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DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C 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: Voices Together <br /> Applicant Organization's Physical Address: 5007 Southpark Dr. Ste 230 Durham, NC 27713 <br /> Applicant Organization's Mailing Address: 5007 Southpark Dr. Ste 230 Durham, NC 27713 <br /> Applicant Organization's Web Address: www.voicestogether.net <br /> Executive Director: Yasmine White <br /> Telephone Number: 919-942-2714 E-Mail: yasmine @voicestogether.net <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: VT in Education <br /> Project/Program Primary Contact and Title: Carrie Kovalick, Communications Director <br /> Telephone Number: 919-942-2714 E-Mail: carrie @voicestogether.net <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $15,000 Total Amount of Funds Requested: $15,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): VT in Education program has been <br /> serving the students in Orange County School Exceptional Children classrooms since 2009. <br /> Children in these classrooms face academic and social challenges that can be devastating. Support <br /> from Orange County Outside Funding will help close the achievement gap, helping these children <br /> succeed academically and into adulthood. <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 /> ❑ CDBG Non-Construction (CH) $ ❑ Grant [' Loan <br /> ❑ CDBG Construction (CH) $ ❑ Grant [' Loan <br /> ❑ HOME CHDO (OC) $ ❑ Grant [' Loan <br /> ❑ HOME Other (OC) $ ❑ Grant [' Loan <br /> x Human Services: ❑ Carrboro $ [' Chapel Hill $ X Orange County $15,000 <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: 7 1/25/2016 <br /> Executive Director Date <br /> Main Application 1/25/2016 1:42:01 PM P a • e 3 o f 2 °1 <br />