organization Executive Signature Printed Name Date Organization Board Chair Signature Organization Board Chair Signature Printed Name Date Section 3 – Financial Stewardship and Managerial (Governance) Stewardship*See instructions for requirements on submitting financial documentation with application – All questions are required to be completedDescribe your process for fraud prevention* Describe your board of directors' involvement in your organization governance, budgeting, planning and fundraising.*(Include how often the Board meets) How often and who reviews the organization financial information and assets?* Does the organization have bylaws and/or other documents describing operations* No Yes If yes, provide a brief description of the general areas covered within the document describing operations. Provide insight into changes that are affecting your organization. Describe changes or what is occurring that affects your organization’s financial security or insecurity.* Strategic Plan*Does your organization have a strategic plan? Yes No If so, provide the date of the most recent update/revision Strategic Plan – Required for total fund request of $5,000 or above for the organization. If requesting less than $5,000, you may attach either: your strategic plan (dated) or include a document (one page maximum, dated) describing the organization's strategic direction."What is your organization's mission?* Citizenship/PartnershipIs your organization's information up to date on the RCUW Volunteer Clearinghouse?* Yes No Does a representative from your organization attend the RCUW hosted Interagency meetings periodically?* Yes No Please describe how your organization has engaged in partnerships or initiatives with other organizations to target underlying issues and changing conditions in the community to benefit a specific community population. Planned FundraisersPlease list your fund raisers planned for a 12 month period. Please provide any additional comments you would like to share regarding financial and managerial stewardship. Section 4 – Outcomes AchievedProvide a brief description of each service for which you are requesting funds, and state the focus area (health, education or financial stability) into which the service best fits, but only choose the one with the most significance. Also, describe performance measures used and the outcomes achieved for a 12-month period of the service delivery including a description of the service recipients, cost to deliver, number of recipients, etc. Describe impact of the service delivery and how you know if the delivered service had the desired impact. Provide results communicated to donors and to your board of directors. If you received funding from RCUW in the recently completed 12-month period, provide the outcome results based on your description used on your application.Service 1:Did you receive funding from RCUW for the recently completed 12-month period (April 1 through March 31) Yes No Service Title:Description of service: Focus Area:*Please Select OneHealthEducationFinancial StabilityDemographics of those served:Were there eligibility requirements? Yes No If yes, describe the requirements: Was a service fee charged? Yes No If yes, explain fee structure:Provide a brief description of the performance measures used and the outcomes achieved for a 12-month period of the service delivery including a description of the service recipients, cost to deliver, number of recipients, etc. Describe impact of the service delivery and how you know if the delivered service had the desired impact. Provide results communicated to donors and to your board of directors. If you received funding from RCUW in the recently completed 12-month period, provide the outcome results based on your description used on your previous application. Service 2:Did you receive funding from RCUW for the recently completed 12-month period (April 1 through March 31) Yes No Service Title:Description of service: Focus Area:*Please Select OneHealthEducationFinancial StabilityDemographics of those served:Were there eligibility requirements? Yes No If yes, describe the requirements: Was a service fee charged? Yes No If yes, explain fee structure:Provide a brief description of the performance measures used and the outcomes achieved for a 12-month period of the service delivery including a description of the service recipients, cost to deliver, number of recipients, etc. Describe impact of the service delivery and how you know if the delivered service had the desired impact. Provide results communicated to donors and to your board of directors. If you received funding from RCUW in the recently completed 12-month period, provide the outcome results based on your description used on your previous application. Service 3:Did you receive funding from RCUW for the recently completed 12-month period (April 1 through March 31) Yes No Service Title:Description of service: Focus Area:*Please Select OneHealthEducationFinancial StabilityDemographics of those served:Were there eligibility requirements? Yes No If yes, describe the requirements: Was a service fee charged? Yes No If yes, explain fee structure:Provide a brief description of the performance measures used and the outcomes achieved for a 12-month period of the service delivery including a description of the service recipients, cost to deliver, number of recipients, etc. Describe impact of the service delivery and how you know if the delivered service had the desired impact. Provide results communicated to donors and to your board of directors. If you received funding from RCUW in the recently completed 12-month period, provide the outcome results based on your description used on your previous application. Service 4:Did you receive funding from RCUW for the recently completed 12-month period (April 1 through March 31) Yes No Service Title:Description of service: Focus Area:*Please Select OneHealthEducationFinancial StabilityDemographics of those served:Were there eligibility requirements? Yes No If yes, describe the requirements: If yes, describe the requirements: Was a service fee charged? Yes No If yes, explain fee structure:Provide a brief description of the performance measures used and the outcomes achieved for a 12-month period of the service delivery including a description of the service recipients, cost to deliver, number of recipients, etc. Describe impact of the service delivery and how you know if the delivered service had the desired impact. Provide results communicated to donors and to your board of directors. If you received funding from RCUW in the recently completed 12-month period, provide the outcome results based on your description used on your previous application. Additional comments that you would like to share regarding outcomes achieved: Section 5 – Funds RequestWhen completing the information for each service for requested funds, please remember that you will be required to share your progress toward your goals (outcomes) on a semi-annual and final outcome report. Please NOTE there is