Northern Berkshire United Way

Allocations Request Pkg for 2004-05

Agency Checklist

By Funding Source

Use this checklist to compile all documentation required for your allocation request. Should you have any questions about the allocation packet, please call the appropriate funding source for information before the deadline indicated. The Agency Checklist is for your use. Forms for all bolded items are included on the web site.

Number of Copies Required

Documentation	Page#	BUW*	NBUW	WCC
Agency Profile	2	2	2	2
Agency Cover letter	3	2	2	2
Board Information	4	2	7	2
Agency Overview	5	11	2	4
Funding Priority Request	6	11	7	4
Program Detail	7,8,9	11	7	4
Persons Served Data	10	11	7	4
Budget Form 1	11	11	7	4
Budget Form 1 Explanation	11a	11	7	4
Budget Form 2	12	11	7	4
Budget Form 3	13	11	7	4
Strategic Plan/Recent Updates		11	7	4
Financial Audit and/or Annual Rpt		4	2	2
Form 990		1	1	1

* Please supply copies per panel for Berkshire United Way

Please indicate agency name and date on every page

Deadline for submission is Friday, February 20 by 3:00 p.m.

Please deliver materials to BUW or NBUW offices.

Page 2 Agency Profile

Agency Name:

________________________________________________________________

Mailing Address: ________________________________________________________________

Contact: ________________________________________________________________

Title: ________________________________________________________________

Telephone: ________________________________________________________________

FAX: ________________________________________________________________

E-Mail: ________________________________________________________________

Other Locations - Address:

______________________________________ _______

Purpose/Activity:

________________________________________________________________

Contact Name: ________________________________________________________________

Telephone: ________________________________________________________________

What is your fiscal year?

________________________________________________________________

Allocation Forms Due: Friday, February 20 by 3:00 p.m. Incomplete or late applications may not be accepted

Page 3

Agency Cover Letter

Please use a format similar to the outline below. Do not necessarily comment program-by-program, but keep this at the overall agency level, mentioning program detail only when it is especially noteworthy. Please limit to 1 1/2 pages.

I. Introductory Remarks

II. Review of last year

Page 4

Board of Directors Summary

The enclosed budget was considered and approved for submission on ________________ at the Board of Directors meeting for this agency. (date)

We hereby certify and have included documentation with this allocation request that we are an official 501(c) 3 under the US Internal Revenue code. We also certify that our agency fulfills the requirement of the non-discrimination policy as follows below.

Name of Agency has adopted a stated policy of non-discrimination in regard to all persons, irrespective of their race, color, creed, religion, national origin, sex, sexual preference, age, disability or veteran’s status, and compliance with all requirements of law and regulations with respect to employment, volunteer participation and the provision of services.

(signed)____________________ (signed)_______________________

Chief Professional Officer Chief Volunteer Officer

(Paid Professional/Executive Director) (Board President)

# Board meetings per year; ______ # Directors:__________

% male:_______ % female: _______

Annual elections held in: ________________

Please list Board members, home address, office held and expiration of term.

You may attach your current list with this information.

Page 5

Agency Overview

1. Agency Mission Statement:

2. Strategic Plan: Are you operating under a strategic plan approved by your board or executive committee? Yes/No. If yes, please assure that the plan has been included in this or previous year’s packages and that any updates are included annually.

3. Please list below your current programs, in priority order, starting with the most important to your agency. Include all programs at your agency. The factors which may influence your comments that are important to the community; historical basis, mission statement, funding influences, and sources, and unmet needs in the community, etc.

4. Are there any significant changes, not mentioned in the cover letter, you anticipate in income from sources other than United Way or Community Chest. Please be specific.

5. What fundraising activities do you anticipate engaging in during the calendar year and what is your projected net revenue? ( This does not fulfill the requirement of notifying your funding sources of these activities.)

Page 6

Funding Priority Request

Please list in descending priority order each program for which you are requesting funding. Priority should be determined by importance of United Way and/or Community Chest funding.

AMOUNTS REQUESTED/PRIORITY

PROGRAM NAME BUW/# NBUW/# WCC/# TOTAL

___________________________________________________________________

TOTALS: ________ ________ ________ __________

BUW NBUW WCC TOTAL

Page 7

Program Detail

Please complete a set of pages 6, 7 & 8, for each program for which funding is requested. If you have several programs, number the pages 6a-9a, 6b-9b, 6c-9c, etc. .

