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DocuSign Envelope ID:4FFDF545-B8C1-4ABF-A6A5-400656A36357 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST <br /> FOR OFFICE USE ONLY <br /> Received By <br /> Agency Senior Care of Orange County; Inc Date/Time I <br /> Complete Y/N <br /> Program(s) Florence Gray Soltys Adult Day Health Program <br /> Section For CDBG & HOME - <br /> Subsection <br /> HUD Regulations <br /> 1. Cover Page a. XIII Applicant Contact Information <br /> b. X[11 Project/Program Contact Information <br /> C. XLI Funding Requests Identified <br /> d. XIII Signed Application Cover Page <br /> 2. Agency a. Xrl Agency's Years in operation 24 CFR 570.506, <br /> Information - b. XE Agency's Purpose/Mission 570.507, 570.610; 24 <br /> CFR Parts 84 or 85 <br /> c. XI—I Agency's Types of Services Provided <br /> d. Xri Agency's Experience <br /> e. XLI Other Pertinent Information <br /> 3. Program/ a. XL] Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. XL Summary of Program 570.201-570. 208, <br /> Information - c. XE] Description of Identified Need 507.503 <br /> (for each d. xfl Description of Population to be Served <br /> program/ <br /> e. XL Activity Manager and Location Description <br /> project for <br /> f. XEI Activity Implementation Timeline <br /> which funding <br /> is requested) g. XIII Agency Collaboration <br /> h. XIII Describe Impact of Reduced/No Allocation <br /> I. XIII Other Pertinent Information <br /> j. XE Complete Target Population/Beneficiary Chart <br /> k. XIII Complete Schedule of Positions <br /> I. XE Signed Conflict of Interest Disclosure <br /> m. XL Complete Work Statement <br /> ilPage <br />