Community Impact Partner Fund FY 2018- FY2020 Cover Page

Agency and Contact Information

Name of Organization:
Employer Identification Number (EIN):
Street Address:
City, State, Zip Code:
*Name of Executive Director:
Phone Number: Email:
*Name of contact person regarding this application:
Title of contact person regarding this application:	Phone Number:	Email:
*Name of data contact person:	Phone Number:	Email:

*If staffing changes occur during the grant cycle United Way must be updated of the contact changes.

Alignment with Community Impact Focus Area

Please select the one Focus Area for which this application is requesting United Way funding.

Education
Financial Stability
Health

Proposal/Strategy Name

Funding and Fiscal Information

Amount of funding being requested for the proposed strategy in FY2018:	$

List all other strategies requesting CIPF funding	Focus Area (using the list above)	Amount requested for FY2018

Agency Fiscal Year	Begins: _____/_____	Ends: _____/_____

Certification

I certify that all statements and information contained in the Request for Funding Proposal are true and complete to the best of my knowledge.

______________________________________________________________________

Signature of Executive Director	Date

______________________________________________________________________

Signature of the Chair of the Board	Date