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Attachments P a g e 14 o f 20 <br />4. ATTACHMENTS <br />Description of Required Attachments <br />a)Financial Audit <br />A recent financial audit that should cover CY2019, for calendar year agencies, and FY2019-20, for fiscal year <br />agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a <br />certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a <br />completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. <br />Agencies with a certified audit/report should not complete the form. Schedule of Receipts and Expenditures <br />form is listed on the Town’s and county website here. <br />b)Agency Budget <br />Please complete the provided template or submit your own budget file (as long as it contains the same <br />information, and in a similar format, as requested in the provided template. Please explain other in your <br />budget). Agency Budget Template is listed on the Town’s and County website here. Please submit In PDF <br />form only. <br />c)Program Budget <br />You may complete the provided template, or you may submit your own budget file (as long as it contains the <br />same information, in the same format, as requested in the provided template. Please explain other in your <br />budget). Program Budget Template is listed on the Town’s and County website here. Please submit in pdf <br />only. <br />d)IRS Federal Form 990 <br />A copy of the agency’s 2019 Form 990 is required. The specific form depends upon the agency’s financial <br />activity. Review the IRS’ table guide, for more details. For Form 990-N (e-postcard) filers, include a copy of the <br />postcard, with the agency’s application materials. <br />e)NC Solicitation License <br />A copy of the agency’s current solicitation license is required. Organizations that solicit contributions in North <br />Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC <br />Secretary of State’s licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If <br />exempt per N.C.G.S. § 131F-3, include a copy of the exemption letter with the agency’s application materials. <br />f)IRS Federal Tax-Exemption Letter <br />A copy of the agency’s current IRS tax-exempt letter that confirms its nonprofit status is required. An agency <br />can request a copy of its letter from the IRS’ Customer Account Services. <br />g)List of Board of Directors <br />Provide the following information about each board of director’s member: name, telephone number, address, <br />occupation or affiliation of each member and the list must identify the principal officers of the governing body, <br />and length of term. <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BADocuSign Envelope ID: 01146459-28D7-41C1-ADA0-09401D3877AD