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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Freedom House Recovery Center, Inc. <br /> Applicant Organization's Physical Address: 104 New Stateside Drive Chapel Hill, NC 27516 <br /> Applicant Organization's Mailing Address: same as above <br /> Applicant Organization's Web Address: www.freedomhouserecovery.orq <br /> Executive Director: Trish E. Hussey <br /> Telephone Number: 919-942-2803 E-Mail: trish.h(a�fhrecovery.orq <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange 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 /> 24/7/365 Urgent Behavioral Health Care (Facility- $5,000 $14,000 $16,000 $35,000 <br /> Based Crisis and Detox Services) To support the day- <br /> to-day services(i.e. staffing,facility costs, supplies and <br /> equipment) <br /> Maggie Alvis Women's and Men's Halfway Houses $5,000 $5,000 $15,000 $25,000 <br /> (Residential Rehabilitation) To support the day-to-day <br /> services (i.e.staffing,facility costs, supplies and equipment) <br /> Community Mental Health Programs (Compeer, $6,000 $6,000 $6,000 $18,000 <br /> ProBono Counseling Network, Family Advocacy <br /> Network) To support the day-to-day services and <br /> education (i.e. staffing, supplies and travel) <br /> Totals $16,000 $25,000 $37,000 $78,000 <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document ha been duly authorized by the governing board of the <br /> applicant. - ' <br /> 1 <br /> Signatu - -- " " _' 7/ 3c1,1 c "1-- <br /> Executive Director Date <br /> Signature: (. /7; <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/27/2017 10:16:45 AM Page 6 of 24 <br />