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DocuSign Envelope ID: B67A2C26-3304-4095-BB1C-73A2BC4A569A <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> O Supplies & Equipment <br /> O Travel & Training <br /> O Other Expenses <br /> 2. Program Budget Detail — Provide description of "other" budget items, not defined. <br /> Other Revenue: Loan payments from homeowners. Other Expenses: Materials and <br /> subcontracted labor. <br /> 3. This program budget represents what percent of the agency budget? 5.8% FY17 <br /> 4. COST PER INDIVIDUAL <br /> This Cost per Individual must reflect the total program budget divided by the total number of program <br /> individuals in this application. <br /> Actual 2015-16 Estimated 2016-17 Projected 2017-18 <br /> Total Cost of Program $127,604 $188,446 $211,080 <br /> Total # of Individuals 17 26 30 <br /> Cost Per Individual $7,506 $7,245 $7,036 <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 or <br /> more a financial audit, prepared by a certified public accountant is required. Agencies with <br /> prior year revenues of less than $500,000 may submit a completed Schedule of Receipts <br /> and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a <br /> 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' table guide, for more details. For Form 990-N (e- <br /> 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 /> Frequently Asked Questions Guide (P F), 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-Exemption Letter <br /> A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An <br /> agency can request a copy of its letter from the IRS' Customer Account Services. <br /> e) Certificate of Liability Insurance <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 2:31 :06 PM Page "'e of 1 <br />