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DocuSign Envelope ID:A65EF081-BF54-47AC-9969-94226D3FBC7E =Xhibit A <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> FOR OFFICE USE ONLY <br /> APPLICATION SUBMITTAL CHECKLIST <br /> Received By <br /> Agency: Habitat for Humanity of Orange County Date/Time / <br /> Program(s): A Brush with Kindness Complete Y/ N <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 /> . 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 <br /> . Program/ a. ® Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. ® Summary of Program 570.201-570. 208, <br /> Information (for c. ® Description of Identified Need 507.503 <br /> each program/ d. ® Description of Population to be Served <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 /> . Financial (for Program Budget Worksheet and Detail should 24 CFR 570.200(a), <br /> each program/ reflect expenses for the entire program and ALL 570.201-570. 208, <br /> project for sources of funding. 507.503 <br /> which funding 24 CFR 570.506, <br /> is requested) a. ® Program Budget Worksheet 570.507, 570.601, <br /> b. ® Program Budget Detail 570.602, 570.607(b), <br /> c. ® Cost Per Unit 570.611 <br /> d. ® Agency Operating Budget Worksheet 24 CFR <br /> 570.502-570.504, <br /> 570.506, <br /> 570.507, 570.610;24 <br /> CFR Parts 84 or 85, <br /> and OMB Circulars A- <br /> 87 or A-122, <br /> Treasury Circular <br /> 1075 <br /> . Supplemental A.❑ Part A: CDBG & HOME <br /> Sections (as B.❑ Part B: Construction/Rehab <br /> applicable) <br /> Main Application 1/25/2016 12:11 :11 PM <br />