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DocuSign Envelope ID: DD554565-B9BA-4128-863D-805D6BC56619 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: Orange County Partnership for Young Children <br /> Applicant Organization's Physical Address: 120 Providence Road, Suite 101,, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 120 Providence Road, Suite 101, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: www,orangesmartstarLorg <br /> Executive Director: Robin Pulver <br /> Telephone Number: 919967-9091 E-Mail: r_pulver@grangesmartstart,orq <br /> DUNS Number: 007892730 <br /> (Dun & Bradstreet, Inc provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Project/Proqram Contact Information <br /> Project/Program Name: Transplanting Traditions Community Farm <br /> Project/Program Primary Contact and Title: Kelly Owensby, Project Director <br /> Telephone Number: 919-967-9091 E-Mail: kowensbyAorangesmartstart.orq <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $171,592 Total Amount of Funds Requested: $15,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Funds will be used to support costs <br /> associated with staffing and contractual services to serve the Transplanting Traditions Community <br /> Farm for Burmese refu.ees, Contractual services include a native Burmese translator. <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) $ Grant Ej Loan <br /> El] CDBG Construction (CH) 1:1 Grant Loan <br /> E] HOME CHDO (OC) E Grant 11 Loan <br /> 1:1 HOME Other (OC) E Grant E Loan <br /> Z Human Services: r Carrboro $5,000 Z Chapel Hill $5,000 Z Orange County $5,000 <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: 1/25/16 <br /> Executive Director Date <br /> Signature: 1/25/16 <br /> Board Chairperson Date <br /> Main Application 1/25/2016 10:25:47 AM <br />