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DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency TABLE Inc. <br /> Received By <br /> Programs) Weekend Meal Backpack Program Date/Time / <br /> Section Subsection <br /> 1. Cover Page a. ® Applicant Contact Information <br /> b. ® Funding Requests <br /> c. Z Signed Application Cover Page <br /> d. ZSigned Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. Z Agency's Years in operation <br /> b. ® Agency's Purpose/Mission <br /> c. Z 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. Z 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. Z Value of Investment <br /> j. Z Impact of Reduced/No Allocation <br /> k. ® Other Pertinent Information <br /> I. Z Target Population/Beneficiary Chart <br /> m. ® Work Statement <br /> n. Z 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. Z NC Solicitation License <br /> d. ® IRS Federal Tax-Exemption Letter <br /> e. ® Certificate of Insurance <br /> f. ® List of Board of Directors <br /> g. Z Solid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/30/2017 4:15:08 PM Page 5 of 19 <br />