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DocuSign Envelope ID:6BDD2794-5ECO-4DFF-B4F6-F496A1C3AB13 i /\ - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> • 1. COVER PAGE (Each program reqmires a separate application.) <br /> i - - - ---' - -- <br /> a) Applicant Contact Information <br /> App'icant Organization's Legal Name: B Centro Hispano. Inc <br /> Applicant Organization's Physical Address: 600 E. Main Gtroet, Durham, NC 27701 <br /> AppUcant Organizton's Mailing Address: same a above <br /> AppHcant Organization's Web Address: wwweIcentronc.or <br /> Executive Director: Pilar Rocha Goldberg <br /> Telephone Number: (919) 687-4635 Ext. 43 E'K8oU: proCh8e|uentroncorq <br /> DUNS Number 150206015 <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) ProiectlProqram Contact Information <br /> Project/Program Name: Community Services & Support <br /> Project/Program Primary Contact and Title: F8@rRooha'Go|dberO. President CE(} <br /> Telephone Number: 018> 087'4035 Ext. 43 E'&4ei|: proohme|oentnono.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost $185.491 Total Amount of Funds Requested: $25^040 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Requesting funds to support provision of <br /> community services for Latino individuals and families in Orange County and its municipalities. <br /> Services include information, referral and support services, Jeqal assistance, community education <br /> & outreach, citizenship classes, and linkage to area resources. <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package for each funding source *Th Parlicipating Jurisdiction reserves the right to <br /> fund projects from any funding source, subject to eligibility and funding constraints. <br /> —� CDBGNnn'Cunatruct|on (CH> $ Grant Loan <br /> . . <br /> CDBG Construction (CH) [71 Grant El Loan <br /> E HOME CHDO (OC) Grant El Loan <br /> |l HOME Other � r Grant _] Loan <br /> _~ (00) <br /> X Human Services: x Carrboro $5,000 x Chapel Hill $7 500 x Orange County $12.54O <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: ki e« av ~ / / f �� <br /> �«z <br /> i Di Date <br /> Signature: Of 2.5 /(0/ <br /> Board Chairperson Date <br /> Main Application 1/2512016 12:35:53 PM Page 3 of 3 <br />