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DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 Exhibit A <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Big Brothers Big Sisters of the Triangle Date/Time <br /> Complete Y/N <br /> RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRrrRRRRRRRRRRRRRRRRRRRRrrRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRrrRRRRRRRRRRRRRRRRRRRRrrre Program(s) Community and School-Based M entori n g <br /> Subsection For CDBG & HOME - <br /> Section HUD Regulations <br /> 1. Cover Page a. ❑ Applicant Contact Information <br /> b. ❑ Project/Program Contact Information <br /> c. ❑ Funding Requests Identified <br /> d. ❑ 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 /> c. ❑ Agency's Types of Services Provided CFR Parts 84 or 85 <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. ❑ Summary of Program 570.201-570. 208, <br /> Information - c. ❑ Description of Identified Need 507.503 <br /> (for each d. ❑ Description of Population to be Served <br /> program/ e. ❑ Activity Manager and Location Description <br /> project for f. ❑ Activity Implementation Timeline <br /> which funding g. ❑ Agency Collaboration <br /> is requested) h. ❑ 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. ❑ Complete Work Statement <br /> Main Application 5/24/2016 8:51:19 AM 0 I:° 1 of 25 <br />