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Application Submittal Checklist 2/9/2017 4:13:51 PM Page 5 of 22 <br />Agency _____Triangle Bikeworks_________ <br />Program(s) __Spoke’n Revolutions________ <br />Section Subsection <br />1. Cover Page a.Applicant Contact Information <br />b.Funding Requests <br />c.Signed Application Cover Page <br />d.Signed Disclosure of Conflicts of Interestand Clause <br />2.Agency Informationa.Agency’s Years in operation <br />b.Agency’s Purpose/Mission <br />c.Agency’s Types of Services Provided <br />d.Agency’s Experiencewith Programs <br />e.Other Pertinent Agency Information <br />f.Schedule of Positions <br />g.Living Wage <br />h.Agency Budget <br />3.Program Information <br />A separate Section 3 is <br />required for eachprogram. <br />a.Human Services Needs Priority <br />b.Type of Program <br />c.Agency Collaboration <br />d.Summary of Program <br />e.Description of Identified Need <br />f.Description of Population to be Served <br />g.Program Staffing, Capacity, & Expertise <br />h.Program Implementation Timeline <br />i.Value of Investment <br />j. Impact of Reduced/No Allocation <br />k.Other Pertinent Information <br />l.Target Population/Beneficiary Chart <br />m.Work Statement <br />n.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.IRS Federal Form 990 <br />c. NC Solicitation License <br />d.IRS Federal Tax-Exemption Letter <br />e. Certificate of Insurance <br />f.List of Board of Directors <br />g.Solid Waste Program Fee (SWPF) Verification <br />FOR OFFICE USE ONLY <br />Received By ________ <br />Date/Time ___________/_________ <br />EXHIBIT A <br />PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 0D59222E-5A4E-4094-9D22-7F342E2FD1A3