Please return this application by April 30, 2014 to the United Way of Prince Edward County, PO Box 122, Farmville, VA 23901 or to



Date: ______


Agency Name: ____________________________  Location:_______________________


Mailing Address: __________________________________________


Contact Person, Title: ______________________________________


Phone: ______________________________


Email: _______________________________________________


Alternate Contact Person: ___________________________________ 


Website: ______________________________


Please attach at least one of the following: Copy of your most recently filed Form 990; Financial Statement from an independent certified public accountant; or for organizations not required to have the above, a detailed Income and Expense Report.




  1. Type of Community Organization (Economic, Education, Housing, Health/Wellness, etc.)


  1. Who are your Constituents?  (For example, women, and youth) ___________________________________________________


  1. Mission Statement: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




  1. Significant accomplishments in last three to five years:






  1. How many members are on your Board of Directors? _____


  1. Please list the primary committees in your organization.
  1. _____________________________________
  2. _____________________________________
  3. _____________________________________
  4. _____________________________________


  1. Number of total volunteers ______ and total volunteer hours per month___________________



Prior Year Accountability Report


  1. Give a brief description of agency's services:


  1. List summary of specific uses of UWPEC funds received in the prior year.


  1. List the total number of citizens served and the counties where they reside.

Prince Edward County ________

Buckingham County     ________


  1. Number of full-time________ and part-time paid employees___________


  1. Please talk about your clients’ learning gains and/or satisfaction with your services (you may use numbers, percentages, and quantitative data).  



  1. If you were asked to rank your top three unmet organizational needs, what would they be?         


1. __________________________________________

2. __________________________________________

3. __________________________________________


  1. AMOUNT OF REQUEST:_________________________


If amount is greater than last year please explain why:


  1. If the information in number 3 above is expected to significantly change, please explain.


  1. List your total annual budget and sources of funding (Attach/include budget if possible)


  1. What are the primary sources of funding for your organization in rank order?
  1. State
  2. Local government
  3. Foundation and Corporations
  4. Individual Donors


  1. What specific changes in funding did you experience during last this six-month period?


  1. In response to the recent economic downturn, which of the following changes has your organization already made? (Check all that apply)


  1. Cut Programs        2.  Cut Spending,         3. Reduced staffing      4. Other______


  1. Thinking of 2014-2015, how do you expect your organization to complete the year financially if you do not receive the requested funds from United Way of Prince Edward County?


  1. List any other information you feel the Board may need:



*Thank you for taking the time to fill out this application.  All information is confidential and will be stored in a secure location.


Please return this application by April 30, 2014 to the United Way of Prince Edward County, PO Box 122, Farmville, VA 23901 or to