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DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION S( mBNIITIAL CHECKLIST FOR OFFICE USE ONLY <br /> Recelved By <br /> Agency Historic Hilisborou.h Commission Date/Tie <br /> Complete Y N <br /> Program(s) Visitor Se ryices at the Burwell Schopi <br /> Historic Site <br /> For CDBG & HOME - <br /> Section Subsection HUD Regulations <br /> 1. Cover Page <br /> 2. Agency a. Agency's Years in operation 24 CFR 570,506, <br /> information b. [2]. Agency's Purpose/Mission 570 507, 57o610; 24 <br /> CFR Pans 84 or 85 <br /> c. Agency's Types of Services Provided <br /> Agency's Experie ce <br /> e. Li Other Pertinent information <br /> 3. Program/ a. El Type of Application and Program identified 24 CFR 570200(a), <br /> Project b. Of Summary of Program 570.201-570 208, <br /> information - c, El Description of Identified Need 507 503 <br /> (for c ch <br /> d r- <br /> Descriptio of P,p,datIOrI to be Served <br /> program/ <br /> project for e. Li Activity Manager and Location Description <br /> f. elf Activity Implementation Timeline <br /> which funding <br /> is requested) g. LI Agency Collaboration <br /> h. El Describe Impact of Reduced/No Allocation <br /> L El Other Pertinent information <br /> j. Col pleto Target Pop lati nii3e eficiary Chart <br /> k. LI Complete Schedule of Positions <br /> I. ix Signed Conflict of Interest Disclosure <br /> m. El Complete Work Statement <br />