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MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Dispute Settlement Center Inc. <br /> Applicant Organization's Physical Address: 302 Weaver Street Carrboro NC <br /> Applicant Organization's Mailing Address: same <br /> Applicant Organization's Web Address: www.disputesettlement.org <br /> Executive Director: Frances Henderson <br /> Telephone Number: (919)929-8800 E=Mail: fenderson(a'7disputesettlement.orq <br /> DUNS Number: 361862451 <br /> (Dun&Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) ProiecUProgram Contact Information <br /> Project/Program Name: Mediation <br /> Project/Program Primary Contact and,Title: Frances Henderson Executive Director <br /> Telephone Number: (919) 929-8800 ext 11 E-Mail: fhendersone-disputesettlement.org. <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $110,000 Total Amount of Funds Requested: $80,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Intake, Information, referral and mediation <br /> for Orange County citizens in Criminal District Court; and 2) mediations for separating couples, <br /> families, and neighbors on a sliding scale basis and Medicaid Appeals mediations. <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) $ ❑ Grant ❑ Loan <br /> ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan <br /> ❑ HOME CHDO $ ❑ Grant ❑ Loan <br /> ❑ HOME Other $ ❑ Grant ❑ Loan <br /> X Human Services: X Carrboro $10,000 x Chapel Hill $ 14,000 ❑ Orange County <br /> $80,000 <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 /> � "^ 1� _E'�C� <br /> Signature: s� <br /> E ire Dire /Date <br /> Signature; �( 2"t <br /> oan:YChair r n Date Y <br /> Main Application 1l 120 6 6:08:45 PM Page of 2 <br /> uoiteoilddy T�oue V apistnO s,aapiAOad <br /> penuituoo - V I eV6d990669Ve-eg6e-306b-3VZ9-gZgdbo09:ol ad010nu3 u6isnoop <br />