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DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 <br />Exhibit A: Provider's Outside Agency Application <br />1. COVER PAGE <br />a] Applicant Contact Information <br />Applicant Organization's Legal Name: A Helpiny Hand <br />Applicant Organization's Physical Address: 1502 West NC Highway 54. suite 455 <br />Durham, NC 27707 <br />Applicant Organization's Mailing Address: 1502 West NC Highway 54, suite 405 <br />Durham, NC 27707 <br />Applicant Organization's Web Address: www.ahelpinghandnc.org <br />Executive Director: Jennifer Ashle <br />Telephone Number:-919-403-5555 ier.ashleyaahelDine handnc org <br />Tax ID Number: 56- 1923835 <br />bj 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 Carrbora Chapel Qr�anr a Total <br />- HS Pill - HS Count -HS <br />Our Caregiving Collaboration is one part Geriatric $6,000 $6,000 $+6,500 $18500 <br />workforce enhancement program which serves to <br />provide vital services to low income seniors. <br />Totals <br />$18,51]0 <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 />Signature: <br />PV/8 <br />Date <br />Date I <br />AGENCY INFORMATION 1/23/2018 11:44:33 AM <br />