Request for Funding | Sedgwick, Maine Official Website

Download to print: Request For Funding – Social Services Agency Questionaire

SOCIAL SERVICE AGENCY

REQUEST FOR FUNDING QUESTIONAIRE

Please complete the following questionnaire and return to the Town of Sedgwick, Attn: Barbara, P.O. Box 40, Sedgwick, Maine 04676. Only those agencies returning this completed form will be considered for funding. Thank you for your time in filling out this questionnaire. The deadline to file is December 31, 2023. After the Town receives this information, you will be contacted with a date and time to meet with the Board of Selectmen and Budget Committee to discuss your request if we feel it is needed. Please have a representative familiar with your organization available for this meeting if it is requested.

_____________________________________________________________________________________

Amount requested for 2024-25 ___________________________________________________________

Name of Agency ______________________________________________________________________

1. Address ______________________________________________________________________

_____________________________________________________________________________________

2. Executive Director ______________________________________________________________

3. Contact Person _________________________________________________________________

4. Contact Number (s) _____________________________________________________________

5. Email ________________________________________________________________________

6. Description of Services Agency provides ____________________________________________

_____________________________________________________________________________________

7. Describe Fee Structure ___________________________________________________________

_____________________________________________________________________________________

8. Total of clients served for current year ______________________________________________

9. Total number of unduplicated Sedgwick residents listed by types of service:

Type of Service Number served

_____________________________________________________________________________________

10. Funding sources for program:

Source Received 2022 or latest ending year

Federal ______________________________________________________________________________

State ________________________________________________________________________________

County ______________________________________________________________________________

Fees ________________________________________________________________________________

Private Insurance ______________________________________________________________________

United Way __________________________________________________________________________

Municipal – please list: _________________________________________________________________

_____________________________________________________________________________________

All other: ____________________________________________________________________________

_____________________________________________________________________________________

Total: ________________________________________________________________________

11. We also request a copy of your Agency’s most recent annual audit/financial statement.

Note: Please do not send any other material for the budget process. We do welcome handouts in our General Assistance program if you would like to provide them.