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DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. Program Information a. El Human Services Needs Priority <br /> b. El Type of Program <br /> A separate Section 3 is c. ❑Agency Collaboration <br /> required for each d. ❑Summary of Program <br /> program. e. ❑Description of Identified Need <br /> f. El Description of Population to be Served <br /> g. ❑Program Staffing, Capacity, & Expertise <br /> h. El Program Implementation Timeline <br /> i. ❑Value of Investment <br /> j. El Impact of Reduced/No Allocation <br /> k. ❑Other Pertinent Information <br /> I. El Target Population/Beneficiary Chart <br /> m. ❑Work Statement <br /> n. El Program Budget, Detail, & Cost per Individual <br /> 4. Attachments a. ❑Audit: Organizations receiving $300,000 or more in <br /> Federal financial assistance, and/or organizations with <br /> more than $500,000 of receipts and expenditures in a <br /> 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 /> DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 7 r 31 <br />