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Docu Sign Envelope ID 16AB4DFA-7125-42E6-B3E7-C6B53151B77C Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Voices Together Date/Time <br /> Complete Y/N <br /> Program(s) VT in Education <br /> Section For CDBG & HOME - <br /> Subsection <br /> HUD Regulations <br /> 1. Cover Page a. II Applicant Contact Information <br /> b. WI Project/Program Contact Information <br /> C. 5 Funding Requests Identified <br /> d. I Signed Application Cover Page <br /> 2. Agency a. Agency's Years in operation 24 CFR 570.506, <br /> Information - b. 12I Agency's Purpose/Mission 570.507, 570.610; 24 <br /> CFR Parts 84 or 85 <br /> C. 12I Agency's Types of Services Provided <br /> d. Ei Agency's Experience <br /> e. MI Other Pertinent Information <br /> 3. Program/ a. Li Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. 12I Summary of Program 570.201-570. 208, <br /> Information - 507.503 <br /> C. 12 Description of Identified Need <br /> (for each d. 12 Description of Population to be Served <br /> program/ <br /> e. KJ Activity Manager and Location Description <br /> project for <br /> f. 12 Activity Implementation Timeline <br /> which funding <br /> g.is requested) a 121 Agency Collaboration <br /> - <br /> h. E Describe Impact of Reduced/No Allocation <br /> i. 5 Other Pertinent Information <br /> j. WI Complete Target Population/Beneficiary Chart <br /> k. WI Complete Schedule of Positions <br /> I. I Signed Conflict of Interest Disclosure <br /> m. 121 Complete Work Statement <br /> i a • o <br />