Form Center

2. 
   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, 2021 for funding starting July 1, 2022.

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.
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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