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EMERGENCY SHELTER GRANTS PROGRAM <br /> 058 APPLICATION SUMMARY FORM <br /> 1. APPLICANT <br /> a. Name of local government: County of Orange <br /> b. Address: 106 E. Margaret bane <br /> Hillsborough, N.C. 27278 <br /> c. County: Orange <br /> d. Local Government Contact Person: Tara L. Pikes <br /> Address: 300 W. Tryon Street <br /> Hillsborough, N.C. 27278 <br /> Telephone: (919) 732-8181 <br /> 2. FINAL SUBRECIPIENT <br /> a. Name of subrecipient (service provider) : Interfaith council for Social Services, Inc <br /> b. Address: 207 Wilson Street <br /> Chapel Hill, N.C. 27514 <br /> c. Subrecipient Contact Person: Chris Moran, amity Services Consultant <br /> Telephone: (919) 929-6380 <br /> 3. SUMMARY OF GRANT REQUEST <br /> Rehabilitation funds requested $ 12,000 <br /> Operations/Services funds requested $ 13,000 <br /> TOTAL $ 25,000 <br /> 4. CERTIFICATION <br /> To the best of my knowledge and belief, data in this application is true and <br /> correct. The document has been duly authorized by the governing body of the <br /> applicant and the applicant will comply with the attached certifications if the <br /> assistance is approved. <br /> a. Typed Name and Title of Chief Elected Official <br /> Shi r1 py g. Manahan.1. Chai_r <br /> b. Signature c. Date <br /> FOR NRCD USE ONLY <br /> DATE RECD _ APPLICATION NO. <br /> ESGP #101 (Revised 10/87) <br />