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Salisbury Rowan Community Action Agency, Inc. <br />Checklist to Submit a Complete Community Services Block Grant (CSBG) Application <br />Please put a check mark in the appropriate box to show that you have included the completed document <br />with your application. All documents are required with the exception of those that say "if applicable." <br />Item <br />Included (�I) <br />Signed Application Certification (blue ink only) <br />Signed Board Membership Roster (blue ink only) <br />✓ <br />Board of Directors Officers and Committees <br />✓ <br />Planning Process Narrative <br />✓ <br />Form 210 — Agency Strategy for Eliminating Poverty <br />✓ <br />Form 212 — One -Year Work Program <br />✓ <br />Monitoring, Assessment and Evaluation Plan <br />✓ <br />Form 212A — CSBG Administrative Support Worksheet (if applicable) <br />✓ <br />Form 225 — Agency Budget Information <br />✓ <br />Form 225N- Budget Narrative <br />✓ <br />Appendices (to be attached by the Applicant): <br />• Organizational Chart (do not include names) <br />• Job Description and Resume for the Agency's Executive Director <br />✓ <br />• Job Description and Resume for the Agency's Chief Financial Officer <br />✓ <br />• Job Descriptions for all CSBG employees (do not include names) <br />• Affirmative Action Plan <br />✓ <br />• Documentation of Public Hearings for Initial Planning Process: <br />✓ <br />Copy of Public Notice(s) from Newspaper(s) <br />✓ <br />Agenda of Public Meeting(s) <br />✓ <br />Copy of Attendance Sheet(s) <br />Minutes of Public Meeting(s) <br />✓ <br />• Documentation for Notice of Intent to Apply: <br />✓ <br />Copy of advertisement(s) <br />✓ <br />• Documentation of Submission to County Commissioners: <br />✓ <br />Certified document from county clerk <br />✓ <br />Commissioners' comments or minutes (if applicable) <br />✓ <br />• Cognizant - Approved Indirect Cost Agreement <br />✓ <br />• Cost Allocation Plan (if applicable) <br />✓ <br />• IRS Tax Exemption Verification <br />✓ <br />• Contracts and leases <br />✓ <br />• Vehicle Registrations <br />NIA <br />Forms to be completed by the Applicant, The forms are included: <br />• IRS Tax Exemption Verification Form (Annual) <br />✓ <br />• Conflict of Interest Acknowledgement and Policy <br />✓ <br />• Conflict of Interest Verification (Annual) <br />✓ <br />• State Grant Certification — No Overdue Tax Debts <br />✓ <br />• State Certification - Contractor Certifications Required by N.C. law <br />✓ <br />• Federal Certifications <br />✓ <br />• Federal Funding Accountability and Transparency Act (FFATA) <br />Attach evidence of Central Contractor Registration CCR <br />✓ <br />Fiscal Year 2015 -16 Community Services Block Grant Application <br />Page 2 of 44 Attachment number 1 <br />F -13 Page 175 <br />