Forms

Please provide important contact information re: agency/nonprofit submitting grant:

2023 Grant Application

Name of Person Submitting Grant(Required)

First Last

Agency / Nonprofit Name

Street Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (If Different from Above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Website

Mission Statement

Primary Contact’s Full Name

First Last

Primary Contact’s Title

Primary Contact’s Phone Number

Primary Contact’s Email Address

Program Name

Amount Requested(Required)

Identify community impact area(s) this program addresses:

Provide Program Background: Year started, accomplishments

Who is the target audience / population?

List other current funding sources and additional revenue sources for this program:

Explain specifically how United Way funding will be used (include whether the funding will help add new services or supplement funding to maintain current service levels):

Current Annual Budget

Number of individuals not served in Dickinson County due to limited resources

Desired Outcomes

Indicators of Success

List positive outcomes already established as a result of this program:

List any influencing factors affecting the outcome results:

*** Please complete and PRINT the below information: Drop off or mail to FIRST BANK

FIRST BANK Attn: Debbie Crandall

500 South Stephenson Avenue Iron Mountain, MI 49801

Program Budget
Balance Sheet From Last Fiscal Year
Profit & Loss Report From Last Fiscal Year
Most Recent 990
Current 501c3 Tax Exempt Certificate/Letter
Board Of Director’s List
Staff List
Program Testimonials
Program Photo

What additional information would you like United Way to know about your program?

Also Drop Off OR Mail the Following Signature Forms

PLEASE PRINT THE SIGNATURE FORMS BELOW. THEY MUST BE MAILED OR DROPPED OFF AT FIRST BANK – 500 S. Stephenson Avenue Location ONLY

NON-DISCRIMINATION FORM
ANTI-TERRORISM COMPLIANCE MEASURERS
SECC AFFIRMATION OF NON-DISCRIMINATION FORM

DOWNLOAD FORMS HERE