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DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />[. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Charles House Association <br />Applicant Organization's Physical Address: 7511 Sunrise Road Chapel Hill <br />Applicant Organization's Mailing Address: 7511 Sunrise Road, Chapel Hill, NC 27514 <br />Applicant Organization's Web Address: www.charleshouse.or <br />Executive Director: Paul Klover <br />Telephone Number: 919 -967 -7570 <br />Tax ID Number: 58- 1582881 <br />E -Mail: PauKcDcharleshouse.oro <br />b) Funding Request <br />List all FYI 8-19 Human Services (NS) 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 />- H5 <br />Ex, Youth Afterschool Program <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />$10,000 <br />$15,000 <br />$5,000 <br />$30,000 <br />DAYTIME ELDERCARE PROGRAM <br />$4000 <br />$10,000 <br />$25,000 <br />$39,000 <br />Totals <br />$4000 <br />$10,000 <br />$25,000 <br />$39,000 <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: 2� <br />9 - <br />Executive Director Da <br />Signature,/// -� <br />Board Chairperson Date <br />AGENCY INFORMATION 1/22/2018 12:24:10 PM P a g e 2 o f 1 5 <br />