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DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) A06licant Contact information <br /> Applicant Organization's Legal Name: Charles House Association <br /> Applicant Organization's Physical Address: 7511 Sunrise Road, Chapel Hill <br /> Applicant Organization's Mailing Address: 7511 Sunrise Road, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: mw.charleshousporg <br /> Executive Director: Paul Klever <br /> Telephone Number: 919-967-7570 E-Mail: paul • charieshoum_ <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding 1.;eing Requested — <br /> For Milo irca_yris) and the Proposed Use of Funds (2-3 lines or less) <br /> ErAgram Carrboro Chapel pranne Total <br /> HS Hill-HS ,,County-HS_ <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> DAYTIME ELDERCARE PROGRAM $4000 $10,000 $25,000 $39,000 <br /> Totals $4000 $10,000 $25,000 $39,000 <br /> c) 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: JA V3e) ,2c))7 <br /> Executive Director Date <br /> SignatureA44-44 S. AV //.10/20/ 7 <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/27/2017 4:48:43 PM Page 2 of 1 7 <br />