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DO NOT SUBMIT THIS PAGE 2/9/2017 4:13:51 PM Page 20 of 22 <br />4.ATTACHMENTS <br />Description of Required Attachments <br />a)Financial Audit <br />A recent financial audit that should cover CY 2015, for calendar year agencies, and FY <br />2015-16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or <br />more a financial audit, prepared by a certified public accountant is required. Agencies with <br />prior year revenues of less than $500,000 may submit a completed Schedule of Receipts <br />and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a <br />certified audit/report should not complete the form. <br />b)IRS Federal Form 990 <br />A copy of the agency’s 2014 Form 990 is required. The specific form depends upon the <br />agency’s financial activity. Review the IRS’ table guide, for more details. For Form 990-N (e- <br />postcard) filers, include a copy of the postcard, with the agency’s application materials. <br />c)NC Solicitation License <br />A copy of the agency’s current solicitation license is required. Organizations that solicit <br />contributions in North Carolina, directly or through a third party, must renew their licenses <br />annually. For more details, refer to the NC Secretary of State’s licensing website and its <br />Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § <br />131F-3, include a copy of the exemption letter with the agency’s application materials. <br />d)IRS Federal Tax-Exemption Letter <br />A copy of the agency’s IRS tax-exempt letter that confirms its nonprofit status is required. An <br />agency can request a copy of its letter from the IRS’ Customer Account Services. <br />e)Certificate of Liability Insurance <br />A copy of the agency’s current certificate, from the agency’s insurance carrier. Table 1 <br />below outlines insurance types and minimums required, for each jurisdiction. If exempt from <br />Worker’s Compensation compliance, include a statement explaining why, with the agency’s <br />application materials. *Note: If Approved for Funding:Approved agencies must provide an <br />updated insurance certificate. The update should reflect the funding jurisdiction as an <br />additional insured party and certificate holder and provide coverage for the duration of the <br />funding period (July 1 – June 30). Renewal certificates must be sent to the jurisdiction 30 <br />days prior to any expiration date, cancellation or modification of any stipulated insurance <br />coverage. <br />EXHIBIT A <br />PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 0D59222E-5A4E-4094-9D22-7F342E2FD1A3