Agency Eligibility - February 2021

Agency Eligibility

Please respond to the questions below to determine your eligibility for our Community Impact RFP Process. In order to continue the process, all applicants must submit the required eligibility documentation below. If eligible, you will receive email confirmation and information on next steps. Please contact Julie Singley, <jsingley@berkshireunitedway.org> with any questions. Thank you.

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* 1. Agency Name

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* 2. Mailing Address (Street Name)

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* 3. City

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* 4. State

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* 5. Zip Code

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* 6. Contact Person Name

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* 7. Contact Person Title

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* 8. Contact Phone Number

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* 9. Contact Email Address

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* 10. Executive Director/CEO

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* 11. Does applicant provide services/activities that address the one of the following: Integrated/Collaborative Approaches, Early Childhood Development, Positive Youth Development, and/or Economic Prosperity. Agencies applying in more than 1 focus area must complete a separate narrative, budget, and performance measures per area.

Yes

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* 12. Do You Meet the Eligibility Requirements below? Yes or No

	Yes	No
Located in and primarily serving residents of central and southern Berkshire County	Located in and primarily serving residents of central and southern Berkshire County Yes	Located in and primarily serving residents of central and southern Berkshire County No
Not-for-profit organization (If yes, provide documentation as part of application)	Not-for-profit organization (If yes, provide documentation as part of application) Yes	Not-for-profit organization (If yes, provide documentation as part of application) No
Incorporated or chartered under appropriate local, state or federal statutes	Incorporated or chartered under appropriate local, state or federal statutes Yes	Incorporated or chartered under appropriate local, state or federal statutes No
Abide by federal and state laws regarding non-discrimination and anti-terrorism	Abide by federal and state laws regarding non-discrimination and anti-terrorism Yes	Abide by federal and state laws regarding non-discrimination and anti-terrorism No
Have a non-discrimination policy (If yes, provide documentation)	Have a non-discrimination policy (If yes, provide documentation) Yes	Have a non-discrimination policy (If yes, provide documentation) No
Have an active, locally based, volunteer board or elected body that meets regularly, makes policy decisions and holds election of officers (if yes, provide list of Board/elected body)	Have an active, locally based, volunteer board or elected body that meets regularly, makes policy decisions and holds election of officers (if yes, provide list of Board/elected body) Yes	Have an active, locally based, volunteer board or elected body that meets regularly, makes policy decisions and holds election of officers (if yes, provide list of Board/elected body) No
Have an administrative structure with defined lines of responsibility, a mission statement and bylaws (if yes, provide documentation)	Have an administrative structure with defined lines of responsibility, a mission statement and bylaws (if yes, provide documentation) Yes	Have an administrative structure with defined lines of responsibility, a mission statement and bylaws (if yes, provide documentation) No
Financially stable, perform a regular budgeting process and able to submit audited financial statements and/or IRS Form 990 with internal control deficiency letters if applicable (if yes, provide agency and program financials as part of application using EXCEL template)	Financially stable, perform a regular budgeting process and able to submit audited financial statements and/or IRS Form 990 with internal control deficiency letters if applicable (if yes, provide agency and program financials as part of application using EXCEL template) Yes	Financially stable, perform a regular budgeting process and able to submit audited financial statements and/or IRS Form 990 with internal control deficiency letters if applicable (if yes, provide agency and program financials as part of application using EXCEL template) No
Have current license, certification and permits if applicable	Have current license, certification and permits if applicable Yes	Have current license, certification and permits if applicable No
Able to demonstrate effectiveness of program/services through measurable outcomes. Applicants must be able to submit quarterly reports via Clear Impact Scorecard if a grant recipient	Able to demonstrate effectiveness of program/services through measurable outcomes. Applicants must be able to submit quarterly reports via Clear Impact Scorecard if a grant recipient Yes	Able to demonstrate effectiveness of program/services through measurable outcomes. Applicants must be able to submit quarterly reports via Clear Impact Scorecard if a grant recipient No

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* 13. If answered no to any question above, please explain.

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* 14. In order to confirm eligibility, please email the following supporting documentation to Julie Singley, jsingley@berkshireunitedway.org:
Documentation of not-for-profit status,
Non-discrimination policy,
List of current Board of Directors,
Mission statement and/or bylaws,
BUW will review your documentation within 3 business days and will notify the contact person listed above with next steps in the application process.
Note that: Financial documentation (Agency budget and financials, Program Budget will be due at the time of the application narrative)