Organization name, mailing address and contact information:

Brief overview of organization – goals, mission, population served.

Number of paid staff _____________________    Number of Volunteers _____________

Governed by Board of Directors ________________   Paid Director ________________

Non-Profit  / Charity Status / IRS Designation __________________________________

Do you receive funding from any government agency, federal or state grants ________________

United Way Recipient ___________  Other funding sources _____________________________

Please attach a description of specific project or program for which funding is being requested:  Include the purpose and goals for this project. Specific population this program will serve.  Describe how you will evaluate this program. 

Total cost of program _____________   Funding requested from the WSW _________

Please attach any pertinent organization information including financial, audit, or annual reports.

Application Reviewed by WSW BOD Date __________________________

Approved / Amount _____________________     Date ________________

Check Number ___________________________  Date ________________

Project Start Date ______________________   Date Completed _______________

Comments __________________________________________________________

___________________________________________________________________

Tabled / Date _______________          Not Approved / Date _________________