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DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency The Art Therapy Institute <br /> Received By <br /> Program: Newcomer's Art Therapy Program Date/Time / <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 Interest and Clause <br /> 2. Agency Information a. ❑ Agency's Years in operation <br /> b. ❑ Agency's Purpose/Mission <br /> c. ❑ Agency's Types of Services Provided <br /> d. ❑ Agency's Experience with Programs <br /> e. ❑ Other Pertinent Agency Information <br /> f. ❑ Schedule of Positions <br /> g. ❑ Living Wage <br /> h. ❑ Agency Budget <br /> 3. Program Information a. ❑ Human Services Needs Priority <br /> b. ❑ Type of Program <br /> A separate Section 3 is c. ❑ Agency Collaboration <br /> required for each program. 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 /> I. ❑ 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 /> Application Submittal Checklist 2/8/2017 3:01:12 PM Page 5 of 20 <br />