TOWN OF NEWTOWN - OUTSIDE AGENCY FUNDING REQUEST APPLICATION

Instructions: This application is to be used by outside agencies to request funds from the Town
of Newtown during the annual budget process. Please fill out completely. You may refer to
attachments. Please e-mail application to the finance director in PDF format at:
finance.director@newtown-ct.gov

I. Identification:

Name of Organization: _Amos House Inc.______________________________

Address 34 Rocky Glen Road, Danbury, CT 06810_______________________

II. Background:

A. Type of Organization: Charitable X Civic

Government Other _________________________

B. Organization’s Mission Statement:

_Amos House is dedicated to ensuring that individuals and families

have the opportunity to achieve the competency and productivity

required for permanent, self-sufficient, independent living.____

____________________________________________________

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TOWN OF NEWTOWN - OUTSIDE AGENCY FUNDING REQUEST APPLICATION

C. Please make a brief list of your organization’s goals: __________

__Our main goal is to equip homeless families and individuals with the
practical skills to manage their own personal and financial needs, the ability to
function in the community, and the ability to secure and maintain permanent
housing.__________________________________________________

1. Outcome: Client moves to permanent housing.

a. Measure 1: At least 50% of clients who leave the Program access

permanent housing.

2. Outcome: Client achieves greater degree of self-

sufficiency.

a. Measure 1: For clients with an identified goal of furthering their

education, at least 75% reached benchmarks toward their educational
and/or vocational goals.

b. Measure 2: For clients with an identified goal of employment, at least

75% secured employment.

c. Measure 3: For clients with the identified goal of securing a legal

source of enhanced income, at least 75% secured an enhanced source
of income.

III. Services Provided:

A. List specific programs and or services that are available to the citizens of
Newtown:

__Each client receives case management services that include as

necessary but not limited to assessment, goal planning, counseling, assistance
with accessing education, training, and employment, referrals to additional
community support services. Amos House provides workgroups, presentations,
and group activities covering topics, which may include but not limited to tenant
education, budgeting, and employment acquisition. Amos House provides
transitional living arrangements as a component of the program for up to 24
months.__________________________________________________

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TOWN OF NEWTOWN - OUTSIDE AGENCY FUNDING REQUEST APPLICATION

B. Does your agency provide these same programs and or services to any
areas outside of Newtown?

YES / NO (if yes – list the programs and or services provided to other
areas)

Program / Services Area Served

Transitional Living Program_________Greater Danbury_____________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

C. To your knowledge, are there any other agencies or programs serving

Newtown that duplicate services or could be reasonably construed as
duplicating services you provide? (if yes, give a brief explanation of any
differences):

__________There is another Transitional Facility located in Danbury. It

is called Renewal House. The subset of the homeless population they
serve are the elderly.__________________________ _____________

__________________________________________________________

__________________________________________________________

__________________________________________________________

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TOWN OF NEWTOWN - OUTSIDE AGENCY FUNDING REQUEST APPLICATION

IV. Please list your current Board of Directors and Officers:

_Joseph Walkovich, President.

Pamela Burdette-Miller, Vice President
Benjamin Chianese, Treasurer
Bruce Simon, Secretary
Angela Taylor, Member
Betsy Pankulis, Member
Penny LoValvo, Member
Ward Meehan, Member
Michael Byl, Member___________________________

V. Agency Contact Person: ___Gladys McFarland___________________

Title: _Executive Director____________________

Phone Number 203- 791-9277__________________________

E-mail amoshouse@aol.com_____________________

Alternate Agency Contact Person: _Diane Gernert__________________

Title: _Administrative Assistant______________

Phone Number __203-791-9277_____________________

E-mail _amoshouse@aol.com____________________

• If primary agency contact information changes, please inform us by e-mail at

finance.director@newtown-ct.gov
TOWN OF NEWTOWN - OUTSIDE AGENCY FUNDING REQUEST APPLICATION

VI. Amount of Funds Requested:

Prior Years Approved Newtown Funding: $___3,300.00__________

2010 - 2011 Agency Budget Request: $____3,300.00___________

VII. Please describe how these funds will be used :

____The funds will be used to help subsidize the cost of client

participation. The funds will not be used for capital
expenditures__________________________________
_________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

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VIII. How many paid staff members do you have? Full Time _3_____; Part Time _1____

What was the general pay increase for the current fiscal year? ___0_________%

IX. Please submit with this application:

• A copy of your last budget

 • A copy of your latest audited financial statements

X. Please feel free to attach any useful information on your organization.

TOWN OF NEWTOWN - OUTSIDE AGENCY FUNDING REQUEST APPLICATION

SIGNATURE FORM

IMPORTANT - this form must be submitted with your formal budget request.

You are required to both print and sign the appropriate spaces below.

Your budget request will not be considered without these signatures.

Name of Organization: __Amos House, Inc._____________________________________

President: Treasurer:

____Joseph Walkovich____________________ ____Benjamin Chianese______________

(print) (print)

______________________________________ __________________________________
(signature) (signature)

Date: ___________________________
TOWN OF NEWTOWN - OUTSIDE AGENCY FUNDING REQUEST APPLICATION

Submittal Check-Off Sheet

Application

Signature Form

Latest Budget

Latest Audited Financial Statements

Any Attachments