Orange County NC Website
Browse       Search
DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Orange Congregations In Mission <br /> Received By <br /> Program(s) Meals on Wheels Date/Time <br /> Samaritan Relief Ministry - <br /> Section Subsection <br /> 1. Cover Page a. El/Applicant Contact Information <br /> b. Er-Funding Requests <br /> c. E1 Signed Application Cover Page <br /> d. ,[2igned Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. Agency's Years in operation <br /> b. E Agency's Purpose/Mission <br /> c. 171 Agency's Types of Services Provided <br /> d. II Agency's Experience with Programs <br /> e. n Other Pertinent Agency Information <br /> f. II Schedule of Positions <br /> g. 0Living Wage <br /> h. [El Agency Budget <br /> 3. Program Information a. Human Services Needs Priority <br /> b. EjTypeofProgram <br /> A separate Section 3 is C. El Agency Collaboration <br /> required for each program. d. Er Summary of Program <br /> e. 0 Description of Identified Need <br /> f. ET Description of Population to be Served <br /> g. 0 Program Staffing, Capacity, & Expertise <br /> h. 0 Program Implementation Timeline <br /> 1. EIF Value of Investment <br /> j. El Impact of Reduced/No Allocation <br /> k. E Other Pertinent Information <br /> L L.,,r Target Population/Beneficiary Chart <br /> m. 0Work Statement <br /> n. IN Program Budget, Detail, &Cost per Individual <br /> 4. Attachments a. Et-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. NC Solicitation License <br /> d. 0"IRS Federal Tax-Exemption Letter <br /> e. 0tertificate of Insurance <br /> f. gList of Board of Directors <br /> g. 0 Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/30/2017 10:05:20 AM P a 5 t 2 3 <br />