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DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency TABLE, Inc. Date/Time <br /> Complete Y/N <br /> Program(s) Weekend Meal Backpack Program <br /> Section For CDBG & HOME - <br /> Subsection HUD Regulations <br /> 1. Cover Page I a. 1 Applicant Contact Information <br /> b. lo 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. i1 Agency's Purpose/Mission 570.507, 570.610; 24 <br /> CFR Parts 84 or 85 <br /> c. Z1 Agency's Types of Services Provided <br /> d. Agency's Experience <br /> e II Other Pertinent Information <br /> 3. Program/ a. 1 Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. 1 Summary of Program 570.201-570 208, <br /> Information - 507,503 <br /> c. 11 Description of Identified Need <br /> (for each d. kh Description of Population to be Served <br /> program/ <br /> e. 1 4 Activity Manager and Location Description <br /> project for <br /> which funding f. Activity Implementation Timeline <br /> is requested) g' I, Agency Collaboration <br /> h. El 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 /> L 1i4 Signed Conflict of Interest Disclosure <br /> m. r Complete Work Statement <br /> I e <br />