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DocuSign Envelope ID:88AE E9B F-924A-442D-B D41-DC640F1E 1 BAC <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact information <br /> Applicant Organization's Legal Name: Dispute Settlement Center, Inc. <br /> Applicant Organization's Physical ddress: 302 Weaver Street, Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: same <br /> Applicant Organization's Web Ad ress: www.disputesettlement.org <br /> Executive Director: Frances Henderson <br /> Telephone Number: (919) 929-8800 E-Mail: fenderson Odisputesettlement.orq <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FYI7-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Prop sed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> HS Hill-HS .County-HS <br /> Conflict Resolution trainings and Restorathke Justice $10,000 ' $15,000 $25,000 <br /> for Youth-in the community and with tuve ile court, " <br /> referrals and their•families. 1°_ ` ° .." <br /> Mediation—Helping settle interpersonal didputes $83,000 $83,000 <br /> referred from Orange County Criminal District Court; <br /> helping separating couples with disagreem nts over <br /> parenting, finances, and other issues;facilitating <br /> conversations between Medicaid recipients and the <br /> state over services <br /> Totals $10,000 $15,000 $83,000 $108,000 <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The documen has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: -•-' ' . OF 2�" /7 <br /> Executive Director Date <br /> Signature: / /�c C <br /> Board airperson Date <br /> AGENCY INFORMATION 1/18/2017 12.07:30 PM Page 6 of 19 <br />