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DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application-7j <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: TABLE Ministries, Inc. <br /> Applicant Organization's Physical Address: 205 W. Weaver Street, Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: 205 W. Weaver Street, Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.tablenc.orq <br /> Executive Director: Ashton C. Tippins <br /> Telephone Number: (919)636-4860 E-Mail: tablencgmail.com <br /> DUNS Number: N/A <br /> (Dun & Bradstreet, lric, provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Proiect/Proqram Contact Information <br /> Project/Program Name: Weekend Meal Backpack Program <br /> Project/Program Primary Contact and Title: Ashton Tippins <br /> Telephone Number: (919)636-4860 E-Mail: tablencgmail.com <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $224,088 Total Amount of Funds Requested: $30,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): We respectfully request $30,000 for the <br /> purchase of food, partial payment of program staff, and assistance with rental of new space and <br /> equipment. <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 /> E CDBG Non-Construction (CH) $ <br /> Grant [11 Loan <br /> LI CDBG Construction (CH) E Grant Eli Loan <br /> Li) HOME CHDO (00) Grant ri Loan <br /> E HOME Other(OC) E Grant El Loan <br /> Human Services: Carrboro $10,000 14 Chapel Hill $10,000 Orange County $10,000 <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: ft, C. ' III Ulf <br /> Executive Director Date <br /> Signature: &it 64///1-- 4hINy1,/L 1/ I(71(0 <br /> Board Chairperson Date <br /> Main Application 1/11/2016 12:10:18 PM P (; 3 o If 1 6 <br />