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DocuSign Envelope ID:38357F45-0FD1-474F-992F-A2DODA42A3E2 Exhibit A <br /> Provider's Outside AgencApplication <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Duke University Health System, Inc. d/b/a Duke Home Care& Hospice <br /> Applicant Organization's Physical Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 <br /> Applicant Organization's Mailing Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 <br /> Applicant Organization's Web Address: https://dhch.duhs.duke.edu <br /> Executive Director: Belle Starr Browning <br /> Telephone Number: 919.620.3853 E-Mail: starr.browning@duke.edu <br /> DUNS Number: <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: Duke Home Care & Hospice <br /> Project/Program Primary Contact and Title: Dale Horton <br /> Telephone Number: 919-479-0318 E-Mail: dale.hortonduke.edu <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $13,864Total Amount of Funds Requested: $7,800.00 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Duke Hospice Bereavement Services will use the <br /> funds to offset the costs of providing care to grieving individuals in Chapel Hill, Carrboro and Orange County. <br /> We continue to offer our services at no cost to any individual in the area who requests our support. <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 /> CDBG Non-Construction (CH) $ Grant E Loan <br /> LI CDBG Construction (CH) E Grant Li Loan <br /> HOME CHDO (OC) pi Grant E Loan <br /> 0 HOME Other (OC) L Grant I Loan <br /> X Human Services: X Carrboro $3,800 X Chapel Hill $3,000 X Orange County $1,000 <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 /> Signature: Y),- <br /> : Director <br /> Date <br /> 4)&i, <br /> Signature: <br /> ( <br /> 2 2. - I 1) <br /> Boar" Chairperson Date <br /> Main Application 1/25/2016 12:06:09 PM H , r <br />