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DocuSign Envelope ID:82431AC9-7F03-4084-815E-A2EFB34C92BB Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency Inter-Faith Council for Social Service Date/Time / <br /> Complete Y N <br /> Program(s) Community House, HomeStart, <br /> Community Services <br /> Section Subsection For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. 0 Applicant Contact Information <br /> b. [..3 Project/Program Contact Information <br /> c. Funding Requests Identified <br /> d1 0 Signed Application Cover Page <br /> 2. Agency a. E Agency's Years in operation 24 CFR 570.506, <br /> Information - b. L Agency's Purpose/Mission 570.507, 570.610; 24 <br /> CFR Parts 84 or 85 <br /> c. E Agency's Types of Services Provided <br /> d. L Agency's Experience <br /> e. E Other Pertinent Information <br /> 3. Program/ a. E Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. E Summary of Program 570.201-570. 208, <br /> Information - 507.503 <br /> c. fl Description of Identified Need <br /> (for each -- <br /> d. Description of Population to be Served <br /> program/ <br /> e. E Activity Manager and Location Description <br /> project for <br /> which funding C Activity Implementation Timeline <br /> is requested) g. T. Agency Collaboration <br /> h. C Describe Impact of Reduced/No Allocation <br /> I. C Other Pertinent Information <br /> j. C Complete Target Population/Beneficiary Chart <br /> k. C Complete Schedule of Positions <br /> Signed Conflict of Interest Disclosure <br /> m. C Complete Work Statement <br /> ilPage <br />