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DocuSign Envelope ID: DDOCFB62- 8EDD- 4B57- ACF6- 9C98BO78AA95 XHIBIT A <br />PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Orange County Literacy Council <br />Applicant Organization's Physical Address: 200 N Greensboro St, C -2, Carrboro, NQ 27510 <br />Applicant Organization's Mailing Address: 200 N Greensboro St, C -2, Carrboro, NC 27510 <br />Applicant Organization's Web Address: www,orangeliteracy.orp <br />Executive Director: Alice Denson <br />Telephone Number:919- 914 -5163 <br />Tax ID Number: 56- 1433933 <br />E -Mail: adenson@_orangeliteracy.org <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 />IProgram <br />Carrboro <br />Chapel <br />Hill - <br />HS <br />Orange <br />County- <br />HS <br />Total <br />- HS <br />Adult Literacy <br />$5,400 <br />$16,600 <br />$16,000 <br />$38,000 <br />Family Reading Partners <br />$ 600 <br />$ 3,400 <br />$ 1,000 <br />$5,000 <br />$6,000 $20,000 <br />$17,000 $43,000 <br />Totals <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 />Signature: <br />utive Director <br />Signature: I _ <br />Eloard Chairperson <br />�/ / <br />Qate ' <br />Z X 17 <br />Date <br />AGENCY INFORMATION 1/31/2017 10:54:56 AM Page 2 of 26 <br />