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DocuSign Envelope ID: D068E7B0- D869- 43F4- B35C- 428F10E3BDC1 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />COEI PkCE.t <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Dispute Settlement Center <br />Applicant Organization's Physical Address: 302 Weaver Street Carrboro NC 27510 <br />Applicant Organization's Mailing Address: same <br />Applicant Organization's Web Address: www.dis utesettlement.or <br />Executive Director: Frances Henderson <br />Telephone Number: 919 929 -8800 <br />Tax ID Number: 56- 1216584 <br />E -Mail: fenderson dis utesettlement_or <br />b) Funding Request <br />List all FY18 -19 Human Services HS Funding Being Requested — <br />For All Proarams] and the Proposed Use of Funds (2 -3 lines or less) <br />Program <br />Ch7_p 'el ' ; <br />0rarrge.. + <br />Total <br />-� T <br />`- HS <br />County-HS. <br />$85,000 <br />Mediation <br />x <br />$85;U00 <br />PY r fib f6 f�gP� i_ <br />� <br />Totals <br />$1404 <br />$18;000 - <br />$85,`000 <br />$117,000 <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 duly authorized by the governing board of the <br />applicant. <br />i <br />Signature: r�ti <br />E/ cutive Director <br />J <br />Signature: <br />Board Chairperson <br />/ -2- 2 if <br />Date <br />/- 2,2--It <br />Date <br />AGENCY INFORMATION 1 /12/2018 12:41:41 PM Page 8 of 27 <br />