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DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Freedom House Recovery Center Date/Time <br /> Program(s) Residential Rehabilitation and Complete YIN <br /> Facility-Based Crisis and Detoxification Services <br /> Section For CDBG & HOME - <br /> Subsection HUD Regulations <br /> 1. Cover Page a. r Applicant Contact Information <br /> b. Project/Program Contact information <br /> c. I1 Funding Requests Identified <br /> d. Z Signed Application Cover Page <br /> 2. Agency a. I Agency's Years in operation 24 CFR 570.506, <br /> Information - b. r Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. Agency's Types of Seivices Provided CFR Parts 84 or 85 <br /> d. El Agency's Experience <br /> e. Z. Other Pertinent Information <br /> 3. Program/ a. Z Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. I Summary of Program 570.201-570. 208, <br /> infer ation 507.503 <br /> c. Z Description of Identified Need <br /> (for each <br /> r Description of Population to be Served <br /> program/ <br /> e. I1 Activity Manager and Location Description <br /> project for <br /> which funding f. I Activity Implementation Timeline <br /> is requested) g. )■ Agency Collaboration <br /> h. 1 Describe Impact of Reduced/No Allocation <br /> i. IZ Other Pertinent Information <br /> j. A Complete Target Population/Beneficiary Chart <br /> k. Z Complete Schedule of Positions <br /> I ■ Signed Conflict of Interest Disclosure <br /> m. I Complete Work Statement <br />