Essential Goods For Basic Needs Agency Agreement Form - United Way of Westchester and Putnam

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Essential Goods for Basic Needs Program Agreement Form

Please fill out the following information to the best of your ability. If anything is not applicable, please put "N/A."

Official Agency Name(Required)

Employment Identification Number (EIN)(Required)

Agency Phone Number(Required)

Agency Website(Required)

Agency Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Chief Executive Officer (CEO)(Required)

Name Agency Phone Agency Email

Authorized individual to receive donation notifications(Required)

Title & Name Agency Phone Agency Email

Agency Related Questions

Please answer the following agency-related questions in their entirety.

Please provide us with your agency’s mission:(Required)

Please provide us with a description of the programs and services your organization provides that will benefit from participation in UWWP’s EGBN Program:(Required)

Please select which items you most commonly utilize and would hope to receive through our EGBN Program:(Required)

Baby Items

Bedding

Books

Clothing

Electronics

Home Goods

Personal Items

School Supplies

Toys

Other

If you selected "Other," please describe:

Nonprofits who are members of the EGBN Program can order donated items at a discounted rate through our Good360 membership. These items (diapers, backpacks, mattresses, holiday presents, etc.) will be available on a limited basis as per the Good360 marketplace. The ordering nonprofit is required to provide payment upfront. Orders will be shipped directly to the nonprofit agency. Please let us know if you would be interested in participating in this program.(Required)

Yes

No

Are you able to receive large scale donations? Please identify if you have access to appropriate transportation (e.g. van, large SUV, U-Haul truck) and staff to receive large scale donations. If you only have access to a small, standard passenger vehicle or cannot lift large items, please do not answer “yes” to this question.(Required)

Yes

No

If you answered “yes” to the previous question, do you also have a loading dock at your agency?

Yes

No

Populations Served Demographics

Please answer the following questions so we can have a better understanding of the populations your agency serves.

How many individuals does your organization serve annually?(Required)

Are there specific needs of your clients that UWWP should know about?(Required)

Gender

Please answer in percentages that total 100 across all categories i.e. 49 Man 49 Woman 2 Non binary. Each field must contain a number (including "Unknown") and no symbols.

Man(Required)

Woman(Required)

Non-Binary(Required)

Unknown(Required)

Other(Required)

Please Explain

Race and Ethnicity

Please answer in percentages that total 100 across all categories i.e. 20 White 40 African American 40 Hispanic. Each field must contain a number (including "Unknown") and no symbols.

Alaska Native(Required)

American Indian(Required)

Asian or Pacific Islander(Required)

Black or African American(Required)

Hispanic, Latino/Latina, or Spanish Origin(Required)

Middle Eastern or North African(Required)

White, Non-Hispanic(Required)

Unknown(Required)

Other(Required)

Please explain

Age

Please answer in percentages that total 100 across all categories. Each field must contain a number (including "Unknown") and no symbols.

0-12(Required)

13-18(Required)

19-24(Required)

25-34(Required)

35-44(Required)

45-54(Required)

55-64(Required)

65 and above(Required)

Unknown(Required)

Ability status

Please answer in percentages that total 100 across all categories. Each field must contain a number (including "Unknown") and no symbols.

Disabled(Required)

Not disabled(Required)

Unknown(Required)

Sexual orientation

Please answer in percentages that total 100 across all categories. Each field must contain a number (including "Unknown") and no symbols.

Bisexual(Required)

Gay or Lesbian(Required)

Heterosexual or straight(Required)

Unknown(Required)

Other

Please provide percentage and explain

Poverty

What percentage of your clients are below the Federal Poverty Level (FPL)?(Required)

What percentage of your clients are below the 200% Poverty Level?(Required)

Do you serve any of the following populations?

People with physical and/or mental disabilities

Incarcerated individuals

LGBTQ identifying individuals

Pregnant women

Refugees

Veterans

People with opioid/substance abuse disorders

Unhoused individuals

BIPOC individuals

Please list all the counties/cities/municipalities where your clients are served:(Required)

Terms and Conditions

All partners must agree to the following rules and requirements. Failure to comply with these terms and conditions will result in removal from the program. By submitting an application, you agree to the following:

Consent(Required)

1. Your agency or organization must submit proof of current 501(c)(3) status from the IRS, or nonprofit status for a school, religious insititution, or housing authority.

Consent(Required)

2. Your agency or organization may use donated goods only as direct charitable donations to people in need.

Consent(Required)

3. Donations may not be distributed to other organizations unless they are a member of the EGBN Program.

Consent(Required)

4. Donations cannot be used for fundraisers, raffles, auctions, given to volunteers or staff members, or sold in retail stores, on websites, in flea markets, or in any other manner.

Consent(Required)

5. Only sign up for donations that you are confident you can pick up. If you schedule a pickup with a donor, you are committing to that donation.

Consent(Required)

6. UWWP has sole discretion for allocating donations, not the donor. All donation approval must go through UWWP.

Consent(Required)

7. Agency/organization representatives must be the one to contact a UWWP donor. A member’s client/customer is NEVER to be given a donor’s information. A member’s client/customer is never to go to a UWWP donor unaccompanied by a representative of the member’s agency.

Consent(Required)

8. In the case of pickups outside of UWWP’s office, the paperwork given to you to be completed upon pickup must be faxed or emailed to us immediately after the pickup

Consent(Required)

9. Members must ensure they have appropriate transportation to accommodate the size of the donation.

Consent(Required)

10. When accepting large and/or heavy donations it is the member’s responsibility to ensure the appropriate number of capable people are available to lift and transport the items.

Consent(Required)

11. Your agency or organization consents to a site visit to be scheduled at a later date.

Consent(Required)

12. You are required to keep basic records of donations received and distributed.

Consent(Required)

13. Your agency or organization agrees to submit impact stories related to the goods they received.

Consent(Required)

14. As an Essential Goods member, you are a partner with UWWP and we ask that you display our logo on your website.

Consent(Required)

15. Failure to comply with these terms and conditions will result in removal from the program.

501(c)3 Please upload a copy of your 501(c)3 status here:(Required)

Drop files here or

Max. file size: 100 MB, Max. files: 2.

Signature of member representative or CEO(Required)

First Last

By typing your name, you are signing this application electronically and you acknowledge that the information above is true to the extent of your knowledge.

Date(Required)

MM slash DD slash YYYY

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White Plains, NY 10606

914.997.6700
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