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DocuSign Envelope ID:6BDD2794-5ECO-4DFF-B4F6-F496A1C3AB13 A - continued <br /> Provider's Oaf : Agato Ai ■-tion <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) A. slicant Contact Information <br /> Applicant Organization's Legal Name: El Centro Hispano, Inc <br /> Applicant Organization's Physical Address: 600 E. Main Street, Durham, NC 27701 <br /> Applicant Organization's Mailing Address: same as above <br /> Applicant Organization's Web Address: www.elcentrono.org <br /> Executive Director: Filar Rocha Goldberg <br /> Telephone Number: (919) 687-4635 Ext, 43 E-Mail. prochaP,elcentronc.org <br /> DUNS Number: 159206015 <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: Education Initiatives <br /> Project/Program Primary Contact and Title: Pilar Rocha-Goldberg, President/CEO <br /> Telephone Number:_(919) 687-4635 Ext. 43 E-Mail: prochaelcentronc.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $97865 Total Amount of Funds Requested: $25,040 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Requesting funds to support education <br /> initiatives for children, youth, and adults in Carrboro-Chapel Hill and surrounding areas. <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 /> Li CDBG Non-Construction (CH) $ Grant Loan <br /> CDBG Construction (CH) Grant El Loan <br /> HOME CHDO (00) E Grant Loan <br /> HOME Other (0C) E Grant Loan <br /> p 12 ir,):1C <br /> X Human Services: x Carrboro $5,000 x Chapel Hill $7500 x Orange County $ <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 /> CC3611?I'Q( & 'q of <br /> Signature: <br /> Execu Eirector Date <br /> Signature: , <br /> r <br /> Board Chairperson Date <br /> Main Application 1/25/2016 12:37:11 PM Page 3 of 3 <br />