Orange County NC Website
Browse       Search
DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t 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: Freedom House Recovery Center, Inc. <br /> Applicant Organization's Physical Address: 104 New Stateside Drive Chapel Hill, NC 27516 <br /> Applicant Organization's Mailing Address: 104 New Stateside Drive Chapel Hill, NC 27516 <br /> Applicant Organization's Web Address: freedomhouserecovery.org <br /> Executive Director: Patricia E. Hussey <br /> Telephone Number: 919-942-2803 ext. 201 E-Mail: Trish.hafhrecovery.org <br /> DUNS Number: 177955887 <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: Chapel Hill Facility-Based Crisis, Detox and Behavioral Health Urgent <br /> Crisis Care Services and Alvis Women's and Men's Halfway Houses <br /> Project/Program Primary Contact and Title: Trish Hussey, CEO <br /> Telephone Number: 919-942-2803 ext. 201 E-Mail: Trish.h@fhrecovery.orci <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $2,396,990 Total Amount of Funds Requested: $57,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): We are asking for funding from the Orange <br /> County Government to support the day-to-day services(i.e. staffing,facility costs,supplies and equipment)in <br /> (1)our residential rehab programs, and(2)to support the Facility Based Crisis and Detox/Behavioral Health <br /> Urgent Crisis Care Center in Chapel Hill. <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) $ El Grant Loan <br /> El CDBG Construction (CH) Grant Loan <br /> C. HOME CHDO (OC) Grant E Loan <br /> LI HOME Other(OC) n Grant C. Loan <br /> El Human Services: EI Carrboro $9,000 [X] Chapel Hill $18,000 I Orange County $30,000 <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 /> Main Application 1/25/2016 4:55:19 PM Page 3 of 24 <br />