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DocuSign Envelope ID E9DE81F9-0070-4074-8F70-93DABC2 4ACE1 _xhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST <br /> FOR OFFICE USE ONLY <br /> Received By <br /> Agency The Women's Center inc. dba Com oass Center Date/Time <br /> for Women and Families <br /> Complete Y/N <br /> Program(s) Domestic Violence Crisis Services Self-Sufficienc Proorams & Communit <br /> Education & Civic En a•ement <br /> Section <br /> S ubsection For CDBG & HOME- <br /> HUD Regulations <br /> 1. Cover Page a. ErApplicant Contact Information <br /> b. [ 'Project/pro gram Contact Information <br /> c, 4Funding Requests Identified <br /> d. Signed Application Cover Page <br /> 2. Agency a. [ Agency's Years in operation <br /> 24 CFR 570.506, <br /> Information - b. DrAgency's Purpose/Mission 570,507, 570.610; 24 <br /> C. LaAgency's Types of Services Provided <br /> CFR Parts 84 or 85 <br /> d. 4Agency's Experience <br /> e. Other Pertinent Information <br /> 3. Program/ a. 2 Type of Application and Program Identified 24 CFR 570,200(a), <br /> Project <br /> b. faSurnmary of Program <br /> 570.201570, 208, <br /> Information - <br /> C. {a Description of Identified Need 507 503 <br /> (for each cl. 4Description of Population to be Served <br /> program/ e, 2 Activity Manager and Location Description <br /> project for <br /> f. Activity Implementation <br /> which funding Timeline <br /> is requested) g. EA-Agency Collaboration <br /> h. 4Describe Impact of Reduced/No Allocation <br /> IOther Pertinent Information <br /> j. 2 Complete Target Population/Beneficiary Chart <br /> k. 2 Complete Schedule of Positions <br /> I. 4Signed Conflict of Interest Disclosure <br /> m. El Complete Work Statement <br /> iiPage <br />