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DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE ; program re�m|resmseparate Xi ti <br /> 1 <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Charles House çiatio <br /> Applicant Organization's Physical Address: 7511 Sunrise Floed, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 7511 Sunrise Road, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: .charleshouse.orq <br /> Executive Director: Paul Klever <br /> Telephone Number: 919-967-7570 E-Mail: pmu|@chor|ashouse.o0Q <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: Charles House-Daytime Eldercare Program <br /> Project/Program Primary Contact and Title: Paul K|ove[, Executive Director <br /> Telephone Number: Q1S'QO7'75TO E-Mail: pau| nhedeshoUne.o[Q <br /> c) Funding Request Identification <br /> Total P 'eoVP[nQramCoot $54U.000 Total Amount of Funds Requested: $35.000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): These funds will be used to support Charles <br /> House Daytime Eldercare Program at the new Center for Community Eldercare in Chapel Hill. These services <br /> support ca re giving families from Orange County and their aging family members, <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package fo i source, *The Participating Jurisdiction reserves the right to <br /> fund p ' nhs from any funding source, subject to eligibility and funding constraints. <br /> • CDBG Non-Construction (CH) $ 0 Grant El Loan <br /> ▪ CDBG Construction (CH) 0 Grant Loan <br /> • HOME CHDO (OC) 111 Grant Loan <br /> | <br /> HOME � / | (�rmnt | | Lo�n <br /> �~ ` ' ' �~ ^~ <br /> r Human Services: Carrboro $4000 I Chapel Hill $11.000 r Orange County $20.000 <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: S :>`1/ 2 <br /> Executive Director Date <br /> Signature: 441444- ��� ���^ � ��' ' ------- ' � <br /> Board Chairperson Date <br /> K8a|nAnnhoation 1/21/2016 12:22:19 PM Page 3 of 1G <br />