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Agency Name <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 />%e,ifh vrmr annlirafinn All dr)r.i imPnt arP r with the exception of those that sav "if applicable." <br />Item <br />Signed Application Certification (blue ink only) <br />Included (�) <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 (do not include names) <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 advertisements) <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 (if applicable) <br />• IRS State Exempt Letter <br />• Contracts and Leases <br />Forms to be completed by the Applicant. The forms are included: <br />• Verification of 501(C)(3) Status (Annual) <br />• Notarized Conflict of Interest Policy /Acknowledgement <br />• Conflict of Interest Verification (Annual) <br />• State Grant Certification — No Overdue Tax Debts <br />• State Certification - Contractor Certifications Required by N.C. Law <br />• Federal Certifications <br />• Federal Funding Accountability and Transparency Act (FFATA) <br />Attach evidence of Central Contractor Reg istration CCR <br />• Vehicle Registrations <br />Fiscal Year 2014 -15 Community Services Block Grant Application <br />Page 2 of 32 <br />Attachment number 2 <br />G -2 Page 271 <br />