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MAIN APPLICATION <br />1. COVER PAGE (Each program requires a separate application.) <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Duke University Health System, Inc. d /b /a Duke HomeCare & Hospice <br />Applicant Organization's Physical Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 <br />Applicant Organization's Mailing Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 <br />Applicant Organization's Web Address: https:Hdhch.duhs.duke.edu <br />Executive Director: Belle Starr Browning <br />Telephone Number: 919.620.3853 E -Mail: starr.browning @duke.edu <br />DUNS Number: <br />(Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br />b) ProiectlProuram Contact Information <br />Project/Program Name: Duke HomeCare & Hospice <br />Project/Program Primary Contact and Title: Dale Horton <br />Telephone Number: 919 -479 -0318 <br />c) Funding Request Identification <br />E -Mail: dale. horton(a)duke.edu <br />Total Project/Program Cost: $13,864Total Amount of Funds Requested: $7,800.00 <br />Proposed Use of Funds Requested (2 -3 Line Maximum): Duke Hospice Bereavement Services will use the <br />funds to offset the costs of providing care to grieving individuals in Chapel Hill, Carrboro and Orange County. <br />We continue to offer our services at no cost to any individual in the area who requests our support. <br />Please check all types, sources, and amounts of funding being requested. You must submit an <br />application package for each funding source. 'The Participating Jurisdiction reserves the right to <br />fund projects from any funding source, subject to eligibility and funding constraints. <br />❑ CDBG Non - Construction (CH) $ ❑ Grant ❑ Loan <br />❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan <br />❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan <br />❑ HOME Other (OC) $ ❑ Grant ❑ Loan <br />X Human Services: X Carrboro $3,800 X Chapel Hill $3,000 X Orange County $9 000 <br />d) To the best of my knowledge and belief all <br />true and current. The document has been <br />applicant. <br />Signature: <br />:,� t Dire( <br />Signature: <br />information and data in this application is <br />duly authorized by the governing board of the <br />i -� -col i,-k <br />Date 2 2- 1 t <br />Boar Chairperson Date <br />Main Application 1/25/2016 12:06:09 PM <br />Page 3 of 16 <br />