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DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1"- <br /> FOR OFFICE USE ONLY <br /> Agency: Chapel Hill-Carrboro Public School Four( <br /> I Received By <br /> Program(s): After School Tutoring; Blue Ribbon N Date/Time / , <br /> Advocate <br /> Section Subsection <br /> 1. Cover Page a. x Applicant Contact Information <br /> b. x Funding Requests <br /> c. x Signed Application Cover Page <br /> d. x Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. x Agency's Years in operation <br /> b. x Agency's Purpose/Mission <br /> c. x Agency's Types of Services Provided <br /> d. x Agency's Experience with Programs <br /> e. x Other Pertinent Agency Information <br /> f. x Schedule of Positions <br /> g. x Living Wage <br /> h. x Agency Budget <br /> 3. Program Information a. x Human Services Needs Priority <br /> b. x Type of Program <br /> A separate Section 3 is C. x Agency Collaboration <br /> required for each program. d. x Summary of Program <br /> e. x Description of Identified Need <br /> f. x Description of Population to be Served <br /> g. x Program Staffing, Capacity, & Expertise <br /> h. x Program Implementation Timeline <br /> I x Value of Investment <br /> j. x Impact of Reduced/No Allocation <br /> k. x Other Pertinent Information <br /> I. x Target Population/Beneficiary Chart <br /> m. x Work Statement <br /> n. x Program Budget, Detail, &Cost per Individual <br /> 4. Attachments a. x 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. x IRS Federal Form 990 <br /> c. x NC Solicitation License <br /> d. x IRS Federal Tax-Exemption Letter <br /> e. x Certificate of Insurance <br /> f. x List of Board of Directors <br /> g. x Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/27/2017 10:08:56 AM P a e 5 of 22 <br />