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DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Inter-Faith Council for Social Service <br /> Applicant Organization's Physical Address: 110 W. Main Street Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: 110 W. Main Street Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.ifcweb.org <br /> Executive Director: John Dorward and Kristin Lavergne <br /> Telephone Number: 919-929-6380 E-Mail: info©ifcmailbox.org <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Procirams) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - HS County-HS <br /> Residential Services: Community House and <br /> HomeStart offer housing, meals, showers and 6,000 13,500 26000 45,500 <br /> laundry, health, mental health and dental care, social <br /> work and referrals. <br /> Food Programs: The Community Kitchen offers free <br /> hot meals every day to anyone who is hungry, and the 4,950 10,000 22,500 37,450 <br /> Food Pantry offers free groceries as often as once a <br /> month to our neighbors in need. <br /> Support Circles use a relationship-based model to <br /> provide support for families and individuals 1,000 1500 1500 4,000 <br /> transitioning out of homelessness. <br /> Totals 11,950 25,000 50,000 86,950 <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The docum t has been duly authorized by the governing board of the <br /> applicant. <br /> 7 r <br /> January 31, 2017 <br /> Signature: . <br /> ecutive Director Date <br /> -; / <br /> January 31, 2017 <br /> Signature: <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/31/2017 11:43:55 AM Pago 3 of 35 <br />