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DocuSign Envelope ID:D2CB2439-4B3B-42E7-A090-286FDDD6E948 - continued <br /> Provider's Outside Agency Application <br /> 1. COVER, PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Chapel Hill - Carrboro Human Rights Cenler <br /> Applicant Organization's Physical Address. 115 W Main St Carrboro NC 27510 <br /> Applicant Organizations Mailing Address: 115W Main St, Carrboro NC 27510 <br /> Applicant Organization's Web Address: rittpl/www.ircpnc,ora/ <br /> Executive Director: KeyinLNQQnan <br /> Telephone Number: 019) 295-0570 E-Mail: knoonanPirconc,org <br /> DUNS Number, <br /> (Dun & Bradstreet, Inc, provides 0-iis number al no charge, at it is required for Federal funding recipients 11). prqjggliPrnirpm_gpptpst information <br /> Project/Program Name: Immigrant and Refugee Community Partnership, <br /> Project/Program Primary Contact and Title: Kevin J, Noonan Executive Director <br /> Telephone Number (919)-295-0570 E-Mail: knoonanQiropprLo_gr <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $30,000 Total Amount of Funds Requested: $7,50(,), <br /> Proposed Use of Funds Requested (2-3 Line Maximum): To supporiplograrhs,operaleg,„byke <br /> tlVd....l7.1E,L.0 a Er9r10 HcILTIOn Rights_cell' 0 kat it:5 irnrnlara..nLand„,f3 et,U1..1Q,P C„PlitElnunitY <br /> aNQ r <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 fund <br /> projects from,9my funding,source, subject to eligibility and funding constiaints <br /> CDBG Non-Construction (CH) $ Grant 0 Loan <br /> 0 CDBG Construction (CH) ID Grant I Loan <br /> 0 HOME CHDO (CC) I: Grant 0 Loan <br /> El HOME Other (OC) [1] Grant Li Loan <br /> XiD Human Services, U Carrboro $;3,75,9 D Chapel Hill $1,759 D Orange County $2,000 <br /> d) To the best of my knowledge and belief all information and data in this application is true and <br /> current. The doe Jfl3 as been,dUTV'authorized by the governing board of the applicant. <br /> Signature: <br /> Kevin J, Noon Exe6(17rector Date 22 January 2016 <br /> Signature:J <br /> Rev, Nathan Allan Hollister, Board Chairperson Date 22 January 2016 <br />