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DocuSign Envelope ID: C4A8ABA9- 961E- 4297- 82F0- 5B1739260CFF <br />1. GONER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Diaper Bank of North Caroline <br />Applicant Organization's Physical Address: 1311 E. Club Blvd. Durham, 27704 <br />Applicant Organization's Mailing Address: 1311 E. Club Blvd. Durham, 27704 <br />Applicant Organization's Web Address: www.ncdiaperbank.org <br />Executive Director: Michelle Old <br />Telephone Number: 919 -886 -8085 <br />Tax ID Number: 32- 0401621 <br />E -Mail: michelle{a)ncdialperbank.org <br />b) Funding Request <br />List all FYI 8-19 Human Services HS Funding Being Requested — <br />For All Programs) and the Proposed Use of Funds (2 -3 lines or less) <br />Program — -- <br />Ex. Youth Afterschool Program -- — <br />Afterschool Program Coordinator salary and materials <br />for youth activities and pr2jects <br />CgrrhgL2 <br />Cha rel <br />Hill - HS <br />Orange <br />County-HS <br />Total <br />$10,000 <br />$15,000 <br />$5,000 <br />$30,000 <br />Outcome Based Diaper Distribution Program: Diaper <br />and Diapering supplies, wrapping supplies, and <br />program management (Distribution Coordinator) <br />salary. <br />Totals <br />$5,000 <br />$5,000 <br />$10,000 <br />$20,000 <br />$5,000 <br />$5,000 <br />$10,000 <br />$20,000 <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 duty authorized by the governing board of the <br />applicant. <br />Signature: �J_ "_LL <br />Executive Director <br />Signature: (- IVA Board Chairperson <br />Date <br />January 23, 2018 <br />Date <br />AGENCY INFORMATION 2/12/2018 7:53:03 PM Page 8 of 28 <br />