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DocuSign Envelope ID: 10C7B77C-A009-4AA3-964B-3B03B9585341 <br /> t xnibit A-continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Bridge II Sports <br /> Applicant Organization's Physical Address: 4122 Bennett Memorial Rd Suite 105, Durham, NC <br /> 27705 <br /> Applicant Organization's Mailing Address: 4122 Bennett Memorial Rd Suite 105, Durham, NC <br /> 27705 <br /> Applicant Organization's Web Address: www.bridge2sports.org <br /> Executive Director: Ashley Thomas <br /> Telephone Number: 866-880-2742 E-Mail: ashleybridge2sports.org <br /> DUNS Number: 00-417-5108 <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Project/Program Contact Information <br /> Project/Program Name: Adapted Sports: Wheelchair Basketball, Boccia Ball, and Adapted Sports <br /> Day <br /> Project/Program Primary Contact and Title: Ashley Thomas <br /> Telephone Number: 866-880-2742 E-Mail: ashleybridge2sports.org <br /> c) Funding Request Identification 4.4c ki <br /> 71,4-145!" 1 " <br /> Total Project/Program Cost: $39400Total Amount of Funds Requested: $24,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): 1.Support for wheelchair basketball and <br /> boccia ball programs ($3000). 2. Funding to conduct adapted sports day in five Orange County <br /> Public Schools or Chapel Hill Carrboro City Schools ($5,000). <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package for each funding source. *The Participating Jurisdiction reserves the right to <br /> fund projects from any funding source, subject to eligibility and funding constraints. <br /> Li CDBG Non-Construction (CH) $ H Grant Loan <br /> fl CDBG Construction (CH) Grant - Loan <br /> — <br /> 7 HOME CHDO (OC) Grant Loan <br /> I- HOME Other (OC) P Grant - Loan <br /> E Human Services: 14 Carrboro $8,000 Fr Chapel Hill $8,000 14 Orange County $8,000 <br /> d) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> V , ti.tymt,p/ <br /> Signature: I'2-1 <br /> et u e irec r Date <br /> Signature: <br /> Board Chairperson Date <br /> Main Application 1/21/2016 10:52:15 AM Page 3 of 29 <br />