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DocuSign Envelope ID: FOFFD659- 4159- 4D4C- 82FD- FF8E51A5A7E4 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />'[. COVER PAGE <br />a App[iicant Cantac t Information <br />Applicant Organization's Legal Name: The Women's Center, Inc. dba Compass Center <br />for Women and Families <br />Applicant Organization's Physical Address: 21.6 Henderson St., Chapel Hill NC 27514 <br />Applicant Organization's Mailing Address: Post Office Box 1057, Chapel Hill, NC 27514 <br />Applicant Organization's Web Address: compassctr.org <br />Executive Director: Cordelia Heaney <br />Telephone Number: (919) 968 -4610 <br />Tax ID Number: 56- 1271474 <br />E -Mail: director@compassUr.org <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 />Program Carrboro Chape Orange, Total <br />HS Hill - HS County -HS <br />To provide domestic violence crisis services, $1.2,207 $41,377 $90,458 $144,042 <br />expanded financial education and career <br />preparedness services, legal information services, <br />connections to community resources, youth and adult <br />training and education on the prevention of <br />interpersonal violence and civic engagement related <br />to women's and gender issues <br />Totals $12;207 I $41,377 $90,458 $144,042 <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: t ! <br />Executive Director Date <br />Signature: ` ter 1 cc, 4 .-- .. <br />rd Chairperson D to <br />AGENCY INFORMATION 1/22/2018 5:50:18 PM Page 8 of 47 <br />