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DocuSign Envelope ID:4FFDF545 e8C1-4Aer~^0A5-400050A30357 I A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> . <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Senior Care of Orange County; Inc. <br /> Applicant Organization's Physical Address: 105 Meadowland Drive; HiUnbonough, NC 27278 <br /> Applicant Organization's Mailing Address: 105 Meadowland Drive; Hi||sb0n}UOh, N(} 27278 <br /> Applicant Organization's Web Address: vvvvvv.so|h/oodu|tdoyheolth.n[g <br /> Executive Director: Alvonia Baldwin <br /> Telephone Number: 913'245'2017 E'Mai|; m|ba|dvvinaoronAecnuntyncAov <br /> DUNS Number: 123760520 <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: Florence Gray Soltys Adult Day Health Program <br /> Project/Program Primary Contact and Title: Alvonia Baldwin, Executive Director <br /> Telephone Number: 919-245-2017 E'Mai|: o|bgldvvinaorengacuuntync.gov <br /> c) Funding Request Identification <br /> Total P ject/Program Cost: $33.500 Total Amount of Funds Requested: $33.500 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Funding towards this one of a kind dual <br /> model; Adult Day Care and Adult Day Health Program in Orange County will provide participant <br /> scholarships for clients in need of a program that may be limited to the affordabili Caregiver respite is <br /> needed due to the severely frail elderly and adults with special needs; program operational support with <br /> purchase of program supplies, snacks, personnel and community resources for the continued sustainability of <br /> the program and as a partnership with the county towards meeting the goals of the Master Aging Plan of <br /> Orange County. Since 2011-2016; The Orange County amount has included up to$25,000 in participant <br /> meal credits which continue to help wigntficumtKy. Below is not a reflection of the meal credit amount. <br /> The in-kind donation is still needed for tbe /nculm. ($53,000ir,oimWunt6cmaawUwKox'OnanAmC000tv). <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package for each funding source, *The Particip ating Jurisdiction resetves the right to <br /> fund projects from any funding source, subject to eligibility and funding constraints. <br /> [— [— <br /> CDBGNon-{�onatruotion (CH) $ . Grant .[— Loan <br /> ▪ [|DBG Construction (CH) F- Grant -- Loan <br /> L MO��E {}MD{} � Grant Loan <br /> F- HOME Other [l Grant -1 Loan <br /> X Human Services: X Carrboro $1,500 X Chapel Hill $2,000 X Orange County $30,000 <br /> Main Application 1/25/2016 12:26:51 PM Page 3 of 2 1 <br />