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DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued <br /> Provider'saNdiOcriatooliication <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: 919-731-6194 ext. 10 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: Meals on Wheels <br /> Project/Program Primary Contact and Title: Kay Stegner, Manager of Client Services <br /> Telephone Number: 919-732-6194 ex.12 E-Mail: ocimsrmembargmail.com <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $61,732 Total Amount of Funds Requested: $17,000 <br /> Proposed Use of Funds Requested(2-3 Line Maximum): Purchase catered meals for Meals on <br /> Wheels recipients who are unable to pay the entire amount of the meal. Though the cost charged <br /> for meals is $2.80, actual cost of a meal is $3.25; $17,900 would subsidize 17 people for one year. <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) $ n Grant I Loan <br /> LII CDBG Construction (CH) EI Grant n Loan <br /> 0 HOME CHDO (OC) I I Grant Lii Loan <br /> 0 HOME Other(OC) E Grant E Loan <br /> X Human Services: n Carrboro $ El Chapel Hill$ X Orange County$17,000 <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 /> e' if fie <br /> Signature: ( ) <br /> E cutive Directoi Date <br /> Signature: cc 7-47/ 7 <br /> Board Chairperson Da e <br /> Main 4nnliratinn 101/71)16 1n..1Q- 7 AM P :4 ri r) f <br />