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2 <br /> EMERGENCY SHELTER GRANTS PROGRAMS <br /> APPLICATION SUMMARY FORM <br /> 1. APPLICANT <br /> a. Name of local government: County of Orange <br /> b. Address: P.O. Box 8181, Hillsborough, N.C. 27278 <br /> c. County: Orange <br /> d. Local Government Contact Person: Tara L. Fikes <br /> Address: P.O. Box 8181, Hillsborough, N.C. 27278 <br /> Telephone: (919) 732-8181 <br /> 2. SHELTER (SUBRECIPIENT) <br /> a. Name of shelter: Inter-Faith Council Community Shelter <br /> b. Address: 100 W. Rosemary Street <br /> Chapel Hill, N.C. 27514 <br /> c. Subrecipient Contact Person: Chris Moran <br /> Telephone: (919) 967-0643 <br /> d. Is subrecipient a domestic violence shelter? Yea No X X . <br /> 3. ADMINISTERING AGENCY <br /> a. Name of administrating agency: N/A <br /> b. Contact person and phone number: <br /> 4. GRANT REQUEST <br /> - Rehabilitation funds requested $ 45,000 <br /> - Operations/Services funds requested $ <br /> TOTAL $ 45.000 <br /> 5. If the local government certifications are to be submitted at a later date than the <br /> application due date, please indicate that date: N/A <br /> 6. CERTIFICATION <br /> To the best of my knowledge and belief, data in this application is true and correct. <br /> The document has been duly authorized by the governing body of the applicant and the <br /> applicant will comply with the attached certifications if the assistance is approved. <br /> a. Typed Name and Title of Chief Elected Official of local government <br /> applicant: <br /> Moses Carey, Jr. , Chair <br /> • - s . - , Board of Commissioners <br /> b. Signature c. Date <br /> ESGP #101 (Revised 3/89) <br />