A: Current Funding Sources (FY July 1, 2009 to June 30, 2010)

Council For Women

Marriage License	$
Displaced Homemaker	$
Divorce Filing Fees	$
DV / SA	$

Department of Health and Human Services

Family Violence Prevention	$
Rape Prevention Education	$

Governor's Crime Commission

Victims of Crime Act	$
Violence Against Women Act	$

United Way	$
Thrift Store	$
Foundations	$
Emergency Shelter Grants	$
City/County Funds	$
Fees From Services	$
Other	$
Specify Other
Other Funds Targeted (next 24 months)	$
Percent of funding from unrestricted funds	%

Budget Category	Most recently completed fiscal year	Current fiscal year (Estimated)	Next fiscal year (Projected)
	mm/dd/yyyy through mm/dd/yyyy	mm/dd/yyyy through mm/dd/yyyy	mm/dd/yyyy through mm/dd/yyyy
Total Income	$	$	$
Total Expenses	$	$	$
Surplus/Deficit	$	$	$

B: Agency Information

Please check the designation that best describes your agency profile.

Stand alone DV service provider
Stand alone SA service provider
Combined DV/SA service provider
Multi-Agency (i.e., DV services, substance abuse services, batterers' treatment services, etc.)

C: Fundraising History

Please provide the dollar amount you raised via fundraising activities for the following years.

• 2007   $
  
• 2008   $
• 2009   $

Please provide the PROJECTED dollar amounts you expect to raise via fundraising activities for
the following upcoming years.

• 2010   $
  
• 2011   $

Please provide a description of your biggest fundraising activity, including amount raised each year and
the number of years for that fundraising event.
(Please limit response to less than 255 characters, more will generate an Error message when submitted.)

D: Personnel (Include information for the entire agency - not just funded personnel)

Total number of employees:

• Full-Time    
• Part-Time   
• Volunteers  

List each staff position by title:

1     2 
3     4 
5     6 
7     8 
9   10

Yes    No	Does your Executive Director conduct annual performance appraisals on staff?
Yes    No	Does the agency Board conduct annual performance appraisals on the Executive Director?
What is the average length of time employees stay at your agency? (Number of months)
Yes    No	Does your organization's Board meet routinely?
If "YES" how frequently? (Daily/Weekly/Monthly/Quarterly/Anually/As Needed...)

E: Victims Served / Services Offered

Please provide the following statistics and calculate based on UNDUPLICATED victims served in 2009:

2009
Victim Category	DV	SA	TOTALS
Adult Victims Served
Child Victims Served

Please indicate the following services that are offered by your program.

	Service
Yes    No	Advocacy
Yes    No	Crisis Hot Line
Yes    No	Children's Services
Yes    No	Counseling and Case Management
Yes    No	Legal Assistance
Yes    No	Transportation Services
Yes    No	Employment Referrals
Yes    No	Job Skills Training
Yes    No	Food Pantry
Yes    No	Transitional Housing
Yes    No	Hospital Accompainment

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