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DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST <br /> Agency Boys & Girls Clubs of Eastern Piedmont <br /> Program(s) Chapel Hill Community for Impact program <br /> Section Subsection For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. N Applicant Contact Information <br /> b. N 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, 570.507, <br /> Information - b. ® Agency's Purpose/Mission 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. ® Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. ® Summary of Program 570.201-570. 208, <br /> Information - 507.503 <br /> c. ® Description of Identified Need <br /> (for each <br /> 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 /> Other Pertinent Information <br /> j. ® Complete Target Population/Beneficiary Chart <br /> k. N Complete Schedule of Positions <br /> I. ® Signed Conflict of Interest Disclosure <br /> m.171 Complete Work Statement <br />