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DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC _Xhlblt A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency A Helping Hand Date/Time <br /> Complete Y 1 N <br /> Program(s) Senior Companion Care <br /> Section Subsection For D' <br /> i Regulations <br /> 1. Cover Page a. 2 Applicant Contact Information <br /> b. Z Project/Program Contact Information <br /> c. Funding Requests Identified <br /> d. Signed Application Cover Page <br /> 2. Agency a. ® Agency's Years in operation 24 CFR 570.506, <br /> Information - b. ® Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. ® Agency's Experience <br /> e. Z Other Pertinent Information <br /> 3. Program/ a. ® Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. N Summary of Program 570,201-570. 208, <br /> Information - 507.503 <br /> c. ® +Description of Identified Need <br /> [for each d. E Description of Population to be Served <br /> program/ <br /> I project for e. [Z Activity Manager and Location Description <br /> which funding f. Z Activity Implementation Timeline <br /> is requested} g• Z Agency Collaboration <br /> h. Z Describe Impact of Reduced/No Allocation <br /> i. M Other Pertinent Information <br /> j. Z Complete Target PopulafionlBeneficiary Chart <br /> k. ® Complete Schedule of Positions <br /> I. 17 Signed Conflict of Interest Disclosure <br /> m. Z Complete Work Statement <br /> i Page <br />