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DocuSign Envelope ID:C8D98134-3597-4323-98FA-COCA282OB225 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency —The Marian Cheek Jackson Center Datefrime <br /> Complete Y j N <br /> Programi(s); Learning Across Generations: <br /> Youth Leadership&Civil Rights Education <br /> 1. Cover Page a. Applicant contact Information <br /> b. [aprojectlProgram Contact Information <br /> c, [Funding Requests Identified <br /> d. DISigned Application Cover Page <br /> 12. Agency a, [3 Agency's Years in operation 24 CFR 570.506, <br /> Information- 570�507,570-610:24 <br /> b. Agency's Purpose/ fission <br /> CFR Parts 84 or 85 <br /> c. `Agency's Types of Services Provided d. aAgency's Experience <br /> e, [110ther Pertinent Information I <br /> i 3. Program/ a, 0-Type of Application and Program Identified 24 CFR 570,200(a), <br /> Project 570,201-57 <br /> 0, 208. <br /> � <br /> b. [ Summary of Program <br /> Information- i 1 50T503 <br /> C. Dpescription of Identified Need <br /> (for each d. if Description of Population to be Served <br /> program/ <br /> project for e. Activity Manager and Location Description <br /> which funding f, 0-1,Activity implementation Timeline <br /> is requested) g• aAgency Collaboration <br /> h. [1pescribe Impact of ReducedlNo Allocation <br /> I, [3,0ther Pertinent Infonnation <br /> j. El Complete Target Population/Seneficiary Chart <br /> k. El Complete Schedule of Positions <br /> 1. [11Slgned Conflict of Interest Disclosure <br /> in. ❑ omplete Work Statement <br />