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DocuSign Envelope ID: E85EF868-A4BB-49ED-96E1-165F3DADBAE4 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Orange County Rape Crisis Center <br /> Received By <br /> Program(s) Client Services & Community Education Date/Time <br /> Section subsection <br /> 1. Cover Page a. 44 Applicant Contact Information <br /> b ri Funding Requests <br /> Signed Application Cover Page <br /> d. LiSigned Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. I Agency's Years in operation <br /> b. Al Agency's Purpose/Mission <br /> C. ri Agency's Types of Services Provided <br /> d. lIl Agency's Experience with Programs <br /> e. lI4 Other Pertinent Agency Information <br /> f. El Schedule of Positions <br /> g. MI Living Wage <br /> h. 114 Agencyl:udget <br /> 3, Program Information a. Human Services Needs Priority <br /> b. 1, Type of Program <br /> A separate Section 3 is c. $21 Agency Collaboration <br /> required for each program. d. 114 Summary of Program <br /> e. 14 Description of Identified Need <br /> r4 Description of Population to be Served <br /> g. L Program Staffing, Capacity, & Expertise <br /> h. le Program Implementation Timeline <br /> L L Value of Investment <br /> j. 114 Impact of Reduced/No Allocation <br /> k. AI Other Pertinent Information <br /> I. 114 Target Population/Beneficiary Chart <br /> m. Z Work Statement <br /> n. IF Program Budget, Detail, &Cost per Individual <br /> 4. Attachments a. El 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. Z IRS Federal Form 990 <br /> c. Ai NC Solicitation License <br /> d. P14 IRS Federal Tax-Exemption Letter <br /> e. 111 Certificate of Insurance <br /> f. List of Board of Directors <br /> g. PO Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/30/2017 5:14:05 PM P q 1 2 2 <br />