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DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Charles House Association <br /> Received By <br /> Program(s) jme Eldercao Date/Time <br /> Sbsectoj <br /> 1. Cover Page a. Applicant Contact Information <br /> b. Funding Requests <br /> C. Pr Signed Application Cover Page <br /> d. WSigned Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. 911 Agency's Years in operation <br /> b. A, Agency's PurposelMission <br /> c. IX Agency's Types of Services Provided <br /> d. V Agency's Experience with Programs <br /> e. 2 Other Pertinent Agency Information <br /> f. 2 Schedule of Positions <br /> g. 14 Living Wage <br /> h. 4 Agency Budget <br /> 3. Program Information a. ■41 Human Services Needs Priority <br /> b. Type of Program <br /> A separate Section 3 is c. NI Agency Collaboration <br /> required for each program. d. Summary of Program <br /> e. VI Description of Identified Need <br /> L 44 Description of Population to be Served <br /> g. 1,1 Program Staffing, Capacity, & Expertise <br /> Fr Program Implementation Timeline <br /> i. r4 Value of Investment <br /> j. Impact of Reduced/No Allocation <br /> k. 1 Other Pertinent Information <br /> I. 2 Target Population/Beneficiary Chart <br /> m. 14 Work Statement <br /> n. A Program Budget, Detail, & Cost per Individual <br /> 4. Attachments a. IL 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. 4 NC Solicitation License <br /> d. II IRS Federal Tax-Exemption Letter <br /> e. 12 Certificate of Insurance <br /> f. List of Board of Directors <br /> g. Af Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/27/2017 4:52:00 PM Page "I of 1 6 <br />