Orange County NC Website
DocuSign Envelope ID:42FC26E4-086D-47F4-A291-0A9A8706CA60 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency El Centro Hispano <br /> Received By <br /> Program(s): ECH-Carrboro Community Services Date/Time <br /> Section Subsection <br /> 1. Cover Page a. 4 Applicant Contact Information <br /> b. i1 Funding Requests <br /> c. I Signed Application Cover Page <br /> d. ■Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. AL 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. I Living Wage <br /> h. I4 Agency Budget <br /> 3. Program Information a. OA Human Services Needs Priority <br /> b. ■ Type of Program <br /> A separate Section 3 is C. A, Agency Collaboration <br /> required for each program. d. J Summary of Program <br /> e. Description of Identified Need <br /> f. 2 Description of Population to be Served <br /> g. ' Program Staffing, Capacity, & Expertise <br /> h. i4 Program Implementation Timeline <br /> i. Fr 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. L 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. Z IRS Federal Form 990 <br /> c. L NC Solicitation License <br /> d. IRS Federal Tax-Exemption Letter <br /> e, Z Certificate of Insurance <br /> f. i4 List of Board of Directors <br /> g. 4 Solid Waste Program Fee (SWPF) Verification <br /> Application Submittal Checklist 1/31/2017 3:16:25 PM Page 2 of 32 <br />