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DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 Exhibit A <br /> Provider's Outside Agency Application <br /> FOR OFFICE USE ONLY <br /> Received By <br /> APPLICATION SUBMITTAL CHECKLIST Date/Time / <br /> Complete Y/N <br /> Agency Rogers Eubanks Neighborhood Association <br /> Program(s) Back to School Bash, Garden, Summer Enrichment Camp <br /> 1. Cover Page a, m` pplicant Contact Information <br /> b. jr-ject/Program Contact Information <br /> c. rig unding Requests Identified <br /> d. Signed Application Cover Page <br /> 2. Agency a. [ â– gency's Years in operation 24 CFR 570.506, <br /> Information - b. r Agency's Purpose/Mission 570.507, 570.610, 24 <br /> c. 1111 A,ency's Types of Services Provided CFR Parts 84 or 85 <br /> d. ICI gency'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, E Summary of Program 570.201--570. 208, <br /> Information - c. 24/Description of Identified Need 507.503 <br /> (for each d, escription of Population to be Served <br /> program! e. 1Activity Manager and Location Description <br /> project for <br /> which funding f. Dr ctivity Implementation Timeline <br /> is requested) g. 'Agency Collaboration <br /> h. 79escribe Impact of Reduced/No Allocation <br /> i. ther Pertinent Information <br /> j. omplete Target Population/Beneficiary Chart <br /> k. omplete Schedule of Positions <br /> I. Conflict of Interest Disclosure <br /> m. //igned <br /> Complete Work Statement <br /> C p <br /> 24 CFR 570.200(a), <br /> 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, <br /> each expenses for the entire program and ALL sources of 507.503 <br /> program/ funding. 24 CFR 570.506, <br /> project for 570.507, 570.601, <br /> which funding a. rogram Budget Worksheet 570.602, 570.607(b), <br /> is requested) b. 2 Program Budget Detail 570.611 <br /> c. Cost Per Unit 24 CFR <br /> 1 Page <br />