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DocuSign Envelope ID: 1A43D806-0D44-4AC1-898C-3042FDBCA241 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Child Care Services Association Received By <br /> Date/Time <br /> Program(s) Child Care Scholarship Program <br /> Section Subsection <br /> 1. Cover Page a. IZ Applicant Contact Information <br /> b. El Funding Requests <br /> C. 4 Signed Application Cover Page <br /> d. 1 Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. [3] Agency's Years in operation <br /> b. IZIAgency'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. r Schedule of Positions <br /> g. 1 4 Living Wage <br /> h. L Agency Budget <br /> 3. Program Information a. 1 Human Services Needs Priority <br /> b. ■ Type of Program <br /> A separate Section 3 is C. Ej Agency Collaboration <br /> required for each program. d. IZI Summary of Program <br /> e. Description of Identified Need <br /> f. Description of Population to be Served <br /> g. El 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. 1 Target Population/Beneficiary Chart <br /> m. L 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. 14 IRS Federal Form 990 <br /> c. NC Solicitation License +additional supporting document <br /> d. Ej IRS Federal Tax-Exemption Letter <br /> e. L Certificate of Insurance <br /> f. 4 List of Board of Directors <br /> g. i1 Solid Waste Program Fee (SWPF) Verification <br /> Application Submittal Checklist 1/27/2017 8:51:47 AM n ) <br />