The United Way of Sarnia-Lambton -


			February 05, 2012

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Full Budget Submission

Service Provider Complete Funding Submission

United Way of Sarnia-Lambton Request for Funding Proposal
** Note that one complete request for funding prosal must be completed for each program.

	Organization Name:

	Name of Program:

	Address:

	Telephone:

	Business # (BN) / Charitable #:

	Organization Contact Person:

	Email Address:

	Title:

	Board Chair/President:

	Term of Office:

	Board Meetings: Frequency	Time:

	Has your Board had difficulty reaching quorum within the past year?	Yes	No
	Are Board approved Minutes available if requested?	Yes	No

NOTE: Should you have any questions, please do not hesitate to e-mail Pamela Bodkin, Community Investment & Finance Director at pam@theunitedway.on.ca

Please check the Impact area(s) the program in this application addresses:

		Supporting Youth at Risk to Achieve Positive, Personal Development
		Healthy, Safe and Independant Seniors
		Empowering and Strengthening Self Sustaining Families

	1) STATEMENT OF SPECIFIC COMMUNITY NEED

	Describe why the community should be compelled to invest in this program Describe the program you would like funded. Describe what problem/need exists in the community and who the target client population is, where do they live, including estimated numbers in need, and any information or statistics that indicates that this is a need. (Please include sources of information and statistics)



	2) PROGRAM OUTCOME GOALS

	What are the program goals in each Impact Area that you are striving to achieve? In other words, identify the intended effect of the program on the Community Impact area. What are you trying to accomplish?

	3) PROGRAM DESCRIPTION AND OUTCOMES

	Describe how this program contributes to the Community Impact area(s) identified above. Then specifically describe what it does to change the lives/or conditions of the targeted client population. This should include program resources, how clients access services, products delivered that lead to direct benefit for the client and the community.

4) PROPOSED PROGRAM OUTCOME OBJECTIVES

Objectives further define the program goals by describing the effect on the client and community that the program is trying to produce. Describe your Program Outcome Objectives. What measurable effects or competencies do you expect clients of this program to achieve during this funding cycle? (An objective is expressed as a number and/or percent of participants achieving the Outcome and must include a timeframe.) Define the specific, targeted changes that are expected in the lives of the program participants. Outcomes should identify changes in behaviour, skills, knowledge, condition or status of the client. Describe the indicators of success (criteria for measuring and assessing results), the actual results that have been achieved in the past 12 months (if available), as well as a projection for the next year. Please state three objectives for each program.

*make note that objectives may be enhanced/changed with written consent from the United Way.

YEAR ONE 2012-2013
Targeted Objective 1 for 2012-2013
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Actual results for this objective over the past 12 months (if available)
Projected results for this objective in 2013-2014

Targeted Objective 2 for 2012-2013
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Actual results for this objective over the past 12 months (if available)
Projected results for this objective in 2013-2014

Targeted Objective 3 for 2012-2013
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Actual results for this objective over the past 12 months (if available)
Projected results for this objective in 2013-2014

YEAR TWO 2013-2014
Targeted Objective 1 for 2013-2014
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Projected results for this objective in 2014-2015
Targeted Objective 2 for 2013-2014
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Projected results for this objective in 2014-2015
Targeted Objective 3 for 2013-2014
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Projected results for this objective in 2014-2015
YEAR THREE 2014-2015
Targeted Objective 1 for 2014-2015
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Targeted Objective 2 for 2014-2015
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Targeted Objective 3 for 2014-2015
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
YEAR FOUR 2015-2016
Targeted Objective 1 for 2015-2016
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Targeted Objective 2 for 2015-2016
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this
Targeted Objective 3 for 2015-2016
Defined Objective (using number and percent of clients
Describe the selected indicator of success and what tools will be used to measure this

5) PROGRAM PARTICIPATION

For United Way Funded Programs Only.

Statistics	Individual people to be served
Statistics	2012-2013	2013-2014	2014-2015	2015-2016






Totals

6) PARTNERSHIPS AND COLABORATIONS

Please describe what partners or collaborations have been developed and are being utilized (if any) with the program to be funded. In general also describe efforts that have been made to coordinate services with other organizations.

7) ROLE / IMPORTANCE OF UNITED WAY FUNDING/ Alternate Sourcecs of Funding

How important is the United Way to you and your program? What role will United Way funding play in meeting the identified need? Please describe your fiscal plan should the United Way funding not be available to you in whole or in part? State what efforts are being made to obtain other funding sources?

8) Does the Organization run a United Way workplace Campaign amoung its:

Staff	Yes	No
Board of Directors	Yes	No
Special Events	Yes	No

Current United Way Allocation (if any)	Current Total Organization Budget
$	$

Program Name		Current Level 2011-2012	Year 1 Request 2012-2013	Year 2 Request 2013-2014	Year 3 Request 2014-2015	Year 4 Request 2015-2016
1.		$	$	$	$	$

For Budget Years 2012-2016

Please list all of the programs/services that this agency provides the community and identify their funding sources.
(Please distinguish United Way Funded; Trillium Foundation; Ministry of Community, Family and Children's Services; Ministry of Health; National Child Tax Benefit etc.)

