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Docu Sign Envelope ID DE3F0775B-3A75-4D97-9EA7-5AC7933304BE Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency: Hillsborough Arts Council Date/Time / <br /> Complete Y N <br /> Program(s): 2016 Sustainable Growth Plan <br /> iff/VW IfffilMiMilfffiffffiffl /f107110fWAY ffillff,111,1111,11111,11111,11110 <br /> Section For CDBG & HOME - <br /> Subsection <br /> HUD Regulations <br /> 1. Cover Page a. EI Applicant Contact Information <br /> b. El Project/Program Contact Information <br /> c. El Funding Requests Identified <br /> d. 111 Signed Application Cover Page <br /> 2. Agency a. El Agency's Years in operation 24 CFR 570.506, <br /> Information - b. El Agency's Purpose/Mission 570.507, 570.610; 24 <br /> CFR Parts 84 or 85 <br /> c. El Agency's Types of Services Provided <br /> d. El Agency's Experience <br /> e. El Other Pertinent Information <br /> 3. Program/ a. 1=1 Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. El Summary of Program 570.201-570. 208, <br /> Information - c. El 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 /> which funding f. El Activity Implementation Timeline <br /> is requested) g. El Agency Collaboration <br /> h. El Describe Impact of Reduced/No Allocation <br /> i. El Other Pertinent Information <br /> j. El Complete Target Population/Beneficiary Chart <br /> k. El Complete Schedule of Positions <br /> I. El Signed Conflict of Interest Disclosure <br /> m. 111 Complete Work Statement <br /> i a • o <br />