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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> j FOR OFFICE...USE O NLY <br /> Agency Bridge II Sports <br /> Received By <br /> Program(s) _Boccia & Wheelchair Basketball _ Date/Time / <br /> wrr,rraA14f 14f 14f 144f 144f 144f 144f 14f 14f 14f J14f 14f 14f 14f 14f 14f 14f 14f 14f 14f 14f 144f 144f 144f 144f 14rJ14f 14f 144f 144f 144f 14f 14f J14f 14f 144f 144f 144f 144f 14f 144f 144f 14f 14 <br /> Section Subsection <br /> 1. Cover Page a. ® Applicant Contact Information <br /> b. ® Funding Requests <br /> c. ® Signed Application Cover Page <br /> d. Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. ® Agency's Years in operation <br /> b. ® Agency's Purpose/Mission <br /> c. ® Agency's Types of Services Provided <br /> d. ® Agency's Experience with Programs <br /> e. ® Other Pertinent Agency Information <br /> f. ® Schedule of Positions <br /> g. ® Living Wage <br /> h. ® Agency Budget <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 program. d. ® Summary of Program <br /> 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 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. ® 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 /> Application Submittal Checklist 1/27/2017 3:48:29 PM Pago 5 of 2G <br />