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DocuSign Envelope ID:88377437-EE99-4E08-B6B1-CD4F113C0672 <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 2015- <br /> 16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more <br /> a financial audit, prepared by a certified public accountant is required. Agencies with prior <br /> year revenues of less than $500,000 may submit a completed Schedule of Receipts and <br /> 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. § 131 F- <br /> 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 /> A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below <br /> outlines insurance types and minimums required, for each jurisdiction. If exempt from <br /> Worker's Compensation compliance, include a statement explaining why, with the agency's <br /> application materials. *Note: If Approved for Funding: Approved agencies must provide an <br /> updated insurance certificate. The update should reflect the funding jurisdiction as an <br /> additional insured party and certificate holder and provide coverage for the duration of the <br /> funding period(July 1 —June 30). Renewal certificates must be sent to the jurisdiction 30 days <br /> prior to any expiration date, cancellation or modification of any stipulated insurance coverage. <br /> DO NOT SUBMIT THIS PAGE 1/27/2017 3:48:29 PM P a g e 25 of 2G <br />