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DocuSign Envelope ID:C8D98134-3597-4323-98FA-COCA2820B225 Exhibit A - continued <br /> Provider's OM Rhatp%i�ppl i cation <br /> L. OVER PAGE (Each program requires a separate application <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name:The Madan Cheek Jackson Center for Saving and Making <br /> History <br /> Applicant Organization's Physical Address:512 W. Rosemary Street,Chapel Hill, NC 27516 <br /> Applicant Organization's Mailing Address:Same as above <br /> Applicant Organization's Web Address:www.jackson center,info <br /> Executive Director: Delta Pollock <br /> Telephone Number:919-960-1670 E-Mail: Hudsonp_iacksoncenter.info <br /> DUNS Number: <br /> (Dun&Bradstreet,Inc.provides this number at no charge,and it is required for Federal funding recipients.) <br /> b) Prjoect[Program Contact Information <br /> Project/Program Name: Learning Across Generations:Youth Leadership&Civil Rights Education <br /> Project,'Program Primary Contact and Title: Hudson Vaughan <br /> Telephone Number:919-960-1670 E-Mail: Hudson @yjacksoncenter.info <br /> c) Funding Request Identification <br /> Total Project/Program Cost:$60.500 Total Amount of Funds Requested:517,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): <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 /> ❑CDSG Non-Construction(CH) $ [-I Grant ❑Loan <br /> ❑CDBG Construction (CH) $_ ❑Grant ❑Loan <br /> ❑HOME CHDO(OC) $ ❑Grant ❑Loan <br /> ❑HOME Other(00) $ ❑Grant ❑Loan <br /> Z Human Services: 0 Carrboro$1,000 Z Chapel Hill$4,000 Z Orange County$10.O00 <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: <br /> Board efiairpers, Date <br /> Main Application 112412016 5:04-130 PM <br />