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APPLICATION SUBMITTAL CHECKLIST <br />FOR OFFICE USE ONLY <br />Agency The Women's Center Inc. dba Com ass Center Date/Time <br />Received By_! <br />for Women and Families / "�r— �._�._ <br />Programs) Domestic Violence Crisis Services Self - ►plere Y/ N <br />Education & Civic En a omen# Sufficient P ro rams Community <br />1. <br />Cover Page a• Applicant Contact Information <br />- � i - . • <br />b• E 'Proiect/program Contact <br />Information <br />c• D Funding Requests <br />Identified <br />d. 9 Signed Application Cover <br />Page <br />2. Agency <br />Information <br />a• 12Agency's Years in operation <br />- <br />-- <br />b• Q'Agency's Purpose/Mission <br />24 CFR 570.506 <br />c- "Agency's Types of Services Provided <br />d Agency's Experience <br />570.507 570.690; 24 <br />CFR Parts 84 or 85 <br />e. Other Pertinent Information <br />3. Program/ <br />Project <br />Information <br />a. 9 Type of Application and Program Identified <br />b. aSummary of program <br />24 CFR 570.200(a) <br />- <br />(for each <br />program/ <br />C. CfDescription of Identified Need <br />d• 'Description <br />507.503 570-201-570, 208, <br />project for <br />of Population to be Served <br />e. Activity Manager <br />and Location Description <br />which funding f. Activity Implementation <br />is requested) <br />Timeline <br />g• ©"Agency Collaboration <br />h. ['Describe Impact of Reduced /No Allocation <br />i 'Other Pertinent Information <br />1 © Complete Target Population <br />/Beneficiary Chart <br />k• aComplete Schedule <br />of Positions <br />I. aftned Conflict of Interest <br />Disclosure <br />M. E� Complete Work Statement <br />i I P a g e <br />