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DocuSign Envelope ID: 5BF9183D-3BD5-4FD7-80DE-F437539D2E9F Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Historical Foundation of Hillsborough Date/Time / 1 <br /> and Orange County Complete Y/N <br /> Program(s) Orange County Historical Museum Heritage <br /> Education Programs, Community Workshops, Exhibits, Collections <br /> Section Subsection For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. ® Applicant Contact Information <br /> b. ® Project/Program Contact Information <br /> c. ® Funding Requests Identified <br /> d. ❑ Signed Application Cover Page <br /> 2. Agency a. ® Agency's Years in operation 24 CFR 570.506, <br /> Information - b. ® Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. ® Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. ® Agency's Experience <br /> e. ❑ Other Pertinent Information N/A <br /> 3. Program/ a. ® 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. ❑ Description of Identified Need 507.503 <br /> (for each d. ❑ Description of Population to be Served <br /> program/ <br /> project for e. ❑ Activity Manager and Location Description <br /> which funding f. ❑ Activity Implementation Timeline <br /> is requested) g. ❑ Agency Collaboration <br /> h. ❑ Describe Impact of Reduced/No Allocation <br /> i. ❑ Other Pertinent Information <br /> j. ❑ Complete Target Population/Beneficiary Chart <br /> k. ® Complete Schedule of Positions <br /> I. ❑ Signed Conflict of Interest Disclosure <br /> m. ❑ Complete Work Statement <br /> i o:° <br />