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Page 7 of 23 <br />1. COVER PAGE <br /> <br />a) Applicant Contact Information <br /> <br />Applicant Organization’s Legal Name: Habitat for Humanity of Orange County <br /> <br />Applicant Organization’s Physical Address: 88 Vilcom Center Drive, Suite L110, <br />Chapel Hill, NC 27514 <br /> <br />Applicant Organization’s Mailing Address: 88 Vilcom Center Drive, Suite L110, <br />Chapel Hill, NC 27514 <br /> <br />Applicant Organization’s Web Address: www.orangehabitat.org <br /> <br />Executive Director: Susan Levy <br /> <br />Telephone Number: (919) 932-7077 ext. 211 <br /> <br />E-Mail: slevy@orangehabitat.org <br /> <br />Tax ID Number: 58-1603427 <br /> <br />b) Funding Request <br />List all FY18-19 Human Services (HS) Funding Being Requested (For All Programs) <br />and the Proposed Use of Funds (2-3 lines or less) <br />Program Carrboro -HS Chapel Hill -HS Orange County-HS Total <br />Home Preservation $5,000 $10,000 $50,000 $65,000 <br />Totals $5,000 $10,000 $50,000 $65,000 <br /> <br />c) To the best of my knowledge and belief all information and data in this <br />application is true and current. The document has been duly authorized by the <br />governing board of the applicant. <br /> <br /> <br />Signature: 1/23/18 <br /> Executive Director Date <br /> <br /> <br />Signature: 1/23/18 <br /> Board Chairperson Date <br /> <br />d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON <br />DISCRIMINATION CLAUSE <br /> <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 1263366F-0902-4D24-AE16-FC2EBB866669