Community Impact Grant - Application Form | United Way of Washington County, MD

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Part 2 - Program Information
Part 3 - Required Documentation
Community Impact Grant - Application Form (Preview)
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PART I - Agency Information

Agency Information

Agency's Name

What category is the focus of your request?

Healthy Community

Youth Opportunity

Financial Security

Community Resiliency

Agency's Address

Address

City/Town

State/Province

ZIP/Postal Code

Mailing Address (if different)

Address

City/Town

State/Province

ZIP/Postal Code

Agency's Phone Number

Agency's EIN Number

Agency's Web Address

Agency's ED/CEO/President Name

Agency's Board Chair Name

Primary Contact Information

Primary Contact First Name

Primary Contact Last Name

Primary Contact E-Mail Address

Primary Contact Phone

Agency's ED/CEO/President Email

Agency's Board Chair Email

Select all areas of which your agency has demonstrated support of United Way of Washington County, MD:

Day of Caring

Campaign

Gift Wrap

Golf Shot

Other

Agency's Mission Statement

Collaborating Agency Information

Are there collaborating agencies associated with this grant? For the purposes of this application, list only the agencies that will be receiving financial support or sharing responsibilities reporting outputs and outcomes.

Yes

Name all collaborating agencies associated with this program. List each agency on a new line. Then, complete the collaborating agency information below for each one.

Collaborating Agency Information

Please provide details for each collaborating agency into the fields below, where relevant. Copy, paste, and answer each of the questions for each agency partner.

Agency Name
Contact Name (First and Last Name)
Agency Email
Agency Phone
Agency Address
Agency EIN Number
Agency ED/CEO President Name (First and Last Name)
Agency Board Chair Name
Agency Website URL
List how agency has demonstrated support of the United Way of Washington County, MD: Day of Caring, Campaign, Telethon, Golf Shot, Day of Caring, Social Media Shares, Other

Collaborating Agency 1 Information

Collaborating Agency 2 Information

Collaborating Agency 3 Information

Collaborating Agency 4 Information

Collaborating Agency 5 Information

Fundraising and Administration

The percent of fundraising and administration must be completed from the information on the IRS Form 990 by adding the amount spent on "management and general" (Part IX, Column C, Line 25) to the "amount spent on fundraising" (Part IX, Column D, Line 25) and dividing the result by "total revenue" (Part 1, line 12).
Please only enter numbers - NO $ or commas.

Management and General Total (Part IX, Column C, Line 25) $

PLUS

Amount Spent on Fundraising (Part IX, Column D, Line 25) $

DIVIDED BY

Total Revenue (Part 1, Line 12) $

Percent of Administration and fundraising nan

If percent of fundraising and administration is over 25%, please explain: