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DocuSign Envelope ID:4F0B7605-00EB-4D90-837E-574BBBBD89EB t A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: EmPOWERment, Inc. <br /> plicant Organization's Physical Address: 109 N. Graham Street, Suite 200, Chapel Hill, NC <br /> 2;516 <br /> Applicant Organization's Mailing Address: 109 N. Graham Street, Suite 200, Chapel Hill, NC 2516 <br /> Applicant Organization's Web Address: www.empowermentinc-nc.org <br /> Executive Director: Delores Bailey <br /> Telephone Number: 919-967-8779 E-Mail: empowermentincncgmail.com <br /> DUNS Number: 00-344-2803 <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: Funding for Property Manager <br /> Project/Program Primary Contact and Title: LaTanya Davis, Property Manager <br /> Telephone Number: 919-967-8779 E-Mail: Iddavis67gmail.com <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $185.083 Total Amount of Funds Requested: $70,000.00 5;554W P earn <br /> Proposed Use of Funds Requested (2-3 Line Maximum): The total use of funds requested is for <br /> property manager and property manager assistant. <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) $15,000 XXXI7Grant I— Loan <br /> E CDBG Construction (CH) Grant 0 Loan <br /> E HOME CHDO (00) Grant El Loan <br /> LI HOME Other (0C) Ej Grant Loan <br /> Human Services: E Carrboro $10,000 Chapel Hill $20,000 E Orange County$25,000 <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: .11-- U-K) "42-1)Cck_.(2e, — 2- — G <br /> Executive Director Date <br /> Signature: "14.0-...- CPita•A".4./ <br /> Board Chairperson Date <br /> Main Application 1/21/2016 2:46:54 PM r ci e 3 of 24 <br />