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DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 <br />Agency <br />Program(s) <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />FOR OFFICE USE ONLY <br />Received By <br />Date /Time / <br />Section <br />Subsection <br />1. Cover Page <br />a. <br />❑ Applicant Contact Information <br />b. <br />❑ Funding Requests <br />C. <br />❑ Signed Application Cover Page <br />d. <br />❑Signed Disclosure of Conflicts of Interest and Clause <br />2. Agency Information <br />a. <br />❑ Agency's Years in operation <br />b. <br />❑ Agency's Purpose /Mission <br />c. <br />❑ Agency's Types of Services Provided <br />d. <br />❑ Agency's Experience with Programs <br />e. <br />❑ Other Pertinent Agency Information <br />f. <br />❑ Schedule of Positions <br />g. <br />❑ Living Wage <br />h. <br />❑ Agency Budget <br />3. Program Information <br />a. <br />❑ Human Services Needs Priority <br />b. <br />❑ Type of Program <br />A separate Section 3 is <br />c. <br />❑ Agency Collaboration <br />required for each program. <br />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 />L <br />❑ Value of Investment <br />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 />n. <br />❑ Program Budget, Detail, & Cost per Individual <br />4. Attachments <br />a. <br />❑ 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. <br />❑ IRS Federal Form 990 <br />c. <br />❑ NC Solicitation License <br />d. <br />❑ IRS Federal Tax - Exemption Letter <br />e. <br />❑ Certificate of Insurance <br />f. <br />❑ List of Board of Directors <br />g. <br />❑ Solid Waste Program Fee (SWPF) Verification <br />Application Submittal Checklist 2/9/2017 4:31:06 PM Page 5 of 22 <br />