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DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact_Information <br /> Applicant Organization's Legal Name:The Cornmunit y Empowerment Fund <br /> Applicant Organization's Physical Address:208 N.Columbia Street, Suite 100LChapel Hill, NC <br /> 27514 <br /> Applicant Organization's Mailing Address: Same as above <br /> Applicant Organization's Web Address:www.communityef.orq <br /> Executive Director: Maggie West <br /> Telephone Number:1919)270-5730 E-Mail:maggiew@communityef.org <br /> Tax ID Number: <br /> b) Funding Request <br /> List FYI7-18 Human Services(Funding Being Requested— <br /> For All all Programs)and the Proposed Use of funds(2-3 lines or less) <br /> Program ,e �x <br /> chapel Orange Total <br /> - Hill H'- s iu" <br /> tx 3� z, s '4:-='..!:a .e �, 1' ,-$ if-f':'',1 i#'�' <br /> g ma Rt s . t taf # - } <br /> , » <br /> Advocate Program $11),0130 $20,000 $33,000 <br /> Program Coordinators-Salary and benefits F <br /> Totals <br /> 4 . $10,400 _ $20,000 $33,000 <br /> c) To the best of my knowledge belief ail mation in application is <br /> true and current. The document and has been di authorized and by the data governing this board of the <br /> applicant. <br /> Signature: i l — <br /> Exectilt Director Date <br /> i r f <br /> Signature: l?tt tZ'E v C <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/27/2017 1:13:44 PM page 6 o f 7 3 <br />