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6 <br /> FOR OFFICE USE ONLY <br /> Agency Received By <br /> ..]Program(s) I Date/Time / <br /> Section Subsection <br /> 1. Cover Page a. El Applicant Contact Information <br /> b. El Funding Requests <br /> c. El Signed Application Cover Page <br /> d. Signed Disclosure of Conflicts of Interest <br /> 2. Agency Information a. El Agency's Years in operation <br /> b. El Agency's Purpose/Mission <br /> c. El Agency's Types of Services Provided <br /> d. El Agency's Experience with Programs <br /> e. El Other Pertinent Agency Information <br /> f. El Schedule of Positions <br /> g. El Living Wage <br /> h. El Agency Budget <br /> 3. Program Information a. El Human Services Needs Priority <br /> b. El Type of Program <br /> A separate Section 3 is c. El Agency Collaboration <br /> required for each program. d. ❑ Summary of Program <br /> e. El Description of Identified Need <br /> f. El Description of Population to be Served <br /> g. El Program Staffing, Capacity, & Expertise <br /> h. El Program Implementation Timeline <br /> i. El Value of Investment <br /> j. El Impact of Reduced/No Allocation <br /> k. El Other Pertinent Information <br /> I. El Target Population/Beneficiary Chart <br /> m. El Work Statement <br /> n. El Program Budget, Detail, & Cost per Individual <br /> 4. Attachments a. El Audit: Organizations receiving $300,000 or more in Federal <br /> financial assistance, and/or organizations with more than $500,000 <br /> of receipts and expenditures in a fiscal year, must secure an audit. <br /> b. El IRS Federal Form 990 <br /> c. El NC Solicitation License <br /> d. El IRS Federal Tax-Exemption Letter <br /> e. El Certificate of Insurance <br /> f. El List of Board of Directors <br /> g. El Solid Waste Program Fee (SWPF)Verification <br /> AGENCY INFORMATION Page 5 of 17 <br />