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DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 <br /> EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency _The Exchange Club's Family Center in Date/Time <br /> Alamance I Complete Y/N <br /> Program(s) _Parent Aide Services <br /> Section Subsection For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. 14 Applicant Contact Information <br /> b. Project/Program Contact Information <br /> c. i4 Funding Requests Identified <br /> d. X4 Signed Application Cover Page <br /> 2. Agency a. 14 Agency's Years in operation 24 CFR 570.506, <br /> Information - b. 74 Agency's Purpose/Mission 570.507, 570.610;24 <br /> C. A. Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. Agency's Experience <br /> a. I Other Pertinent Information <br /> 3. Program/ a. Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. I Summary of Program 570.201-570. 208 <br /> Information- 507.503 <br /> c. I1 Description of Identified Need <br /> (for each <br /> d. i1 Description of Population to be Served <br /> program/ <br /> e. 4 Activity Manager and Location Description <br /> project for <br /> which funding <br /> Activity Implementation Timeline <br /> 1* <br /> is requested) g' Agency Collaboration <br /> h. i4 Describe Impact of Reduced/No Allocation <br /> I. L Other Pertinent Information <br /> j. ■ Complete Target Population/Beneficiary Chart <br /> k. 4 Complete Schedule of Positions <br /> I. Signed Conflict of Interest Disclosure <br /> m. Complete Work Statement <br /> iiPage <br />