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<br />AGENCY INFORMATION 1/23/2018 3:44:19 PM Page 7 of 21 <br /> <br />1. COVER PAGE <br /> <br />a) Applicant Contact Information <br /> <br />Applicant Organization’s Legal Name: Table Ministries, Inc. <br /> <br />Applicant Organization’s Physical Address: 209 E. Main Street, Carrboro, NC 27510 <br /> <br />Applicant Organization’s Mailing Address: same as above <br /> <br />Applicant Organization’s Web Address: www.tablenc.org <br /> <br />Executive Director: Ashton Tippins <br /> <br />Telephone Number: (919)636-4860 E-Mail: info@tablenc.org <br /> <br />Tax ID Number: 26-1471735 <br /> <br />b) Funding Request <br />List all FY18-19 Human Services (HS) Funding Being Requested – <br />For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> <br />Program Carrboro <br />- HS <br />Chapel <br />Hill - HS <br />Orange <br />County-HS <br />Total <br />Ex. Youth Afterschool Program <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />$10,000 $15,000 $5,000 $30,000 <br />Food 9000 9000 9000 27000 <br />Program Staff Support 3000 3000 3000 9000 <br />Rent 3000 3000 3000 9000 <br /> <br /> <br /> <br /> <br /> <br />Totals 15,000 15,000 15,000 $45,000 <br /> <br /> <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 /> <br /> <br />Signature: 1/19/18 <br /> Executive Director Date <br /> <br /> <br />Signature: 1/23/18 <br /> Board Chairperson Date <br /> <br />