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DocuSign Envelope ID: 07FEE1A8-- �E83�rF-- 44CF- 9l9IC4 -6l A6EEg4aC`399BD2 <br />",ppuoa ,tArog faHonp�CIVIUffg51 nLalg.QiWt illty_Awareness Council ION <br />Applicant Organization's Physical Address: 504 West Franklin Street Chapel Hill, NC 27514 <br />Applicant Organization's Mailing Address: 504 West Franklin Street Chapel Hill, NC <br />27514 <br />Applicant Organization's Web Address: www.trianciledac.org <br />Executive Director: Dr. Timothy Miles <br />Telephone Number: 919 -245 -4337 E -Mail: ocdac(q�,ararlgecpgntync.goy <br />Tax ID 'Number: 58- 2062891 <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 <br />Carrboro <br />Ch_ apel <br />Hill - HS <br />Orange <br />Count - <br />HS _ - <br />Total <br />-- <br />-HS <br />Ex. Youth Afterschool- Program <br />Afterschool Program Coordinator salary and <br />materials for youth actlVities and omiects <br />$10,000 <br />$15,000! <br />$5,.000 <br />$30,000 <br />Technology Training and Equipment [disabled <br />3000 <br />3500 <br />3500 <br />$10,000 <br />Para -time Staff Grant Writer /Admin <br />3500 <br />3500 <br />3000 <br />$10,000 <br />Professional Training and ADA Related Servs <br />3500 <br />3500 <br />3000 <br />$10,000 <br />I <br />Totals <br />$30,000 <br />c) To the best of my knowledge and belief all information and data in this application is <br />true and current. The doe ent has been duly authorized by the governing board of the <br />applicant, 7/1 n <br />Signature: <br />xe 6ve(birebto l,� Date <br />Signature: `"' <br />Boa airrs Date <br />AGENCY INFORMATION 211/2017 9'47:16 AM a g e 6 of 2 2 .. <br />