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Page 5 <br />PART I - FACESHEET <br />APPLICATION FOR FEDERAL ASSISTANCE 1. TYPE OF ® <br /> Non-Constivetion <br />Application <br />2. DATE SUBMITTED TO CORPORATION FO 3. a. DATE RECEIVED BY STATE: 3.b. STATE APPLICATION IDENTIFIER: <br />NATIONAL SERVICE (CNS): ~ SCH# 00-C-0000-0505 CFDA#94.002 <br />03-25-2002 4. a DATE RECEIVED BY CNS: ~ 4.b. CNS GRANT NUMBER: . <br /> 02SRSNC034 <br />5. APPLICANT INFORMATION <br />LEGALNAME: ORANGE COUNTY GOVERNMENT NAMH AND CONTACT INFORMATION FOR PROJECT DIliECTOR OR OTHER <br /> PERSON TO BE CONTACTID ON MATTERS INVOLVING THIS APPLICATION (give <br />ORGANIZATIONAL UNIT: ORANGE COUNTY DEPARTMENT ON AGING area codes): <br />ADDRESS (give:veer ochre:s. ~; may. sr~e ~a~ ~~: NAME: KATHERINE L. PORTER <br />Orange County Government Department on Aging TELEPHONE NUMBER: (919) 968 - 2054 <br />Box 8181 <br />P. O <br />. FAx NUMBER: (919) 968 - 2093 <br />Hillsborough, NC 27278 <br />6. EMPZOYER IDENTIFICATION NUMBER (EII~9: 7. TYPB OF APPLICANT: (enter appropriate letter in baxJ ^ <br />B <br /> <br />8. TYPE OF APPLICATION (Check appropriate box): A. Stata K Independent School District <br /> <br />® B. County L State ConGVlled Institution of Higher Learning <br />CONI7N[JATION <br />^NEW G Municipal J. Private University <br />^REVISION D. Towasbip K. IndianTnbe <br /> B. Interstate L. Individual <br />If Revision, ender appropriate letter(s) m box(es): ^ ^ F. Inter~micipal iG1. Profit Organization <br />. G. Special District N. Private Non-Profit Organization <br />A. Increase Award B. Decrease Award C. Increase Diaation O. Other (specify) <br />D. I)aaease Duration E. Ofher (specify): 9. NAME OF FEDERAL AGENCY: <br /> Corporation for National & Community Service <br /> <br />10. CATALOG OF FIDERAL DOMESTIC ASS] STANCH NUMBER: 11. DBSCRIPTIVB TiTLB OF APPLICANT' S PROJECT: <br />~~` ~'~2 <br />' RETIRED & SENIOR VOLUNTEER PROGRAM <br />FGP: 94.011 <br />SCP: 94.016 9 4 0 0 2 <br />Senior Derrronshation: 94.015 - <br />12. AREAS AFFECTID BY PROJBCT (List Cities, Countks, States, ete): <br />TOWNS OF: T•7r-.r TROUGH, CHAPEL HQZ, AND CARRBORO <br />ORANGE COUNTY, NORTH CAROLINA <br />13. PROPOSED PROJECT: START DATE: U7~U 12003 END DATE: U6~30~2U06 <br />14. ESTIMATID FUNDING: 15. IS APPLICATION SUBJECT TO REVIEW BY STATE EXF.CCTrIVB <br />a. ~~ S 170,073 ORDER 12372 PROCESS? ' <br /> a. YES. THIS PREAPPISCATION/APPLICATIONWASMADE AVAII.ABLE <br />b. APPLICANT <br />000 <br />S 1SO TO THB STATH EXHCUTTVE ORDER 12372 PROCESS FOR <br /> , RBVIEW ON: <br />. <br />a STATE S DATB 04!06/2003 <br /> b. NO. ^ PROGRAM IS NOT COVERED BY E.O. 12372 <br />d. LOCAL s 40,431 <br />. ^ OR PROGRAM HAS NOT BEEN SSLHGTED BY STATB FOR <br />REVIEW <br />e. OTHHR S <br /> <br /> 16. IS THE APPLICANT DBLINOUENT ON ANY FEDHRAL DEBT? <br />£ TOTAL S 360,504 ^ YBS if"Yes," attach an explanation. ®NO <br />ALL DATA IN THLS APPLICATION/PREAPPLICATION ARE TRUE AND OORRECT. THE DOCUbffi~T HAS BEEN DULY <br />TO THE BEST OF MY KNOWLEDGE AND BELIEF <br />17 <br />, <br />. <br />AUTHORI2>ID BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WII I. COMPLY W1TH THE ATTACH) ASSURANCES IF THE ASSISTANCE 1S AWARDBD. <br />a. TYPED NAME OF AUTHORIZED REPRESENTATIVE: b. TTI7.E: o. TBLBPHONE NUMBER: <br />Mazgazet Browa ~ Chair, Orange County Board of Commissioners 919-245-2300 <br />d. SIGNATURE OF AUTHORi'ZID REPRESENTATIVE: e. DATE SIGNID: <br /> 04/01/2003 <br />Modified Standard Form 424-NSSC (Rev 4/01) <br />