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DocuSign Envelope ID: 7A9252AF- OE3A- 47EE- A4F6- 2A3D9DF527FF <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: The Marian Cheek Jackson Center for Saving and <br />Making_Histo <br />Applicant Organization's Physical Address: 512 W. Rosemary Street Cha ep I Hill, NC 27516 <br />Applicant Organization's Mailing Address: Same as above <br />Applicant Organization's Web Address: www.jacksoncenter.info <br />Executive Director: Della Pollock <br />Telephone Number: (919) 960 -1670 <br />Tax ID Number: 46- 1988511 <br />E -Mail: hudsonjacksoncenter.info <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 <br />Carrboro <br />Chapel <br />Orange <br />Total <br />- HS <br />Hill - HS <br />igountymHS <br />Learning Across Generations: Capacity building for <br />$5,000 <br />$10,000 <br />$15,000 <br />$30,000 <br />and expansion of K -12 civil rights education curricula <br />and audio immersion program rooted in social justice <br />work and youth-led activism <br />Promise of Home: To expand our emergency home <br />$7,000 <br />$ <br />$25,000 <br />$32,000 <br />repair program & long -term neighbor retention support <br />efforts <br />Totals <br />$12,000 <br />$10,000 <br />$40,000 <br />$62,000 <br />c) To the best of my knowledge and belief all information and data in this application is true <br />and current. The document has been duly authorized by the governing board of the <br />applicant. <br />i' <br />Signature: <br />cu a Di ctor <br />Signature: <br />Board C airperson <br />Date — <br />Date <br />