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DocuSign Envelope ID: 1BCF0634-CD89-4310-96E4-A32E6E1A91A6 <br /> ( <br /> I C A Ro <br /> N .Arkvi, 0 <br /> GOP 2017-18 <br /> cow- <br /> ARTS GRASSROOTS ARTS PROGRAM <br /> °NANCE COUNTY <br /> tommtsslom iiiivirw.ncarts.org APPLICATION FORM <br /> PART 1 APPLICATION ORGANIZATION INFORMATION <br /> Organization Name: Historical Foundation cf Hillsborough &Orange County(Orange Courtly Historical Museum) <br /> Street Address: 201 N. Churton Street <br /> City. Hillsborough j State: North Carolina p: 27278 <br /> Phone: 919-732-2201 Websile: voitiiworangeNChistory,org <br /> Authorizing Official Name: Ernest Dollar <br /> Authorizing Official Title: Board Chairperson <br /> Authorizing Official Phone, 919-491-5398 I Authorizing Official Email: ernestdollar@gmait com <br /> Applicant Race;Caucasien,HispanicilNative South American Organization EIN: <br /> ORGANIZATIONAL FINANCES <br /> Please attach a complete income and expense statement(an audit may be substituted)for your last fiscal year and <br /> complete operating budgets for the current fiscal year and next fiscal year. Public schools and other large governmental or <br /> community agencies should attach arts program financial information only Please copy the totals from these attachments <br /> in the spaces below: <br /> 1741i*YO**Wilti/l10itill":77", <br /> Actual income: $65,52731 Projected Income: $54524.52 Projeclzd income: $68271 <br /> Actual Expenses: $64,936.71 Projected Expense: $ 53,751.84 Projecr d Expense: $67684 <br /> PART 2. PROJECT INFORMATION <br /> PROJECT DIRECTOR INFORMATION if dfferent from Authorizing Official) <br /> Project Director Name: Candace Midgett <br /> Project i irector Title: Executive Director, Orange County Historical Museum <br /> Street Address: 201 N. Churton Street <br /> City: Hillsborough State: NC Zip:27278 <br /> Phone: 919,-732-2201 directurE orangerichistory,org <br /> PROJECT SUMMARY <br /> Title of Grant Program or Project: Art & History, a Community Partnership: <br /> e cunt Historical MuseusunnuFairview Community and artist Renzo OrtegaL <br /> Grant Amount Requested: $3172 <br /> Project Start Date(No earlier than July 1, 2017):July 1, 2017 <br /> Project E dd Date No later than June 30, 2018): June 30, 2018 <br /> SCHOOLS ONLY: <br /> Are you booking your artists through The Arts Center's Arts in Schools Program? D YES X NC <br /> / OW k GY 1;161 "",r1',` ilk 'v v Vvv <br />