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DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA - continued <br /> Provider's Outside AqpnLy_Application <br /> MAIN APPLILA I ION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Boys & Girls Clubs of Eastern Piedmont (BGCEP) <br /> Applicant Organization's Physical Address: 288 East Street, Suite 1008, Pittsboro, NC 27312 <br /> Applicant Organization's Mailing Address: PO Box 1788, Pittsboro, NC 27312 <br /> Applicant Organization's Web Address: bgcepnc.org <br /> Executive Director: Sarah Marion, MPA <br /> Telephone Number: 919-663-6159 E-Mail: smarion©bgcepnc.org <br /> DUNS Number: 079238323 <br /> a) Pro'ect/Pro.ram Contact Information <br /> Project/Program Name: BGCEP Community Impact Program in Chapel Hill <br /> Project/Program Primary Contact and Title: Marywinne Sherwood, Board Member <br /> Telephone Number_919-967-4264 <br /> E-Mail: marywinne@yahoo.com <br /> b) Funding Request Identification <br /> Total Project/Program Cost: $127,360 Total Amount of Funds Requested: $30,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum):Funds will be used to help support <br /> salaries and benefits for the full time Program Manager and for two part time assistants, without <br /> whom it would be impossible to deliver services to the youth in the program. <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) $ 0 Grant II Loan <br /> LI CDBG Construction (CH) El Grant Eli] Loan <br /> [I] HOME CHDO (00) Grant LI Loan <br /> 11 HOME Other(00) [1] Grant El Loan <br /> Human Services: EiCarriporo $10,000 Chapel Hill $10,000 ElOrange County $10,000 <br /> c) 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: (- 7< ; _ J_ <br /> Erectzr Date <br /> Signature: 6 <br /> ' Board Chair son Date <br /> Main Application 1/18/2016 13:13:17 al/p1 P a q a 3 a 22 <br />