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DocuSign Envelope ID:72266CE5-DF5A-471E-B671-CC65C8960691 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: EmPOWERment, Inc <br /> Applicant Organization's Physical Address: 109 N. Graham Street, Suite 200, Chapel Hill, NC <br /> 27516 <br /> Applicant Organization's Mailing Address: 109 N. Graham Street, Suite 200, Chapel Hill, <br /> NC 27516 <br /> Applicant Organization's Web Address: www.empowermentinc-nc.orq <br /> Executive Director: Delores Bailey <br /> Telephone Number: 919-967-8779 E-Mail: empowermentincncgmail.com <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 /> Rental Property Management Program $15,000 $20,000 $30,000 $65,000 <br /> Services, Support, materials and salary for the <br /> Property Manager and Property Manager Assistant <br /> Totals $15,000 $20,000 $30,000 $65,000 <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 /> (e(Signature: /— -/?' <br /> Executive Director Date <br /> Signature: ( S 7(7 <br /> BoarO/Chairperson Date <br /> AGENCY INFORMATION 1/25/2017 9:41:22 AM P It <br />