a Section 6 for you to complete.1st Service Funds Request Yes No Service 1 Title:Amount Requested for this service:Service Description (Include expected service recipient demographics, who will deliver service, when and how often will the service be delivered, estimated cost to deliver the service per service recipient, and any partnerships with other organizations for delivery of service): Service Objective:How many years has the service been delivered by organization?How many years has the service been delivered in Roane County?If this service is also provided or delivered by another local organization, please describe how your organization’s service is different from the other organization.Which of the following focus areas does this service primarily support:Please Select OneHealthEducationFinancial StabilityNeed:Describe how and when the need by Roane Countians was identified, and estimate the number who need the service along with the expected impact of the delivered service.Describe how and/or what tells you if you met the need and what was the impact. Describe the results you provide your Board of Directors and donors. 2nd Service Funds Request Yes No Service 2 Title:Amount Requested for this service:Service Description (Include expected service recipient demographics, who will deliver service, when and how often will the service be delivered, estimated cost to deliver the service per service recipient, and any partnerships with other organizations for delivery of service): Service Objective:How many years has the service been delivered by organization?How many years has the service been delivered in Roane County?If this service is also provided or delivered by another local organization, please describe how your organization’s service is different from the other organization.Which of the following focus areas does this service primarily support:Please Select OneHealthEducationFinancial StabilityNeed:Describe how the need by Roane Countians was identified, when was it identified, estimate number who need the service, expected impact of service delivery.Describe how and/or what tells you if you met the need and what was the impact. Describe the results you provide your Board of Directors and donors. 3rd Service Funds Request Yes No Service 3 Title:Amount Requested for this service:Service Description (Include expected service recipient demographics, who will deliver service, when and how often will the service be delivered, estimated cost to deliver the service per service recipient, and any partnerships with other organizations for delivery of service): Service Objective:How many years has the service been delivered in Roane County?How many years has the service been delivered by organization?If this service is also provided or delivered by another local organization, please describe how your organization’s service is different from the other organization.Which of the following focus areas does this service primarily support:*Please Select OneHealthEducationFinancial StabilityNeed:Describe how and when the need by Roane Countians was identified, and estimate the number who need the service along with the expected impact of the delivered service.Describe how and/or what tells you if you met the need and what was the impact. Describe the results you provide your Board of Directors and donors. 4th Service Funds Request Yes No Service 4 Title:Amount Requested for this service:Service Description (Include expected service recipient demographics, who will deliver service, when and how often will the service be delivered, estimated cost to deliver the service per service recipient, and any partnerships with other organizations for delivery of service): Service Objective:How many years has the service been delivered in Roane County?How many years has the service been delivered by organization?If this service is also provided or delivered by another local organization, please describe how your organization’s service is different from the other organization.Which of the following focus areas does this service primarily support?:Please Select OneHealthEducationFinancial StabilityNeed:Describe how and when the need by Roane Countians was identified, and estimate the number who need the service along with the expected impact of the delivered service. Describe how and/or what tells you if you met the need and what was the impact. Describe the results you provide your Board of Directors and donors. Please provide any additional comments you would like to share regarding the funds request. Section 6 – Past SuccessProvide 1 Success Story:This will be a narrative description of service recipient’s success. The story should be about an actual person, not a program composite. This information helps reviewers to understand the service (and any additional, related services) provided which affects the outcome and/or impact to the service recipient. Protect client confidentially by changing names and details as these stories may be shared with the community in fundraising efforts for RCUW. RCUW may use this success story in promotional materials. Please list any additional comments related to your application that you feel are important for the Community Investment Committee in the area below: Submitting your application: Strategic Plan – REQUIRED for total fund request of $5,000 or above for the organization. Fund request for less than $5,000 – Submit Strategic Plan OR short statement (one page maximum) about the strategic direction of your organization. Contact: RCUW Community Impact Coordinator: Corinne Shaw via email cshaw@unitedwayroane.org or by phone 865-882-7711*Submit the Community Investment Grant application using the “submit” button provided below. Then upload the requested documents using the process provided below. The following is a “completion” checklist for your use to assure the requested documents have been uploaded. A note to let the Coordinator know your application has been submitted via Website Current IRS Determination Letter as a non-profit (501C Status) Current registration or exemption letter from the State of Tennessee, Division of Charitable Solicitations Most recent Audit 3 years of 990’s (if gross receipts >$50,000) and annual budgets (include comments on significant items) 3 years of financial information – Audited Profit & Loss Statement, Balance Sheet and Cash Flow Statement, Annual Budgets (Please make comments on significant items) List of Board of Directors Board Meeting Minutes (3 most recently held meetings) * Requested documents have been named per example above and uploaded. Community Investment Submission Agency Name*Contact Name*Contact E-mail Address* Brief description of agency:* Upload Documents* Drop files here or All attached files should have the organization name in the file name with title of document! Examples: RCHELPSPEOPLEINNEED FY2016 990 RCHELPSPEOPLE Strategic Plan (A shortened organization title is acceptable and/or recognizable acronym such as MECAA or SCHAS)
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