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DocuSign Envelope ID: CBOC1343-06EB-4BE7-9AF6-62EE77BD69FE Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Date/Time <br /> Agency Planned Parenthood South Atlantic <br /> Complete Y/N <br /> Program(s) Sexual Health Education and Outreach Teurtutrummumummututuummuumumummutuummuume <br /> Section Subsection For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. X Applicant Contact Information <br /> b. X Project/Program Contact Information <br /> c. X Funding Requests Identified <br /> d. X Signed Application Cover Page <br /> 2. Agency a. x Agency's Years in operation 24 CFR 570.506, <br /> Information - b. x Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. x Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. x Agency's Experience <br /> e. x Other Pertinent Information <br /> 3. Program/ a. x Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. x Summary of Program 570.201-570. 208, <br /> Information - 507.503 <br /> (for each c. x Description of Identified Need <br /> program/ d. x Description of Population to be Served <br /> project for e. x Activity Manager and Location Description <br /> which funding f. x Activity Implementation Timeline <br /> is requested) g. x Agency Collaboration <br /> h. x Describe Impact of Reduced/No Allocation <br /> i. Other Pertinent Information <br /> j. x Complete Target Population/Beneficiary Chart <br /> k. x Complete Schedule of Positions <br /> I. x Signed Conflict of Interest Disclosure <br /> m. x Complete Work Statement <br /> 1 IF") <br />