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DocuSign Envelope ID:9B26E979-2C09-4BE7-801C-3DDB484D92EE XHIBIT A <br /> PROVIDER"S OUTSIDE AGENCY APPLICATION <br /> 1, COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: OCRA (Orange County Rural Alliance) <br /> Applicant Organization's Physical Address: 490t Schley Rd, Hillsborough, NC 27278 <br /> Applicant Organization's Mailing Address: PO Box 642, Hillsborough, NC 27278 <br /> Applicant Organization's Web Address: none <br /> Executive Director: Norma B. "White <br /> Telephone Number: 919732-8527 E-Mail: newhite@embaromalLoorn <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FYI 7i8 Human Services (HS) Funding Being Requested— <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carftgoro Chattel Orange Total <br /> -HS Hill - HS County:HS <br /> Ex, Youth Afterschool Program $10,0$• $15,000 $5,000 $30 000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth aonvities andiardiects <br /> Deliver meals for 50 rural homebound seniors three <br /> times per week for 50 weeks $25,000 <br /> Totals $26,000 <br /> e) 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 boar' of the <br /> applicant <br /> 1,74,1„.4, 7,1310 17,1(47 <br /> Signature: Norma B. White January,26, 2017 <br /> President Date <br /> Signature Alex Castrelorr January 20, 2017 <br /> Board Chairperson Date: <br /> AGENCY INFORMATION 1/26/2017 3A2.32 PM e 3 ri <br />