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DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Orange County Living Wage <br /> Applicant Organization's Physical Address: 218 Lake Manor Rd., Chapel Hill, NC 27516 <br /> Applicant Organization's Mailing Address: PO Box 1502, Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.orangecountylivingwage.org <br /> Executive Director: Susan Romaine <br /> Telephone Number: 919-619-3408 E-Mail: susanAorangecountylivingwage.org <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FYI 7-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrbor Chapel Orange Total <br /> o HS Hill - HS County: <br /> HS <br /> OCLW Certification Efforts <br /> Operational Support—This money will support the salary $10,000 $10,000 <br /> of a part time administrative assistant(10 hours/week at <br /> $20/hour). <br /> Hosting Fees—This money will cover hosting fees to $1,000 $1,000 <br /> support the OCLW website, email service, and mobile <br /> application. <br /> Social Media—This money will cover the expenses of a $2,000 $2,000 <br /> social media contractor who will handle content and <br /> platform management for OCLW. <br /> Website—This money will cover the expense of $3,000 $3,000 <br /> maintenance and some content redesign of the OCLW <br /> website, <br /> I Mobile Application—This money will cover the $2,000 $2,000 <br /> maintenance costs of OCLW's newly developed mobile <br /> application. <br /> Accounting Services—This money will cover the costs of $2,000 <br /> $2,000 <br /> preparing tax returns, payroll services,and other <br /> assistance. <br /> Totals $20,000 $20,000 <br /> DO NOT SUBMIT THIS PAGE 12/15/2016 9:57:17 AMPa9e 8 of 31 <br />