Orange County NC Website
Browse       Search
DocuSign Envelope ID:24839407 oe2D-47A2 e388-3eEA00100uC1 i /\ - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE program requires a rate H��� <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Chapel Hill-Carrboro Meals on Wheels <br /> Applicant Organization's Ph i l Address: 1712 Willow Drive Chapel Hill NC 275104 <br /> Applicant Organization's Mailing Address: P0 Box 2102 Chapel HU| NC27515 <br /> Applicant Organization's Web Address www.chcmow.orq <br /> Executive Director: Stacey Yusko <br /> Telephone Number: 919-942-2948 E'K8ei|: stmceyohcnnow.org <br /> DUNS Number: na <br /> (Dun & Bradstreet, Inc. provides this number at no oharge, and it is required for Federal funding recipients.) <br /> b) Project/Program Contact Information <br /> Project/Program Name: Meals for the Homebound <br /> Project/Program Primary Contact and Title: Stacey Yusko Executive Director <br /> Telephone Number: 919-942-2948 E-Mail: staceychcmow.orq <br /> c) Funding Request Identification <br /> Total Pr ject/Program Cost: $308,000 Total Amount of Funds Requested: $45.000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): To offset the subsidy we provide those <br /> who can't contribute to the cost of the meal we deliver <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 /> CDBG Non-Construction (CH) $ 0 Grant E Loan <br /> CDBG Construction (CH) � Grant Loan <br /> ` ' �� <br /> L <br /> HOME CHDO (OC) 0Grant ri Loan <br /> | <br /> HOME Other (OC) � Grant [7 Loan <br /> 141 Human Services: I Carrboro $15.000 I Chapel Hill $15.000 Orange County $15,000 <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: <br /> Signature: ' ° <br /> ' <br /> Main Application 1/20/2016 11:21:36 /\M Page 3 of � � � <br />