Funds requested from: New program? YES or NO

BUW NBUW WCC

Approx. # of years program in operation First time funded? YES or NO

Program Name: _______________________________________________

1. Program Rationale: Briefly, what is the general purpose of this program?

2. How has the need for this program been determined?

3. Please provide a brief description of this program and the location and specific activities provided. Include target population (age, sex, income, geographic region etc.) hours of program’s operation (not agency hours).

Page 8

Program Detail, continued….

4. A . What other programs in your community are there that address this need and target population?

B . Does this program collaborate significantly with these or with other groups? If so, please describe.

5. List last year’s specific goals and objectives for this program and indicate your progress in achieving them.

6. A . List this year’s goals and your performance targets/outcomes with appropriate measures.

B . Indicate changes you will make. If you plan resource additions or reductions, please indicate what these would be and the increase/decrease this will cause in program performance. Please use outline/bullet format where possible.

Page 9

Program Detail continued

7. Program measures:

Primary Unit of Service (hours, meals, days, # participants etc.) _____________

# Units projected during funding year: _________________

Total # of paid program staff: _________________________

Full time: ______________Part-time ______________Consultants:______

Hours per week: _________Hours per week: _________

Total # of unpaid program staff: _________________

Volunteers: __________Interns: _________ Other: _________

8. Has this program been evaluated or accredited by outside sources during the past year. If so, please attach.

9. Does the program receive client fees? ________________________

If so, how are they determined (sliding fees etc)?

Fee range: _____________________________

Fees were last established on ____________ and will be reviewed on .

(date) (date)

10. Please list other sources of funding for this program. Please include source, amount requested and amount received.

Page 10

Count of Persons served/Units Provided for Each Program for

Most-recently Completed Year

	Based on recipients' towns-of-residence, indicate the program count by community.
	Please list up to 5 programs per sheet and total across and down.
	Indicate whether count is by # persons or # unit of services.
	For each program, indicate if the count is unduplicated (Yes) or not (No)
		Program	Program	Program	Program	Program	Total by
		Name	Name	Name	Name	Name	Town
	People/Units?
	Unduplicated?
	Community
	Adams
	Alford
	Becket
	Cheshire
	Clarksburg
	Dalton
	Egremont
	Florida
	Great Barrington
	Hancock
	Hinsdale
	Housatonic
	Lanesboro
	Lee
	Lenox
	Monterey
	Mt Washington
	New Ashford
	New Marlborough
	North Adams
	Otis
	Peru
	Pittsfield
	Richmond
	Sandisfield
	Savoy
	Sheffield
	Stamford
	Stockbridge
	Tyringham
	Washington
	West Stockbridge
	Williamstown
	Windsor
	NY State
	Vermont
	Connecticut
	Other
	Program Totals
Copy additional sheets as needed
							10

Page 11.

BUDGET FORM 1				11
If your fiscal year is NOT 7/1 to 6/30,	please indicate when it is:_________________
	ANNUAL RPT	PROPOSED BUDGET	OPERATING BUDGET	PROPOSED BUDGET
GENERAL BUDGET INCOME	LAST YEAR	CURRENT YEAR	CURRENT YEAR	NEXT YEAR
1. Allocated BUW
2. Allocated NBUW
3. Allocated WCC
4. Other United Ways
5. County & City
6. State Grants/Contracts
7. Contributions
8. Special Events
9. Membership Dues
10. Client Service Fees
11. Third Party Fees
12. Sales of Materials
13. Investment Income
14. FEMA
15. Designations - UW/Comec/CFC
16. Other - Including BUW Grants
TOTAL BUDGET INCOME	0	0	0	0

DIRECT EXPENSES
17. Salaries
18. Employee Benefits
19. Payroll Taxes
20. Professional Fees
21. Supplies
22. Telephone
23. Postage & Shipping
24. Occupancy
25. Equipment Rental & Maintenance
26. Printing & Publication
27. Travel
28. Training
29. Special Assist. Individuals
30. Membership Dues
31. Liability Insurance
32. Depreciation
33. Other -
34. Other -
35. Other -
36. Other -
37. Board Designations
38. Payments to Affliates
TOTAL DIRECT EXPENSES	0	0	0	0

SURPLUS OR (DEFICIT)	0	0	0	0

Page 11a.

Budget Form 1 Explanation

Agency Name:

Please describe any significant Income or Expense changes on Budget Form 1(p. 11).

11a

Page 12.

