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APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br />Received By <br />Agency Piedmont Health Services, Inc. Date /Time / <br />Complete Y / N <br />Program(s) Carrboro Community Health Center <br />Section <br />1. Cover Page <br />Subsection <br />a. ® Applicant Contact Information <br />b. ® Project /Program Contact Information <br />c. ® Funding Requests Identified <br />d. ® Signed Application Cover Page <br />For CDBG & • <br />HUD Regulations <br />2. Agency <br />a. ® Agency's Years in operation <br />24 CFR 570.506, <br />Information - <br />b. ® Agency's Purpose /Mission <br />570.507, 570.610; 24 <br />c. ® Agency's Types of Services Provided <br />CFR Parts 84 or 85 <br />d. ® Agency's Experience <br />e. ® Other Pertinent Information <br />3. Program/ <br />a. ® Type of Application and Program Identified <br />24 CFR 570.200(a), <br />Project <br />b. ® Summary of Program <br />570.201 -570. 208, <br />Information - <br />c. ® Description of Identified Need <br />507.503 <br />(for each <br />d. ® Description of Population to be Served <br />program/ <br />e. ® Activity Manager and Location Description <br />project for <br />f. ® Activity Implementation Timeline <br />which funding <br />is requested) <br />g• ®Agency Collaboration <br />h. ® Describe Impact of Reduced /No Allocation <br />i. ® Other Pertinent Information <br />j. ® Complete Target Population /Beneficiary Chart <br />k. ® Complete Schedule of Positions <br />I. ® Signed Conflict of Interest Disclosure <br />m. ® Complete Work Statement <br />i I P a g e <br />