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DocuSign Envelope ID: 3CD68914-055B-4274-9AF2-A50FD766FB76 t A - continued <br /> Providergtokii*MmeRlication <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Volunteers for Youth, Inc. <br /> Applicant Organization's Physical Address: 205 Lloyd Street, Suite 103 Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: 205 Lloyd Street, Suite 103 Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.volunteersforyouth.orq <br /> Executive Director: Susan Worley <br /> Telephone Number: 919-967-4511 E-Mail: susan(@yolunteersforyouth.org <br /> DUNS Number: 803184337 <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: Volunteers for Youth, Inc. <br /> Project/Program Primary Contact and Title: Susan Worley, Executive Director <br /> Telephone Number: 919-967-4511, E-Mail: susanvolunteersforyouth.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $262,648 Total Amount of Funds Requested: $28,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Volunteers for Youth seeks funding to <br /> provide community service, teen court, and mentoring opportunities to at risk Orange County <br /> children and youth between the ages of 8 and 15. <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 /> Z CDBG Non-Construction (CH) $5,000 El Grant El] Loan <br /> Li CDBG Construction (CH) El Grant [] Loan <br /> 111 HOME CHDO (OC) El] Grant fl Loan <br /> ci HOME Other (OC) E] Grant Ei Loan <br /> Z Human Services: Z Carrboro $3,000 tsi Chapel HID $10,000 14 Orange County <br /> $10000 <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: A <br /> ''rector A Date <br /> Signature: 111 r.c• <br /> Boars Chairperson Date - <br /> Main Applicatio 1/21/2016 11:03:12 AM Page 3 of 21 <br />