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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 3. Program Information a. ❑ Human Services Needs Priority <br /> b. ❑Type of Program <br /> Afterschool Program C. ❑Agency Collaboration <br /> d. ❑Summary of Program <br /> e. ❑Description of Identified Need <br /> f. ❑Description of Population to be Served <br /> g. ❑Program Staffing, Capacity, & Expertise <br /> h. ❑Program Implementation Timeline <br /> i. ❑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. ❑Program Budget, Detail, & Cost per Individual <br /> 3A. Program Information 0. ❑Human Services Needs Priority <br /> p. ❑Type of Program <br /> Day Camp Program. q. ❑Agency Collaboration <br /> r. ❑Summary of Program <br /> S. ❑Description of Identified Need <br /> t. ❑Description of Population to be Served <br /> u. ❑Program Staffing, Capacity, & Expertise <br /> v. ❑Program Implementation Timeline <br /> w. ❑Value of Investment <br /> x. ❑Impact of Reduced/No Allocation <br /> y. ❑Other Pertinent Information <br /> z. ❑Target Population/Beneficiary Chart <br /> aa. ❑Work Statement <br /> bb.❑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. ❑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 /> 1/12/2017 2:56:42 PM I:' 3 ,r 29 <br />