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DocuSign Envelope ID:913F749B-B9E8-4103-AF9D-A4296D01069E Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Licio Doi() of Budo Karate Date/Time / <br /> Cornpiete Yj N <br /> Program(s) Young Warriors Program <br /> Section Subsection For CDBG & HOME- <br /> HUD Regulations <br /> 1. Cover Page a. Ej Applicant Contact Information <br /> b. Ej Project/Program Contact Information <br /> c. Li Funding Requests Identified <br /> d. Li Signed Application Cover Page <br /> 2. Agency a. E Agency's Years in operation 24 CFR 570.506, <br /> Information - b. n Agency's Purpose/Mission 57o.507, 570.610; 24 <br /> c. E Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. Li Agency's Experience <br /> e. E Other Pertinent Information <br /> 3. Program/ a. El Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project I . El Summary of Program 570.201-570. 208, <br /> Information - c. 1 Description of Identified Need 507.503 <br /> (for each d. El Description of Population to be Served <br /> program/ <br /> e. El Activity Manager and Location Description <br /> project for <br /> f. 0 Activity Implementation Timeline <br /> which funding <br /> is requested) g. 0 Agency Collaboration <br /> h. Li Describe Impact of Reduced/No Allocation <br /> I. E] Other Pertinent Information <br /> j. Complete Target Population/Beneficiary Chart <br /> k. El Complete Schedule of Positions <br /> 1. 1 Signed Conflict of Interest Disclosure <br /> m. 1 Complete Work Statement <br /> ilPage <br />