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DocuSign Envelope ID.72266CE5-DF5A-471E-B671-CC65C8960691 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency EmPOWERment <br /> Received By <br /> Program(s) Rental Property Management Date/Time <br /> Section Subsection <br /> 1. Cover Page a, Applicant Contact Information <br /> b. II 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. 1,1 Agency's Types of Services Provided <br /> d. 19 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. l■ Human Services Needs Priority <br /> b. Type of Program <br /> A separate Section 3 is c. IA Agency Collaboration <br /> required for each program. d. F9 Summary of Program <br /> e. ■ Description of Identified Need <br /> f. a Description of Population to be Served <br /> g. Program Staffing, Capacity, & Expertise <br /> h. E Program Implementation Timeline <br /> i. I Value of Investment <br /> j. Impact of Reduced/No Allocation <br /> k. i4 Other Pertinent Information <br /> I. ■ Target Population/Beneficiary Chart <br /> m. ■ Work Statement <br /> n. A 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. IA Certificate of Insurance <br /> f. I List of Board of Directors <br /> g. II Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/25/2017 4:42:59 PM P 5 5 o 2 <br />