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DocuSign Envelope ID:BF9F1016-CEDB-4BF6-9DF2-A6DAB623164C Exhibit A <br /> Provider' 000, ,,,itnfi)L ,glication <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The Community Empowerment Fund <br /> Applicant Organization's Physical Address: 108 W. Rosemary Street, Chapel Hill, NC275,16 <br /> Applicant Organization's Mailing Address: 108 W. Rosemary Street, Chapel Hill, NC 27516 <br /> Applicant Organization's Web Address: ,www.communityempowermentfund.org <br /> Executive Director: Maggie West <br /> Telephone Number: 919-200-0233 E-Mail: maggiewAcommunityef.org <br /> DUNS Number: 036791351 <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: Advocate Program <br /> Project/Program Primary Contact and Title: Ma..ie West Program Coordinator <br /> Telephone Number: 919-200-0233 E-Mail: maggiew(d),communityetorg <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $144,960, Total Amount of Funds Requested: $14,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): CEF is requesting funding to provide <br /> relationship-based support to individuals experiencing or at-risk of experiencing homelessness: We <br /> propose to assist participants in gaining employment, housing, and personal savings. <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 /> LI CDBG Non-Construction (CH) $ Ei Grant El Loan <br /> LI CDBG Construction (CH) 0 Grant 0 Loan <br /> 0 HOME CHDO (OC) E Grant Loan <br /> 0 HOME Other (OC) I] Grant 1] Loan <br /> I Human Services: I Carrboro $2,000 Chapel Hill $4 500 I Orange County $7,500 <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: <br /> Executive Director Date <br /> Signature: (7) / (P 6 <br /> Board Chairperson Date <br /> Main Application 1/24/2016 1 :54:12 PM , <br />