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DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Dispute Settlement Center Received By <br /> Program(s) Mediation Date/Time / <br /> I RRRrRRRRRREFFEEFFERRr RRRREFFERRRRRRRRRRfiRRRRRRRRREFFERRRRRr7RRRRRRRRRRRRRRREFFE RRRRRRRRRRRRRREFFEfiRRRRRRRRRRRRRRRRRRRRr7REFFERRRE <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. x1=1 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 2/8/2017 11:26:12 AM Page 5 r 2 2 <br />