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External Entity Funding Request Form

2. <p align="center"><img src="http://va-orangecounty.civicplus.com/DocumentCenter/View/101"><br> Orange County Finance Department <br>112 W. Main Street <br>Orange, VA 22960</p>

   
   Orange County Finance Department
   112 W. Main Street
   Orange, VA 22960

4. Orange County, VA External Entity Request Form

6. Due Date
   Forms are due December 31, 2020 for funding starting July 1, 2021.

   Forms are due December 31, 2020 for funding starting July 1, 2021.

8. Agency Name*

9. Has Orange County funded this agency previously?*

   1. Yes
   2. No

11. Address1

13. Address2

15. City

16. State

17. Zip

19. Phone Number*

20. Fax Number

21. Contact E-mail Address

23. Web Address

24. Federal ID Number

26. Agency Main Contact Name & Title

27. Main Contact Phone Number

29. Main Contact E-mail Address

33. Agency Mission

35. Number of Years in Existence

36. Localities Served

40. Program 1

41. Program 1 Personnel Expenses

42. Program 1 Benefits

44. Program 1 Operating Expenses

45. Program 1 Total Budget

46. Program 1 Requested Amount

50. Program 2

51. Program 2 Personnel Expenses

52. Program 2 Benefits

54. Program 2 Operating Budget

55. Program 2 Total Budget

56. Program 2 Requested Amount

60. Program 3

61. Program 3 Personnel Expenses

62. Program 3 Benefits

64. Program 3 Operating Budget

65. Program 3 Total Budget

66. Program 3 Requested Amount

70. Program 4

71. Program 4 Personnel Expenses

72. Program 4 Benefits

74. Program 4 Operating Budget

75. Program 4 Total Budget

76. Program 4 Requested Amount

80. Program 5

81. Program 5 Personnel Expenses

82. Program 5 Benefits

84. Program 5 Operating Budget

85. Program 5 Total Budget

86. Program 5 Requested Amount

90. Agency Administration Personnel Expenses

91. Agency Adminstration Benefits

92. Agency Administration Operating Expenses

94. Agency Adminstration Total Budget

95. Agency Administration Requested Amount

97. Capital Outlay

99. Total Agency Budget

100. Total Amount Requested*

102. Please Attach the Following Documentation

     1. IRS 501(c)(3) letter
     2. Audit Report (with management letter)
     3. Current Board Roster (with contact information)

103. IRS 501(c)(3) Attachment*

104. Audit Report Attachment*

105. Board Roster Attachment*

107. Agency Director's Signature

108. Date

112. Complete the following for each program serving Orange County citizens and for which funding is requested. Any incomplete applications or programs that do not have a full application will not be considered for funding. Please do not include any unrequested information. Orange County reserves the right to request additional information once the application has been submitted.

114. Program 1

116. Is this a new program?

     1. Yes
     2. No

117. Program Name

118. Program Contact

120. Program 1: Purpose/Description

     (The description should not exceed 10 lines of text)

122. Program 1: Justification of Need

     (Please state clearly why this service should be provided to the citizens of Orange County and why the Board of Supervisors should consider this funding request. If this is a new program, be sure to include the benefit to the County for funding a new request. The justification should not exceed 10 lines of text, and should inculde the most recent data available)

124. Program 1: Target Audience

     (The information listed above should describe the specific population targeted by the program and should not exceed 5 lines of text)

126. Program 1: Service Area

     (Please describe the program's intended geographic service area. This may include entire regions, localities, or specific schools, neighborhoods, etc.)

128. Program 1: Service Delivery

     (Please state the geographic location of the service, the duration and frequency offered to the clients. If service area includes other municipalities please indicate what amount of funding ($ or %) is received from that locality)

130. Program 1: Client Fees

     (Please describe the fees clients must pay for the services provided in this program, and how those fees are determined)

132. Please indicate, in detail reasons for increases or decreases in the amounts requested for FY2022. Include whether these changes come from increases in personnel, benefits, or operating expenses. If an increase is being requested, please describe the impact not receiving an increase would have on the program.

136. Program 2

138. Is this a new program?

     1. Yes
     2. No

139. Progam 2 Name

140. Program Contact

142. Program 2: Purpose/Description

     (The description should not exceed 10 lines of text)

144. Program 2: Justification of Need

     (Please state clearly why this service should be provided to the citizens of Orange County and why the Board of Supervisors should consider this funding request. If this is a new program, be sure to include the benefit to the County for funding a new request. The justification should not exceed 10 lines of text, and should inculde the most recent data available)

146. Program 2: Target Audience

     (The information listed above should describe the specific population targeted by the program and should not exceed 5 lines of text)

148. Program 2: Service Area

     (Please describe the program's intended geographic service area. This may include entire regions, localities, or specific schools, neighborhoods, etc.)

