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DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency The Exchange Club's Family Center in <br /> Alamance County Received By <br /> Pate/Tithe. �, <br /> Program(s) Parent Aide Program '' '..,_,... <br /> Section Subsection <br /> 1. Cover Page 9 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. r 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. n Description of Population to be Served <br /> g. ® Program Staffing,Capacity, &Expertise <br /> h. ® Program Implementation Timeline <br /> L ®Value of Investment <br /> j. ® Impact of Reduced/No Allocation <br /> It. ® 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 /> of receipts and expenditures in a fiscal year,must secure an audit. <br /> b. ® IRS Federal Form 990 <br /> c. ® NC Solicitation License <br /> d_ ® IRS Federal Tax-Exemption Letter <br /> e. Certificate of Insurance <br /> f. ® List of Board of Directors <br /> g. ® Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/27/2017 1:48.20 PM Page I of 12 <br />