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DocuSign Envelope ID:A65EF081-BF54-47AC-9969-94226D3FBC7E t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 6. Attachments a. ® Audit: Organizations receiving$300,000 or OMB Circular A-133 <br /> more in Federal financial assistance, and/or <br /> organizations with more than $500,000 of <br /> receipts and expenditures in a fiscal year, must <br /> secure an audit. <br /> b. ® IRS Federal Form 990 <br /> c. ® NC Solicitation License <br /> d. ® IRS Federal Tax-Exemption Letter <br /> e. ® Certificate of Insurance 24 CFR Parts 84 or <br /> f. ® List of Board of Directors 85 <br /> g. ® Articles of Incorporation/Bylaws 24 CFR 570.208, <br /> h. ® Authorization to Request Funds 570.500(c), 570.611 <br /> i. ® Authorized official designation <br /> ® Solid Waste Program Fee (SWPF) Verification <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Habitat for Humanity of Orange County <br /> Applicant Organization's Physical Address: 88 Vilcom Center Dr. #L110, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 88 Vilcom Center Dr. #L110, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: www.orangehabitat.org <br /> Executive Director: Susan Levy <br /> Telephone Number: (919) 932-7077 ext. 211 E-Mail: slevy0oranaehabitat.org <br /> DUNS Number: 095849568 (Dun & Bradstreet, Inc. provides this number at no charge, and it is <br /> required for Federal funding recipients.) <br /> b) Proiect/Program Contact Information <br /> Project/Program Name: A Brush with Kindness <br /> Project/Program Primary Contact and Title: Adwoa Asare, Community Development Manager <br /> Telephone Number: (919) 932-7077 ext. 233 E-Mail: aasare(@orangehabitat.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $146,133 Total Amount of Funds Requested: $50,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Habitat is seeking $25,000 to assist <br /> with funding its A Brush with Kindness program. Habitat will serve 15-18 low and very low- <br /> income homeowners in Orange County who are in need of exterior repairs on their homes. <br /> Main Application 1/25/201 6 1 2:11 :11 PM :' "I .7 <br />