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Salisbury Rowan Community Action Agency <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 <br />document with your application. <br />Item <br />Included or NIA <br />Signed Application Certification (blue ink only) <br />Signed Board Membership Roster (blue ink only) <br />Board of Directors Officers and Committees <br />Planning Process Narrative <br />Form 210 — Agency Strategy for Eliminating Poverty <br />Form 212 — One Year Work Program <br />Monitoring, Assessment and Evaluation Plan <br />Form 212A — CSBG Administrative Support Worksheet (if applicable) <br />Form 225 — Agency Budget Information <br />Form 225N- Budget Narrative <br />Appendices (to be attached by the Applicant): <br />• Organizational Chart <br />• Job Description and Resume for the Agency's Executive Director <br />• Job Description and Resume for the Agency's Chief Financial Officer <br />• Job Descriptions for all CSBG employees <br />• Affirmative Action Plan <br />• Documentation of Public Hearings for Initial Planning Process: <br />Copy of Public Notice(s) from Newspaper(s) <br />Agenda of Public Meeting(s) <br />Copy of Attendance Sheet(s) <br />Minutes of Public Meeting(s) <br />• Documentation for Notice of Intent to Apply: <br />Copy of advertisement(s) <br />• Documentation of Submission to County Commissioners: <br />Certified document from county clerk <br />Commissioners' comments or minutes (if applicable) <br />• Cognizant- Approved Indirect Cost Agreement <br />• Cost Allocation Plan <br />• Verification of 501(C)(3) Status <br />• State Grant Certification — No Overdue Tax Debts <br />• Notarized Conflict of Interest Policy <br />• Federal Certifications <br />• Contracts <br />Fiscal Year 2013 -14 Community Services Block Grant Application <br />Page 2 of 42 <br />Attachment number 1 <br />F -6 Page 66 <br />