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DocuSign Envelope ID: 373C6CF5-BA35-4F9B-A420-087EBFE4784E t A - continued <br /> Provider's kNifkiciOcm9,yrik9Nlication <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Chapel Hill Training Outreach Project Inc.,/KidSCope <br /> Applicant Organization's Physical Address: 800 Eastowne Dr., Suite 105, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 800 Eastowne Dr., Suite 105, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: www.chtop.orq <br /> Executive Director: Mike Mathers <br /> Telephone Number: 919-490-5577, x223 E-Mail: mmathers( chtop.org <br /> DUNS Number: 122881048 <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: KidSCope <br /> Project/Program Primary Contact and Title: Linda Foxworth, Director <br /> Telephone Number: 919-644-6590, x4810 E-Mail: Ifoxworth(akidscope.chtop.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $156,116 Total Amount of Funds Requested: $81,700 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): KidSCope will provide therapeutic mental <br /> health services and parent education to young Orange County children and their families. <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 /> _ <br /> CDBG Non-Construction (CH) $ Grant _ Loan <br /> 111 CDBG Construction (CH) $ Ej Grant F Loan <br /> HOME CHDO $ Grant T Loan <br /> _ <br /> E HOME Other $ Grant Loan <br /> J Human Services: 4 Carrboro $2,200 r Chapel Hill $4,500 14 Orange County $75,000 <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 /> Signature: _U6e-(/_ r ,-C._ 7 (72 /// .' <br /> / <br /> Ex zi.c <br /> UJtivelDirector <br /> 4t <br /> Date 7Signature: ( n / ilit 71. a >4■-) <br /> B ard Chairperson Date <br /> Main Application 1/20/2016 2:52:21 PM Page 1 of 'I <br />