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DocuSign Envelope ID:7D246B6F-37D5-48F7-99D7-98C230BA1C70 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST <br /> FOR OFFICE USE ONLY <br /> Received By <br /> Agency Behavioral Insights, Inc. Date/Time / <br /> Complete Y/N <br /> Program(s) _DV classes and Sentencing Plan Service <br /> Section For CDBG & HOME - <br /> Subsection <br /> HUD Regulations <br /> 1. Cover Page a. xLI Applicant Contact Information <br /> b. xE Project/Program Contact Information <br /> c. x❑ Funding Requests Identified <br /> d. xEl Signed Application Cover Page <br /> 2. Agency a. x❑ Agency's Years in operation 24 CFR 570.506, <br /> Information - b. x❑ Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. x Agency's Types of Services Provided CFR Parts 84 or 85 <br /> Ll <br /> d. xE Agency's Experience <br /> e. x❑ Other Pertinent Information <br /> 3. Program/ a. XD Type of Application.and Program Identified 24 CFR 570.200(a), <br /> Project b. XE Summary of Program 570.201-570. 208, <br /> Information - c. X Description of Identified Need 507.503 <br /> ❑ <br /> (for each d. X❑ Description of Population to be Served <br /> program/ <br /> project for e. XD Activity Manager and Location Description <br /> which funding f. X1 Activity Implementation Timeline <br /> is requested) g• Agency Collaboration <br /> h. XD Describe Impact of Reduced/No Allocation <br /> i. X❑ Other Pertinent Information <br /> j. XD Complete Target Population/Beneficiary Chart <br /> k. XD Complete Schedule of Positions <br /> I. X❑ Signed Conflict of Interest Disclosure <br /> m. XE Complete Work Statement <br /> ilPage <br />