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DocuSign Envelope ID:60192208-BFA3-4E38-9277-B2390FDDC97D <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION -_ <br /> FOR OFFICE USE ONLY <br /> Received By <br /> Agency Behavioral Insights, Inc. <br /> Date/Time <br /> Program(s): Programming to Fulfill Court & CPS ���� w,. �x un � � �u_ �__.wA, - <br /> Mandates <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 1/30/2017 10:59:14 AM Page 5 of 21 <br />