Budget Form 2 - Present Operating Budget (e.g. 7/1/03-6/30/04)


	Agency Name:							ALLOCATION BY PROGRAM
	Budget	Grand	Total	Supporting Srvices		Total					PROGRAM SERVICES
	for 7/1/03-6/30/04	Total	Supporting	Management	Fund Raise	Program
	Our FY =	(4+5)	(3+4)	& General	& Other	Services


	INCOME	1	2	3	4	5		6	8	9	10	11			12	13	14
1	Allocation BUW	0				0
2	Allocation NBUW	0				0
3	Allocation WCC	0				0
4	Other United Ways	0				0
5	County & City	0				0
6	State Grants / Contracts	0				0
7	Contributions	0				0
8	Special Events	0				0
9	Membership Dues	0				0
10	Client Service Fees	0				0
11	Third Party Fees	0				0
12	Sales of Materials	0				0
13	Investment Income	0				0
14	FEMA	0				0
15	Desig-UW-Comec-CFC	0				0
16	Other (inc.BUW grants)	0				0
	TOTAL INCOME	0			0	0	0	0	0	0	0	0	0	0	0
	EXPENSES
17	Salaries	0	0			0
18	Employee Benefits	0	0			0
19	Payroll Taxes	0	0			0
20	Professional Fees	0	0			0
21	Supplies	0	0			0
22	Telephone	0	0			0
23	Postage & Shipping	0	0			0
24	Occupancy	0	0			0
25	Equip. Rental & Maint.	0	0			0
26	Printing & Publication	0	0			0
27	Travel	0	0			0
28	Training	0	0			0
29	Spec. Assist. Individuals	0	0			0
30	Membership Dues	0	0			0
31	Liability Insurance	0	0			0
32	Deprec. Blds. & Equip.	0	0			0
33		0	0			0
34		0	0			0
35		0	0			0
36		0	0			0
37	Board Designations	0	0			0
38	Payments to Affiliates	0	0
	TOTAL DIRECT EXP.	0	0	0	0	0	0	0	0	0	0	0	0	0	0
						0
39	Allocation of M & G					0
40	GRAND TOTAL EXP.	0			0	0	0	0	0	0	0	0	0	0	0
41	Surplus / Deficit	0			0	0	0	0	0	0	0	0	0	0	0
42	Total # Units of Service
43	Cost per Unit

	* NOTE: Please make sure that the proposed number of units agrees with information provided on the Program Information Form. Must Calculate Cost per Unit

Page 13

Budget Form 3 - Proposed Operating Budget (e.g. 7/1/04-6/30/05)

																			Page 13
	Agency Name:							REQUESTED ALLOCATION BY PROGRAM
	Proposed			Supporting Services
	for 7/1/04-6/30/05	Grand	Total		Fund	Total					PROGRAM SERVICES
		Total	Supporting	Management	Raising	Program
	Our FY =	(4+5)	(3+4)	& General	& Other	Services

	INCOME	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18
1	Allocation BUW	0				0
2	Allocation NBUW	0				0
3	Allocation WCC	0				0
4	Other United Ways	0				0
5	County & City	0				0
6	State Grants / Contracts	0				0
7	Contributions	0				0
8	Special Events	0				0
9	Membership Dues	0				0
10	Client Service Fees	0				0
11	Third Party Fees	0				0
12	Sales of Materials	0				0
13	Investment Income	0				0
14	FEMA	0				0
15	Desig-UW-Comec-CFC	0				0
16	Other (inc.BUW grants)	0				0
	TOTAL INCOME	0			0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	EXPENSES
17	Salaries	0	0			0
18	Employee Benefits	0	0			0
19	Payroll Taxes	0	0			0
20	Professional Fees	0	0			0
21	Supplies	0	0			0
22	Telephone	0	0			0
23	Postage & Shipping	0	0			0
24	Occupancy	0	0			0
25	Equip. Rental & Maint.	0	0			0
26	Printing & Publication	0	0			0
27	Travel	0	0			0
28	Training	0	0			0
29	Spec. Assist. Individuals	0	0			0
30	Membership Dues	0	0			0
31	Liability Insurance	0	0			0
32	Deprec. Blds. & Equip.	0	0			0
33		0	0			0
34		0	0			0
35		0	0			0
36		0	0			0
37	Board Designations	0	0			0
38	Payments to Affiliates	0	0
	TOTAL DIRECT EXP.	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
						0
39	Allocation of M & G					0
40	GRAND TOTAL EXP.	0			0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
41	Surplus / Deficit	0			0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
42	Total # Prog. Units
43	Cost per # Units of Service

	* NOTE: Please make sure that the proposed number of units agrees with information provided on the Program Information Form. Must Calculate Cost per Unit

By Funding Source

Documentation

Agency Profile

Please use a format similar to the outline below. Do not necessarily comment program-by-program, but keep this at the overall agency level, mentioning program detail only when it is especially noteworthy. Please limit to 1 1/2 pages.