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DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> Total Project/Program Cost: $ 12,000 Total Amount of Funds Requested: $ 12,000 — <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Funds for the Summer Enerichment_ <br /> Camp will be used towards field trips, food and day to day camp necessities to include staff_,_, <br /> counclers and teachers. <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 n Loan <br /> E CDBG Construction (CH) $ ❑ Grant [ Loan <br /> r] HOME CHDO (00) $ [ Grant _ Loan <br /> C HOME Other (OC) $ ❑ Grant [ Loan <br /> n Human Services: // Carrboro $ 20,000 ►1 Chapel Hill $ 20,000 -1 Orange County <br /> $ 20,000 <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 /> 0A. - \- 4,0 <br /> Signature: — <br /> 1�' t,or Date <br /> Signature: Ex p V 2-� 2.4 Board Chairperson Date <br /> Main Application1/25/2016P a g e of 3 2 <br />