Community Impact Grant Application

United Way is committed to investing in local programs producing measurable results.

Please provide the following:

Copy of IRS determination letter indicating 501(c)(3) Non- Profit Status (required)
If you are not a 501(c)(3) and do not have an IRS determination letter please fill out this form (click here) (this can be uploaded in the required field marked for the 501(c)(3) form)
EIN number (enter at the end of application)
Counter Terrorism Compliance Act Form - fill out electronically (click here)
Current list of Officers and Board of Directors (if applicable)
Copy of most recent form 990 (Federal Tax Return, if applicable)
Program/Project budget (upload)

Questions? dawn@unitedwaydekalb.org

PART I - Agency Information

Agency's Name *

Street Address *

City *

State *

Zip Code *

Phone Number

Mailing Address (if different)

Person Completing this request *

Email Address *

Title *

CEO's First Name *

CEO's Last Name *

CEO's Title *

CEO's Email Address *

Part II - Program Information

Program Name *

Amount Requested *

Mission Statment of Agency/Organization/Geographic Area served *

Specific use for United Way funds (Detailed breakdown of budget line items) *

Part III - Outcomes Data

Community Impact (Who, How & How Many) *

Criteria used to measure outcomes/effectiveness of proposed program *

Other sources of revenue and fundraising *

EIN number *

Upload Copy of IRS determination letter indicating 501(c)(3) Non-Profit Status(required) *

Files must be less than 128 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Board of Directors listing *

Files must be less than 128 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Upload your most recent 990 *

Files must be less than 128 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Upload your Program Budget *

Files must be less than 128 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Any additional comments *

We certify that this request for funding from the United Way of DeKalb County, Inc. has been approved for submisssion by quorum of the Board of Directors of this organization, and agree to submit two required grant reports by the due date indicated. *

By typing your name above you certify that you have authorization to sign this grant application for the agency named above.

Date *

Month

Day

Year

Community Impact Grant Application

Questions? dawn@unitedwaydekalb.org

PART I - Agency Information

Part II - Program Information

Part III - Outcomes Data

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