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Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST <br /> FOR OFFICE USE ONLY <br /> s <br /> I Received By <br /> Agency Orange County Rape Crisis Centeratelme J <br /> Ai <br /> yy <br /> Programs) Client Services & Community Education5w �, <br /> Section For CDBG & HOME <br /> Regulations Subsection <br /> HUD <br /> 1. Cover Page a. pplicant Contact Information <br /> b. ProjectlProgram Contact Information <br /> c. Funding Requests Identified <br /> d. [Signed Application Cover Page <br /> 2. Agency a. Wf 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 <br /> 3. Program/ a. ype of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. Summary of Program 570.201-570. 208, <br /> Information- C. escription of Identified Need 507.503 <br /> (for each d. escription of Population to be Served <br /> program/ e. [Activity Manager and Location Description <br /> project for <br /> which funding f. [Activity Implementation Timeline <br /> is requested) 9, Agency Collaboration <br /> h. QZ Describe Impact of Reduced/No Allocation <br /> I. [ Other Pertinent Information <br /> Complete Target Population/Beneficiary Chart <br /> k. 7 Complete Schedule of Positions <br /> I. [� Signed Conflict of Interest Disclosure <br /> m. Complete Work Statement <br /> 4. <br /> i Pagc <br />