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DocuSign Envelope ID: 5F353138-C664-4703-97A3-A28BCE0500B7 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Boomerang Youth, Inc. <br /> Received By <br /> Program(s) Boomerang Date/Time / <br /> Section Subsection <br /> 1. Cover Page a. ❑ Applicant Contact Information <br /> b. ® Funding Requests <br /> c. ❑ Signed Application Cover Page <br /> d. Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. ® Agency's Years in operation <br /> b. ® Agency's Purpose/Mission <br /> c. ❑ Agency's Types of Services Provided <br /> d. ❑ Agency's Experience with Programs <br /> e. ❑ Other Pertinent Agency Information <br /> f. ❑ Schedule of Positions <br /> g. ® Living Wage <br /> h. ® Agency Budget <br /> 3. Program Information a. ® Human Services Needs Priority <br /> b. ® Type of Program <br /> A separate Section 3 is c. ❑ Agency Collaboration <br /> required for each program. d. ® Summary of Program <br /> e. ® Description of Identified Need <br /> f. ❑ Description of Population to be Served <br /> g. ❑ Program Staffing, Capacity, & Expertise <br /> h. ® Program Implementation Timeline <br /> i. ® Value of Investment <br /> j. ® Impact of Reduced/No Allocation <br /> k. [' Other Pertinent Information <br /> I. ❑ Target Population/Beneficiary Chart <br /> m. ® Work Statement <br /> n. ® Program Budget, Detail, & Cost per Individual <br /> 4. Attachments a. ® Audit: Organizations receiving $300,000 or more in Federal <br /> financial assistance, and/or organizations with more than $500,000 <br /> NOTE:Audit and Form 990 are for <br /> the YMCA of the Triangle of receipts and expenditures in a fiscal year, must secure an audit. <br /> b. ❑ IRS Federal Form 990 <br /> NC Solicitation License:YMCA and c. ❑ NC Solicitation License <br /> Boomerang Youth exemptions <br /> attached d. ® IRS Federal Tax-Exemption Letter <br /> e. ❑ Certificate of Insurance <br /> SWPF: Boomerang leases program f. ❑ List of Board of Directors <br /> space from Amity Church in Chapel <br /> Hill g. ® Solid Waste Program Fee (SWPF)Verification <br /> Pago 1 of 15 <br />