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DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 A - continued <br /> Provider'saith55Agication <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Orange Congregations in Mission, Inc. <br /> Applicant Organization's Physical Address: 300 Millstone Dr. Hillsborough, NC 27278 <br /> Applicant Organization's Mailing Address: 300 Millstone Dr. Hillsborough, NC 27278 <br /> Applicant Organization's Web Address: www.ocimnc.org <br /> Executive Director: Rev. Sharon S. Freeland <br /> Telephone Number: 919-732-6194 E-Mail: ocimexecdirembargmail.corn <br /> DUNS Number: 612251009 <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: Samaritan Relief Ministry <br /> Project/Program Primary Contact and Title: Kay Stagner, Manager of Client Services <br /> Telephone Number: 919-732-6194 ext. 12 E-Mail: ocimsrm(d.embargmail.com <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $569,700 Total Amount of Funds Requested: $33,415 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): These funds would be used to purchase <br /> food for the Samaritan Relief Ministry food pantry, and emergency assistance for rent and utilities; a <br /> portion goes to Support Services, which administratively supports Orange Congregations in <br /> Mission, for wages for the program manager. <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 /> El CDBG Non-Construction (CH) $ n Grant E Loan <br /> fl CDBG Construction (CH) n Grant ElLoan <br /> fl HOME CHDO (OC) n Grant I— Loan <br /> fl HOME Other(OC) fl Grant 0 Loan <br /> X Human Services: El Carrboro $ 0 Chapel Hill$ X Orange County$33,415 <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:Uwv, ) aVAA4- I / 2 / <br /> Executive Director Date <br /> Signature: Z 7- /4/di 7e)/6 <br /> Board Chairpers dr !Vat° <br /> Main 4nnliratinn 1/71/7111A 4..-42- 2 AAA P n r n 1 7 <br />