2018-451-E Finance - The Arts Center outside agency agreement

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DocuSign Envelope ID: C47D73DC -CC50- 4723 - 8253- AE01785E7FAA EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. This program budget represents what percent of the agency budget? 38.2% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2016, for calendar year agencies, and FY 2016- 17, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit /report. Agencies with a certified audit /report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2016 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990 -N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131 F- 3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax - Exemption Letter A copy of the agency's IRS tax - exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an PROGRAM INFORMATION 1/23/2018 1:53:53 PM Page 20 of 22 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program $542,983 $559,410 $576,353 Total # of Individuals 31,708 32,818 33,967 Cost Per Individual $17.12 $17.04 $16.96 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2016, for calendar year agencies, and FY 2016- 17, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit /report. Agencies with a certified audit /report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2016 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990 -N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131 F- 3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax - Exemption Letter A copy of the agency's IRS tax - exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an PROGRAM INFORMATION 1/23/2018 1:53:53 PM Page 20 of 22