New Agency Interest Form | United Way of Lincoln County

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Thank you for your interest in becoming a funded United Way of Lincoln County (UWLC) Partner Agency.

To qualify to become a UWLC funded agency, new prospective agencies must have a completed New Agency Interest Form submitted and on file by the first Friday in March to be considered for funding during their next eligible grant cycle year.

Agency Approval Process:

Complete the online interest form and meet the requirements according to policy 403. (Please note: Any exceptions to policy 403 must be approved by the UWLC Board of Directors.)
Allocation committee will reach out to interview prospective partner agency to address any concerns and get further details.
Allocation committee votes and sends to the board for final approval.

Date of Application:

Name of Agency:

Agency Executive Director:

Executive Director Phone:

Ext:

Executive Director Email:

Agency Chairman or President Name:

Agency Chairman or President Email:

Agency Mailing Address:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Agency Phone Number:

Ext:

Agency Fax Number:

Agency Website:

Facebook URL:

What is your agency’s fiscal year? (ex: January to December, June to July, etc.)

Agency Mission Statement:

Name of Person completing New Agency Interest Form:

Email of Person completing New Agency Interest Form:

Eligible Services

The Agency must offer programs directed toward addressing Health, Education, and Income needs to the residents of the UWLC service area in a meaningful fashion. Generally, an organization would not be considered that is organized primarily for religious or political purposes. These categories are defined as follows:

Religious: support to propagate the faith of any particular religion or sect. This does not include non-denominational services available to the public such as food banks. Such an organization must clearly distinguish, in budget and program, a demarcation between its human/social services and religious services.

Political: substantial lobbying, non-human service related advocacy and/or partisan political activity so as to be eligible for tax exempt status.

If the below standards are not in place, agency must explain how the standard(s) is/are going to be met prior to becoming a funded partner agency or why the standard does not apply.

The Allocations Committee will review the New Agency Interest Form for how the standard(s) are or are not being met, how the standard(s) that are currently not being met will be met prior to your agency becoming a funded parter agency, or why the standard(s) does not apply.

The Allocations Committee will review your agency's submitted New Agency Interest Form and report their findings to the full board to be considered for funding in 2023/2024.

Documentation and Oragnization Standards

The Agency has a solicitation license.

Yes

Upload: Annual Solicitation license

Upload requirements

The organization is a nonprofit with tax exempt status.

Yes

Upload: letter from IRS or 501 (C)(3) documentation

Upload requirements

Most recent year-end financial statements (audited statements). The Agency with an annual budget of $500,000 or more has an independent audit; agencies with an annual budget of $250,000-$499,000 has a review completed by a certified public accountant; in the case of agencies with budgets of $100,000-$249,000, a compilation conducted annually by a certified public accountant, or agencies with an annual budget of $0 - $100,000 internal financial statements.

Yes

Upload: audited statements

Upload requirements

Upload: 990 IRS tax form - balance sheet, cash flow, etc.

Upload requirements

The Agency conforms to the Sarbanes/Oxley Act.

Yes

The Agency is governed by a board that meets at least four times a year, operates with a quorum and records minutes of all meetings.

Yes

Upload: board of directors list and list of attendance at meetings (50% or more)

Upload requirements

The agency has an affirmative action policy on cultural diversity for its staff, governing body and services. The staff is sufficiently qualified by training and experience.

Yes

The agency has written personnel policies approved by the board and available to the entire staff.

Yes

The organization has a Code of Ethics.

Yes

The organization has a non-discriminatory policy/statement.

Yes

The organization agrees to the following Anti-Terrorism compliance: I hereby certify that all United Way funds and donations will be used in compliance with all applicable antiterrorist financing and asset control laws, statutes, and executive orders.

Yes

Agency and/or staff require accreditation or licensing to provide service.

Yes

Not Applicable

The Agency has insurance coverage commensurate with the risks associated with its programs (property, general liability, professional liability, fidelity bond, directors’ and officers’ liability, vehicle, etc.).

Yes

If any agency standard(s) are not met or are not applicable, please explain below how the standard(s) are going to be met prior to your agency becoming a funded partner agency or why the standard(s) are not applicable.

Proposed Program/Service Information

UWLC Focus Areas:

Education
Health
Financial Stability

How does your agency plan to use UWLC funding as it relates to the funding focus areas above?

By checking this box, I acknowledge that our Agency Executive Director and Agency Board Chair/President is in agreement with all information submitted on this New Agency Interest Form.

Your signature below is verification that your Agency has all of the above required standards in place, can be produced if requested or needed by the UWLC, and if standard(s) is/are not in place, plan(s) to meet standard(s) is/are documented or if standard(s) does/do not apply is/are documented.

Name of Person authorized to submit the 2022-2023 New Agency Interest Form:

Signature of Person authorized to submit the 2022-2023 New Agency Interest Form: