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DocuSign Envelope ID: DBF0775B-3A75-4D97-9EA7-5AC7933304BF t A - continued <br /> Provider's Outside AgencTApplication <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Hillsborough Arts Council <br /> Applicant Organization's Physical Address: 102 North Churton Street, Hillsborough NC 27278 <br /> Applicant Organization's Mailing Address: Same <br /> Applicant Organization's Web Address: WWW.hillsboroughartscouncil.org <br /> Executive Director: Neil Stutzer, Chair (We don't have an Executive Director) <br /> Telephone Number: 919 643-2500 cell, 919-698-1859 E-Mail: info@hilisboroughartscouncil.org <br /> DUNS Number: 83-074-7544 <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: 2016 Sustainable Growth Plan <br /> Project/Program Primary Contact and Title: Neil Stutzer, Chair <br /> Telephone Number: cell 919 698-1859 E-Mail: nstutzerPhillsboroughartscouncil.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $30,000Total Amount of Funds Requested: $15,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): We ask for a combined total investment of <br /> $30,000/year from the Town of Hillsborough and Orange County that will allow HAG to <br /> professionalize its administration and develop the financial and service partnerships that will be <br /> sustainable into the future. <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) $ LI Grant El Loan <br /> E CDBG Construction (CH) fl Grant ri Loan <br /> E HOME CHDO El Grant rj Loan <br /> El HOME Other El Grant L Loan <br /> XE1 Human Services: n Carrboro $ [' Chapel Hill $ XL Orange County $15,000 <br /> d) To the best of my knowledge and belief all information and data in this application is <br /> true and curre,t. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature A --?-4-41 • _., / -16 <br /> •- IP Date ; ; <br /> "- <br /> /—./ 3g) <br /> Signature: 47 , /0 _ <br /> Treasurer f Date <br /> Main Application 1/18/2016 1:15:20 PM °'; <br />