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DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 4. ATTACHMENTS <br /> Description of Required Attachments <br /> a) Financial Audit <br /> A recent financial audit that should cover CY 2015, for calendar year agencies, and FY <br /> 2015-16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 <br /> or more a financial audit, prepared by a certified public accountant is required. Agencies <br /> with prior year revenues of less than $500,000 may submit a completed Schedule of <br /> Receipts and Expenditures form (see application materials), in lieu of an audit/report. <br /> Agencies with a certified audit/report should not complete the form. <br /> b) IRS Federal Form 990 <br /> A copy of the agency's 2014 Form 990 is required. The specific form depends upon the <br /> agency's financial activity. Review the IRS'tta ie uidq, for more details. For Form 990-N <br /> (e-postcard)filers, include a copy of the postcard, with the agency's application materials. <br /> c) NC Solicitation License <br /> A copy of the agency's current solicitation license is required. Organizations that solicit <br /> contributions in North Carolina, directly or through a third party, must renew their licenses <br /> annually. For more details, refer to the NC Secretary of State's licensing website and its <br /> 'roqu °qtly I ed Questions Guide PDF about exemptions. If exempt per N.C.G.S. § <br /> 131 F-3, include a copy of the exemption letter with the agency's application materials. <br /> d) IRS Federal Tax-Exern tion Letter <br /> A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. <br /> An agency can request a copy of its letter from the IRS' Customer Account Services. <br /> e) Certificate of Liability Insurance <br /> A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 <br /> below outlines insurance types and minimums required, for each jurisdiction. If exempt <br /> from Worker's Compensation compliance, include a statement explaining why, with the <br /> agency's application materials. *Note: if Approved for :Approved agencies must <br /> provide an updated insurance certificate. The update should reflect the funding <br /> jurisdiction as an additional insured party and certificate holder and provide coverage for <br /> the duration of the funding period (July 1 — June 30). Renewal certificates must be sent <br /> to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any <br /> stipulated insurance coverage. <br /> Page 18 of 20 <br />