150. Program 2: Service Delivery

     (Please state the geographic location of the service, the duration and frequency offered to the clients. If service area includes other municipalities please indicate what amount of funding ($ or %) is received from that locality)

152. Program 2: Client Fees

     (Please describe the fees clients must pay for the services provided in this program, and how those fees are determined)

154. Please indicate, in detail reasons for increases or decreases in the amounts requested for FY2022. Include whether these changes come from increases in personnel, benefits, or operating expenses. If an increase is being requested, please describe the impact not receiving an increase would have on the program.

158. Program 3

160. Is this a new program?

     1. Yes
     2. No

161. Program 3 Name

162. Program Contact

164. Program 3: Purpose/Description

     (The description should not exceed 10 lines of text)

166. Purpose 3: Justification of Need

     (Please state clearly why this service should be provided to the citizens of Orange County and why the Board of Supervisors should consider this funding request. If this is a new program, be sure to include the benefit to the County for funding a new request. The justification should not exceed 10 lines of text, and should inculde the most recent data available)

168. Program 3: Target Audience

     (The information listed above should describe the specific population targeted by the program and should not exceed 5 lines of text)

170. Program 3: Service Area

     (Please describe the program's intended geographic service area. This may include entire regions, localities, or specific schools, neighborhoods, etc.)

172. Program 3: Service Delivery

     (Please state the geographic location of the service, the duration and frequency offered to the clients. If service area includes other municipalities please indicate what amount of funding ($ or %) is received from that locality)

174. Program 3: Client Fees

     (Please describe the fees clients must pay for the services provided in this program, and how those fees are determined)

176. Please indicate, in detail reasons for increases or decreases in the amounts requested for FY2022. Include whether these changes come from increases in personnel, benefits, or operating expenses. If an increase is being requested, please describe the impact not receiving an increase would have on the program.

180. Program 4

182. Is this a new program?

     1. Yes
     2. No

183. Program 4 Name

184. Program Contact

186. Program 4: Purpose/Description

     (The description should not exceed 10 lines of text)

188. Program 4: Justification of Need

     (Please state clearly why this service should be provided to the citizens of Orange County and why the Board of Supervisors should consider this funding request. If this is a new program, be sure to include the benefit to the County for funding a new request. The justification should not exceed 10 lines of text, and should inculde the most recent data available)

190. Program 4: Target Audience

     (The information listed above should describe the specific population targeted by the program and should not exceed 5 lines of text)

192. Program 4: Service Area

     (Please describe the program's intended geographic service area. This may include entire regions, localities, or specific schools, neighborhoods, etc.)

194. Program 4: Service Delivery

     (Please state the geographic location of the service, the duration and frequency offered to the clients. If service area includes other municipalities please indicate what amount of funding ($ or %) is received from that locality)

196. Program 4: Client Fees

     (Please describe the fees clients must pay for the services provided in this program, and how those fees are determined)

198. Please indicate, in detail reasons for increases or decreases in the amounts requested for FY2022. Include whether these changes come from increases in personnel, benefits, or operating expenses. If an increase is being requested, please describe the impact not receiving an increase would have on the program.

202. Program 5

204. Is this a new program?

     1. Yes
     2. No

205. Program 5 Name

206. Program Contact

208. Program 5: Purpose/Description

     (The description should not exceed 10 lines of text)

210. Program 5: Justification of Need

     (Please state clearly why this service should be provided to the citizens of Orange County and why the Board of Supervisors should consider this funding request. If this is a new program, be sure to include the benefit to the County for funding a new request. The justification should not exceed 10 lines of text, and should inculde the most recent data available)

212. Program 5: Target Audience

     (The information listed above should describe the specific population targeted by the program and should not exceed 5 lines of text)

214. Program 5: Service Area

     (Please describe the program's intended geographic service area. This may include entire regions, localities, or specific schools, neighborhoods, etc.)

216. Program 5: Service Delivery

     (Please state the geographic location of the service, the duration and frequency offered to the clients. If service area includes other municipalities please indicate what amount of funding ($ or %) is received from that locality)

218. Program 5: Client Fees

     (Please describe the fees clients must pay for the services provided in this program, and how those fees are determined)

220. Please indicate, in detail reasons for increases or decreases in the amounts requested for FY2022. Include whether these changes come from increases in personnel, benefits, or operating expenses. If an increase is being requested, please describe the impact not receiving an increase would have on the program.

Leave This Blank:


222. 1. Receive an email copy of this form.
223. Email address

     This field is not part of the form submission.

224. Submit

* indicates a required field