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DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Mental Health America of the Triangle Date/Time / 1 <br /> Complete Y/N <br /> Program(s) Family Advocacy Network <br /> Section Subsection For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. X Applicant Contact Information <br /> b. X Project/Program Contact Information <br /> c. X Funding Requests Identified <br /> d. X 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 /> d. X Agency's Experience <br /> e. X Other Pertinent Information <br /> 3. Program/ a. X Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. X Summary of Program 570.201-570. 208, <br /> Information - c. X Description of Identified Need 507.503 <br /> (for each d. X Description of Population to be Served <br /> program/ <br /> project for e. X Activity Manager and Location Description <br /> which funding f. X Activity Implementation Timeline <br /> is requested) g. XAgency Collaboration <br /> h. X Describe Impact of Reduced/No Allocation <br /> i. X Other Pertinent Information <br /> j. X Complete Target Population/Beneficiary Chart <br /> k. X Complete Schedule of Positions <br /> I. X Signed Conflict of Interest Disclosure <br /> m. X Complete Work Statement <br />