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DocuSign Envelope ID: DDOCFB62- 8EDD- 4B57- ACF6- 9C98BO78AA95 XHIBIT A <br />PROVIDER'S OUTSIDE AGENCY APPLICATION <br />FOR OFFICE USE ONLY <br />Agency Orange County Literacy Council Received By <br />Program(s) Adult Literacy, Family Reading Partne Date/Time / <br />1. Cover Page a. <br />b. <br />C. <br />d. <br />® Applicant Contact Information <br />®Funding Requests <br />®Signed Application Cover Page <br />®Signed Disclosure of Conflicts of Interest and Clause <br />2. Agency Information a. ®Agency's Years in operation <br />b. ® Agency's Purpose /Mission <br />c. ® Agency's Types of Services Provided <br />d. ® Agency's Experience with Programs <br />e. ® Other Pertinent Agency Information <br />f. ® Schedule of Positions <br />g. ® Living Wage <br />h. ® Agency Budget <br />3. Program Information a. <br />® Human Services Needs Priority <br />b. <br />®Type of Program <br />A separate Section 3 is c. <br />® Agency Collaboration <br />required for each program. ' d. <br />® Summary of Program <br />e. <br />® Description of Identified Need <br />f. <br />® Description of Population to be Served <br />g. <br />®Program Staffing, Capacity, & Expertise <br />h. <br />®Program implementation Timeline <br />i. <br />® Value of Investment <br />I j. <br />®Impact of Reduced /No Allocation <br />k. <br />® Other Pertinent Information <br />I. <br />® Target Population /Beneficiary Chart <br />M. <br />® Work Statement <br />In. <br />® 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 />Application Submittal Checklist 1/31/2017 10:55:42 AM Page 1 of 26 <br />