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DocuSign Envelope ID:4F0B7605-00EB-4D90-837E-574BBBBD89EB Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency EmPOWERment, Inc. Date/Time <br /> Complete Y./N <br /> Program(s) Funding for Property Manager <br /> Section Subsection <br /> For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. E3Applicant Contact Information <br /> b. oject/Program Contact Information <br /> c. M-Funding Requests identified <br /> d. "'gned Application Cover Page <br /> 2. Agency a. 111 Agency's Years in operation 24 CFR 570.506, <br /> Information - b. El ;Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. J - ''Agency's Experience <br /> e. E2/Other Pertinent Information <br /> 3. Program/ a. ZI,TY'pe of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. 74—Symmary of Program 570.201-570. 208, <br /> Information - 507,503 <br /> C. 1, tescription of Identified Need <br /> (for each <br /> d. (L.../Description of Population to be Served <br /> program/ <br /> e. DActivity Manager and Location Description <br /> project for <br /> which funding .f It/ Activity Implementation Timeline <br /> U,Agency Collaboration <br /> is requested) g° <br /> h. Dt„escribe Impact of Reduced/No Allocation <br /> L :_td37er Pertinent InformationinCOA.S.... <br /> j. Complete Target Population/Beneficiary Chart <br /> k. [' complete Schedule of Positions <br /> V/Signed Conflict of Interest Disclosure <br /> m. Z,Complete Work Statement <br /> if <br />