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JLHCA, Inc. Checklist to Submit a Complete Community Services Block Grant (CSBG) Application Please put a check mark in the appropriate box to show that you have included the completed document 1A1i+h vnur nnnlirn+inn All rine imonk Arp rpnijirA(i with thA AXCP.ntinn of those that say "if aDDlicable." Item Included (�) Signed Application Certification (blue ink only) ✓ Signed Board Membership Roster (blue ink only) ✓ Board of Directors Officers and Committees ✓ Planning Process Narrative ✓ Form 210 — Agency Strategy for Eliminating Poverty ✓ Form 212 — One -Year Work Program ✓ Monitoring, Assessment and Evaluation Plan ✓ Form 212A — CSBG Administrative Support Worksheet (if applicable) Form 225 — Agency Budget Information ✓ Form 225N -Budget Narrative ✓ Appendices (to be attached by the Applicant): • Organizational Chart (do not include names) • Job Description and Resume for the Agency's Executive Director • Job Description and Resume for the Agency's Chief Financial Officer • Job Descriptions for all CSBG employees (do not include names) • Affirmative Action Plan • Documentation of Public Hearings for Initial Planning Process: Copy of Public Notice(s) from Newspaper(s) ✓ Agenda of Public Meetings) N/A Copy of Attendance Sheet(s) N/A Minutes of Public Meeting(s) N/A • Documentation for Notice of Intent to Apply: Copy of advertisement(s) ✓ • Documentation of Submission to County Commissioners: Certified document from county clerk Commissioners' comments or minutes (if applicable) • Cognizant -Approved Indirect Cost Agreement • Copy of the Proposal Application submitted to the cognizant agency for approval of the Indirect Cost Rate • Cost Allocation Plan (if applicable) • IRS Tax Exemption Verification • Vehicle Registrations Fiscal Year 2016-17 Community Services Block Grant Application Page 2 of 33