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DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST <br /> I FOR OFFICE USE ONLY <br /> Received By <br /> Agency CHARLES HOUSE ASSOCIATION Date/Time <br /> Complete Y/N <br /> Program(s) Daytime Eldercare Program <br /> Section For CDBG & HOME - <br /> Subsection HUD Regulations <br /> 1. Cover Page a. 1.1 Applicant Contact Information <br /> b. 1411 Project/Program Contact Information <br /> c. or Funding Requests Identified <br /> d. r Signed Application Cover Page <br /> 2. Agency a. Agency's Years in operation 24 CFR 570,506, <br /> Information - b. Agency's Purpose/Mission 570.507, 570.610; 24 <br /> CFR Parts 84 or 85 <br /> c. 4 Agency's Types of Services Provided <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. I Summary of Program 570.201-570. 208, <br /> Information - c. r Description of Identified Need 507.503 <br /> (for each <br /> d. Description of Population to be Served <br /> program/ <br /> e. 11 Activity Manager and Location Description <br /> project for <br /> f. r Activity Implementation Timeline <br /> which funding <br /> is requested) g. Agency Collaboration <br /> h. I 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. 4 Complete Work Statement <br /> ilF) age <br />