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DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Agency The Arc of the Triangle FOR OFFICE USE ONLY <br /> Received By <br /> Program(s) Social, Volunteer, Individual Services Date/Time <br /> Section Subsection <br /> 1. Cover Page a. x Applicant Contact Information <br /> b. x Funding Requests <br /> C. ❑ Signed Application Cover Page <br /> d. ❑Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. x Agency's Years in operation <br /> b. x Agency's Purpose/Mission <br /> c. x Agency's Types of Services Provided <br /> d. x Agency's Experience with Programs <br /> e. x Other Pertinent Agency Information <br /> f. x Schedule of Positions <br /> g. x Living Wage <br /> h. x Agency Budget <br /> 3. Program Information a. x Human Services Needs Priority <br /> b. x Type of Program <br /> A separate Section 3 is c. x Agency Collaboration <br /> required for each program. d. x Summary of Program <br /> e. x Description of Identified Need <br /> f. x Description of Population to be Served <br /> g. x Program Staffing, Capacity, & Expertise <br /> h. x Program Implementation Timeline <br /> L x Value of Investment <br /> j. x Impact of Reduced/No Allocation <br /> k. x Other Pertinent Information <br /> I. x Target Population/Beneficiary Chart <br /> M. x Work Statement <br /> n. x 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. x IRS Federal Form 990 <br /> c. x NC Solicitation License <br /> d. x IRS Federal Tax-Exemption Letter <br /> e. x Certificate of Insurance <br /> f. x List of Board of Directors <br /> g. x Solid Waste Program Fee(SWPF)Verification <br /> Application Submittal Checklist 1/26/2017 5:52:39 PM P a g e 5 of 26 <br />