SERVICE/PROGRAM	FUNDING SOURCE

Program Budget for Years 2012-2016

Program Name:

	Proposed 2012-2013	Proposed 2013-2014	Proposed 2014-2015	Proposed 2015-2016
REVENUE
3100-Federal Government	$	$	$	$
3200-Provincial Government	$	$	$	$
3300-Municipal Government	$	$	$	$
3350-Revenue From Other United Ways	$	$	$	$
3400-Investment Income	$	$	$	$
3500-Fees From Users	$	$	$	$
3600-Special Events	$	$	$	$
3700-General Contributions	$	$	$	$
3750-Bingos/Nevada	$	$	$	$
3800-Membership Fees	$	$	$	$
3900-Other	$	$	$	$

4000-United Way Allocation	$	$	$	$
EXPENDITURES
4100-Salaries & Wages	$	$	$	$
4200-Employee Benefits	$	$	$	$
4300-Travel	$	$	$	$
4400-Training & Recruitment	$	$	$	$
4500-Building Occupancy	$	$	$	$
4600-Purchased Professional Services (Non-Client related)	$	$	$	$
4700-Program Expenses	$	$	$	$
4800-Purchased Professional Services (Case/Client related)	$	$	$	$
5000-Client Personal Assistance	$	$	$	$
5400-Promotion & Publicity	$	$	$	$
5500-Office Administration Expense	$	$	$	$
5600-Captial Acquisitions	$	$	$	$
5700-Other Miscellaneous	$	$	$	$
5750-Dues to Affiliates	$	$	$	$

Total Organization Budget for Years 2012-2016

	Proposed 2012-2013	Proposed 2013-2014	Proposed 2014-2015	Proposed 2015-2016
REVENUE
3100-Federal Government	$	$	$	$
3200-Provincial Government	$	$	$	$
3300-Municipal Government	$	$	$	$
3350-Revenue From Other United Ways	$	$	$	$
3400-Investment Income	$	$	$	$
3500-Fees From Users	$	$	$	$
3600-Special Events	$	$	$	$
3700-General Contributions	$	$	$	$
3750-Bingos/Nevada	$	$	$	$
3800-Membership Fees	$	$	$	$
3900-Other	$	$	$	$

4000-United Way Allocation	$	$	$	$
EXPENDITURES
4100-Salaries & Wages	$	$	$	$
4200-Employee Benefits	$	$	$	$
4300-Travel	$	$	$	$
4400-Training & Recruitment	$	$	$	$
4500-Building Occupancy	$	$	$	$
4600-Purchased Professional Services (Non-Client related)	$	$	$	$
4700-Program Expenses	$	$	$	$
4800-Purchased Professional Services (Case/Client related)	$	$	$	$
5000-Client Personal Assistance	$	$	$	$
5400-Promotion & Publicity	$	$	$	$
5500-Office Administration Expense	$	$	$	$
5600-Captial Acquisitions	$	$	$	$
5700-Other Miscellaneous	$	$	$	$
5750-Dues to Affiliates	$	$	$	$

For Budget Years 2012-2016

Please list variances exceeding a minimum of $1,000 or 10% related to the United Way Funded Program budget figures, between 2012 - 2016 proposed and subsequent years, with explanation.

Income:

Account No.	Variance ($ and %)	Explanation

Expenditures:

Account No.	Variance ($ and %)	Explanation

For Budget Years 2012-2016

Include in Revenue portion of Program Budget and Total Organization Budget where appropriate

A. RESTRICTED FUNDS (Funds where use has been restricted to specific purposes by donor).

Name of Restricted Fund	Purposes or Uses	Other Conditions or Restrictions	Dollar Balance
			$
			$
			$

B. DESIGNATED FUNDS (Funds where use has not been restricted by the donor but which have use limitations imposed by the Organizations Board of Directors or By-laws).

Name of Designated Fund	Purposes or Uses	Other Conditions or Restrictions	Dollar Balance
			$
			$
			$

C. CAPITAL FUNDS (Funds designated for Capital purchases that have value exceeding $500).

Capital Category	Purposes or Uses	Additions	Dollar Balance
			$
			$
			$

* Bequests, reserves created from operating funds
Suggested Capital Categories: Building, Automotive, Office Equipment and Program Equipment

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Full Budget Submission

YEAR ONE 2012-2013

YEAR TWO 2013-2014

YEAR THREE 2014-2015

YEAR FOUR 2015-2016

For Budget Years 2012-2016

Program Budget for Years 2012-2016

Total Organization Budget for Years 2012-2016

For Budget Years 2012-2016

For Budget Years 2012-2016