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DocuSign Envelope ID: 10F0B4DA-C8B5-4AB3-9AFA-939AE0010B18 (HIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Agency The Marian Cheek Jackson Center FOR OFFICE USE ONLY <br /> Program(s) Learning Across Generations: Received By <br /> Youth Leadership and Civil Rights Ciiatetrime. <br /> Education <br /> Section Subsection <br /> 1. Cover Page a II Applicant Contact Information <br /> b. r Funding Requests <br /> c, 4 Signed 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. 14 Agency's Purpose/Mission <br /> c. Agency's Types of Services Provided <br /> d. it: Agency's Experience with Programs <br /> e, II Other Pertinent Agency Information <br /> f. X4 Schedule of Positions <br /> g. 10.41 Living Wage <br /> h. ' Agency Budget <br /> I <br /> 3. Program Information a. Human Services Needs Priority <br /> b. i Type of Program <br /> A separate Section 3 is c, 4 Agency Collaboration <br /> required for each program. d. "'" Summary of Program <br /> e. C Description of Identified Need <br /> f. 4 Description of Population to be Served <br /> 9. ""Pril Program Staffing, Capacity, &Expertise <br /> h. Program implementation Timeline <br /> L II Value of Investment <br /> j. C Impact of Reduced/No Allocation <br /> k. L Other Pertinent Information <br /> L 4 Target Population/Beneficiary Chart <br /> rn. 11" Work Statement <br /> n: 0, Program Budget, Detail, & Cost per Individual <br /> 4. Attachments a. 4 Audit: Organizations receiving $300,000 or more in Federal <br /> financial assistance,and/or organizations with ore 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 /> IRS Federal Tax-Exemption Letter <br /> e. 14 Certificate of Insurance <br /> f. kilt List of Board of Directors <br /> g. L Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/31/2017 10:50:57 AM <br />