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DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 d. ❑ Summary of Program <br /> program. e. ❑ Description of Identified Need <br /> f. ❑ Description of Population to be Served <br /> g. ❑ 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. ❑ 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 <br /> Federal financial assistance, and/or organizations with <br /> more than $500,000 of receipts and expenditures in a <br /> 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 /> Page 3 of 20 <br />