Agency Allocation Request

Agency Name(Required)

Address(Required)

Street Address City State ZIP Code

Agency Contact Name(Required)

First Last

Agency EIN(Required)

Agency Phone(Required)

Program Information

Program Name(Required)

Program Mission(Required)

Program Target Population(Required)

Date This Program Started(Required)

Requested Amount of Funding for Program(Required)

Percent of Budget Used for Program Operations(Required)

Program Logic / Community Needs

Community Needs(Required)

Please identify no more than five community needs at which this program is directed. Identify the number of people in Miami County who could potentially benefit from this program.

Community Impact(Required)

To what longer-term benefit (impact) in the community does this program contribute?

Evidence it Works(Required)

Provide evidence that the program is based on sound underlying principles. Is this program an evidence-based/promising practices/innovative model?

Capacity(Required)

What is the capacity of this program? (number that can be served, units that can be provided, etc.) What capacity was achieved this past year?

Is there a waiting list for this program?(Required)

Yes

No

Other

Waiting List

Please identify the number of people in Miami County waiting for service. How long are these individuals on the waiting list? How are the needs of these individuals being met?

Past Year Outcomes

Please complete the fields below for this past funding year.

What are the Outcomes (intended benefits) of this program?(Required)

What is the Target Population(Required)

What is the Geographic Target Area?(Required)

Describe the program inputs.(Required)

What are the outcome indicators for this program?(Required)

What is the outcome target(s)?(Required)

What is the time frame for outcome measurement?(Required)

What were the Actual Outcome Results from this past year?(Required)

Comparing these results with the established indicators and targets. Were results on target? If not, why not?

Current Year Anticipated Outcomes

Do you anticipate any outcome changes from last year?(Required)

Yes

No

Anticipated Outcomes

List any SIGNIFICANT changes from last year in the following categories: • Outcomes (Intended Benefits) • Target Population • Geographic Area • Program Inputs • Program Activities • Outcome Indicators • Outcome Target (s) • Time Frame

Outcome Measurement

For your outcome measurement plan, please provide the following:

Name and Description of instrument used to measure the outcome indicator(s).(Required)

Outcome Measurement Documentation(Required)

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Please upload a copy, and include validation data or reference to validation data.

Number of clients who comprise the measurement sample(Required)

How are clients in the measurement sample selected?(Required)

What is your process for tracking and reporting outcome data?(Required)

Program Improvement

Program Improvement(Required)

Please describe your program improvement system and program improvement plans (if warranted), particularly if the program did not meet or exceed its outcome targets.

Coordination and Accessibility

Cooperation(Required)

How does this program cooperate and coordinate with other programs in the delivery of services?

Partners(Required)

Please identify your collaborative partners, the role of each partner and how they benefit the program.

Accessibility(Required)

How do you insure that your program is accessible for your clients, focusing on issues such as: times available, customer service and location?

Calculation of Administrative Costs and Program Operations Percentage (xlsx)

The percentage is computed from IRS Form 990 submitted with this application. Add amount shown in Part IX, (Statement of Functional Expenses), Line 25, Column C (Management and General Expenses) to amount in Line 25, Column D (Fundraising Expenses), and divide the sum by Part VIII (Statement of Revenue), Line 12, Column A (Total Revenue). All percentages must be listed to the tenth of a percent (e.g. 15.7%).

Line 25C (pg 10) (management and general)(Required)

Line 25D (pg. 10) (fundraising)(Required)

ACPOP Total

Line 12A (pg. 9) (total revenue)(Required)

Percentage of Operations

2025-2026 Agency Total Budget (xlsx)

In the following fields, please enter last year's actual Revenue. Once this task is completed, we will provide your calculated totals.

A. Contributions/Special Events/Membership Dues

B. Fees and Grants from Government Agencies

C. Grants from Area Foundations

D. Program Service Fees/Sales

E. United Way of Miami County Allocation

F. United Way Special Grants

G. All Other Income Sources

Total Support/Revenue from Prior Year

In the following fields, please enter last year's actual Expense. Once this task is completed, we will provide your calculated totals.

I. Salaries and Benefits

J. Administration and Overhead

K. Specific Program Costs

L. Membership Dues or Support to National

M. Other

Total Expenses from Prior Year

Surplus/Deficit in Prior Year

Year End Balance - Restricted Funds PY

Prior year restricted funds

Year End Balance - Unrestricted Funds PY

In the following fields, please enter this current years actual Revenue. Once this task is completed, we will provide your calculated totals.

A. Contributions/Special Events/Membership Dues

B. Fees and Grants from Government Agencies

C. Grants from Area Foundations

D. Program Service Fees/Sales

E. United Way of Miami County Allocation

F. United Way Special Grants

G. All Other Income Sources

Total Support/Revenue from Current Year

In the following fields, please enter the current year actual Expense. Once this task is completed, we will provide your calculated totals.

I. Salaries and Benefits

J. Administration and Overhead

K. Specific Program Costs

L. Membership Dues or Support to National

M. Other

Total Expenses - Current Year

Surplus/Deficit in Current Year

Year End Balance - Restricted Funds CY

Current year restricted funds

Year End Balance - Unrestricted Funds CY

Current year unrestricted funds

In the following fields, please enter next year's projected Revenue. Once this task is completed, we will provide your calculated totals.

A. Contributions/Special Events/Membership Dues

B. Fees and Grants from Government Agencies

C. Grants from Area Foundations

D. Program Service Fees/Sales

E. United Way of Miami County Allocation

F. United Way Special Grants

G. All Other Income Sources

Total Support/Revenue Projected for Next Year

In the following fields, please enter next year's projected Expense. Once this task is completed, we will provide your calculated totals.

I. Salaries and Benefits

J. Administration and Overhead

K. Specific Program Costs

L. Membership Dues or Support to National

M. Other

Total Projected Expenses for Next Year

Surplus/Deficit Projected for Next Year

Year End Balance - Restricted Funds

Restricted funds for next year

Year End Balance - Unrestricted Funds

Unrestricted funds for next year

Program Questions Regarding Management of Agency Resources

Please complete this page for each program requesting United Way funding.

Problems(Required)

To what extent has the program experienced any problems with fiscal resources during the past year? If problems were incurred, what was done?

Changes in Revenue or Expense(Required)

Please identify and explain any changes of 10% or more (increase or decrease) in revenue and/or expenses from the previous year.

Comparisons(Required)

How do the current year’s and the proposed year’s cost per unit compare to local, state, and/or national average costs per units? (N/A If no data is available.)

Improvement Plans(Required)

What is the agency’s plan for generating/increasing other revenue to meet its budgetary needs for this program? What is the status of this plan?

How many volunteers are involved in the Delivery of program services?(Required)

How are these volunteers utilized (activities)?(Required)

How many volunteers provide Support for this program?(Required)

How are these volunteers utilized (activities)?(Required)

In-Kind Donations(Required)

Describe how the program utilizes in-kind donations of goods and services.

Community Impact

Community Impact(Required)

Please highlight and explain areas of your existing program that correspond to any of the United Way of Miami County’s Community Impact areas. Provide any outcome data to support your impact in this area.

Stepping Up to the Plate(Required)

Describe what this program could do to support any of the community impact areas. If applicable, identify funds needed to provide this (these) service(s).

Signatures

Board President(Required)

Executive Director / President / CEO(Required)

Number

Date