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Outside Agency Funding Application <br /> July 1, 2014 through June 30,2015 <br /> APPLICATION DUE FRIDAY,JANUARY 24, 2014 AT 5:00PM <br /> Agency Name: Piedmont Health Services,Inc. <br /> Street Address: 299 Lloyd Street,Carrboro,NC 27510 <br /> Mailing Address: 299 Lloyd Street,Carrboro,NC 27510 <br /> Website Address: www iedmonthealth.or_ <br /> Executive Director: Brian Toomey, MSW <br /> Telephone: 919 537-7494 E-Mail:_toomeyb@tiedmonthealth.org <br /> Contact Person: fen Cunningham <br /> Telephone: (919)913-1097 E-Mail: cunningj @piedmonthealth.org <br /> Fax: 919 933-9201 Federal ID Number: 56-0952737 <br /> Funding Source Summary— Current Funding Requested Funding <br /> Briefly state haw any.awarded (FY13-14) (FY14-15) <br /> ftinds would be used, <br /> Orange County Government $10,000 $11,000 <br /> Summary of intended use of funds: To support the Carrboro Community Health Center in <br /> its mission of being a sliding-fee primary care home for vulnerable and/or economically- <br /> disadvantaged residents of Orange County. <br /> Town of Cho el Hill $3,000 $4,000 <br /> Summary of intended use of funds: To support the Carrboro Community Health Center in <br /> its mission of being a sliding-fee primary care home for vulnerable and/or economically- <br /> disadvantaged residents of Chapel Hill. <br /> Town of Carrboro $2,000 $3,000 <br /> Summary of intended use of funds: To support the Carrboro Community Health Center in <br /> its mission of being a sliding-fee primary care home for vulnerable and/or economically- <br /> disadvantaged residents of Carrboro. <br /> Executive A ctor Tian Toomey) / otr Chair anie Wiantafillou) <br /> Date Date <br /> Revised November 21,2013 Page 1 of 15 Pages <br />