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DocuSign Envelope ID: El 573D55-1 DCO -4F4C- 9784- 749E3E95640B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant _Contact Information <br />Applicant Organization's Legal Name: Chapel_ Hill Carrboro Meals on Wheels <br />Applicant Organization's Physical Address: 1712 Willow Drive Suite 1 Chapel Hill NC 27514 <br />Applicant Organization's Mailing Address: PO Box 2102 Chapel Hill NC 27515 <br />Applicant Organization's Web Address: www.chcmow.org <br />Executive Director: Rachel Sobel Bearman <br />Telephone Number 919 -942 -2948 <br />Tax ID Number: 59- 1721954 <br />E -Mail: Rachel. bearman[_ehcmow.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 <br />Carrboro <br />Chapel <br />Hill - HS <br />Orange <br />County-HS <br />Total <br />- HS <br />Ex. Youth Afterschool Program <br />Afterschool Program Coordinator salary and materials <br />for youth activities and pLojects <br />$10,000 <br />$15,000 <br />$5,000 <br />$30,000 <br />Funds requested to subsidize the delivery of lunches <br />every Monday -Friday to the homebound and elderly <br />who cannot afford to cover the cost of the meals. <br />$18,000 <br />$23,000 <br />$18,000 <br />$59,000 <br />Totals <br />$18,000 <br />$23,000 <br />$18,000 <br />$59,000 <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 />Signature <br />Signature <br />1`x2 -.11 <br />Date <br />Date <br />AGENCY INFORMATION 1/2212018 8:21:25 AM Page 8 of 26 <br />