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DocuSign Envelope ID: EA54395E-EA79-461 B-8A4A-AODF56E9A02D <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency A Helping Hand <br /> Received By <br /> Program(s) Caregivinq Collaboration Date/Time <br /> Section Subsection <br /> 1. Cover Page a. y Applicant Contact Information <br /> b. Funding Requests <br /> c. E igned 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. 121 Agency's Purpose/Mission <br /> c. Ezi Agency's Types of Services Provided <br /> d. 2/Agency's Experience with Programs <br /> e. g Other Pertinent Agency Information <br /> f. [�Schedule of Positions <br /> g. al Living Wage <br /> h. [Agency Budget <br /> 3. Program Information a. Human Services Needs Priority <br /> b. Q Type of Program <br /> A separate Section 3 is c. [l Agency Collaboration <br /> required for each program. d. Ei Summary of Program <br /> e. EA Description of Identified Need <br /> f. [/1 Description of Population to be Served <br /> g. 0 Program Staffing, Capacity, &Expertise <br /> h. Er Program Implementation Timeline <br /> i. [,1f Value of Investment <br /> j. E Impact of Reduced/No Allocation <br /> k. [ Other Pertinent Information <br /> I. © Target Population/Beneficiary Chart <br /> m. [A 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. 0 IRS Federal Form 990 <br /> c. d NC Solicitation License <br /> d. [ IRS Federal Tax-Exemption Letter <br /> e. 0 Certificate of Insurance <br /> f. 'List of Board of Directors <br /> g. 0 Solid Waste Program Fee(SWPF)Verification <br /> Application Submittal Checklist 1/31/2017 3:19:07 PM <br />