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EXHIBIT A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Orange County Living Wage Date/Time / <br /> { <br /> Complete Y/t <br /> Program{s} Living Wage Certification Program <br /> Section Subsection For CDBG & HOME <br /> Regulations HUD <br /> 1. Cover Page a. **D Applicant Contact Information <br /> b. *' ProjecVPrograrn Contact Information <br /> c. **Q Funding Requests identified <br /> d. **[ Signed Application Cover Page <br /> 2. Agency a. **Q Agency's Years in operation 24 CFR 570.506, <br /> Information b. **Q Agency's Purposelmission 570.507, 570.510; 24 <br /> c. ***Q Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. *D Agency's Experience <br /> e. **El Other Pertinent Information <br /> 3. Program/ a. *"El Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. *" ] Summary of Program 570.201-5701. 208, <br /> Information- c. ** Description of Identified Need 507.503 <br /> (for each d. **El Description of Population to be Served <br /> program/ e. **[] Activity Manager and Location Description <br /> project for <br /> which funding f. Activity Implementation Timeline <br /> which <br /> g• *" Agency Collaboration <br /> h. * Describe Impact of Reduced/No Allocation <br /> i. n Other Pertinent Information <br /> j. Complete Target Population/Beneficiary Chart <br /> k. **Q Complete Schedule of Positions <br /> I. Signed Conflict of Interest Disclosure <br /> m. "' Complete Work Statement <br />