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DocuSign Envelope ID:E519448F-9F6D-4100-BF62-D7625621FFEB XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Orange County Partnership for Young Children <br /> Received By <br /> Program(s) Transplanting Traditions Community Farm Date/Time <br /> Section Subsection <br /> 1. Cover Page a. Fly Applicant Contact Information <br /> b. 04 Funding Requests <br /> C. I Signed Application Cover Page <br /> d. I Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. 1 Agency's Years in operation <br /> b. Agency's Purpose/Mission <br /> c. 1-41 Agency's Types of Services Provided <br /> d. 1 Agency's Experience with Programs <br /> e. A, Other Pertinent Agency Information <br /> f. I Schedule of Positions <br /> g. 1 Living Wage <br /> h. r Agency Budget <br /> 3. Program Information a. l Human Services Needs Priority <br /> b. r1 Type of Program <br /> A separate Section 3 is c. X4 Agency Collaboration <br /> required for each program. d. i4 Summary of Program <br /> e. Description of Identified Need <br /> f. ■ Description of Population to be Served <br /> g. i4 Program Staffing, Capacity, & Expertise <br /> h. 1.1 Program Implementation Timeline <br /> i. Value of Investment <br /> j. Impact of Reduced/No Allocation <br /> k. I4 Other Pertinent Information <br /> I. k■ Target Population/Beneficiary Chart <br /> m. Work Statement <br /> n. i1 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. X4 IRS Federal Form 990 <br /> C. I NC Solicitation License <br /> d. Z IRS Federal Tax-Exemption Letter <br /> e. I1 Certificate of Insurance <br /> f. 4,4 List of Board of Directors <br /> g. Solid Waste Program Fee(SWPF)Verification <br /> Application Submittal Checklist 1/31/2017 3:59:06 PM Page 2 of 18 <br />