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DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Orange Congregations in Mission Date/Time / 1 <br /> Complete Y/N <br /> Program(s) Samaritan Relief Ministry <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. 570.201-570. 208, <br /> ❑ Summary of Program <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. x Agency 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. ❑ Complete Work Statement <br />