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DocuSign Envelope ID: 80124B29- E4DA- 4BOD- A879- D287FCF3F3CA <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Refugee Support Center <br />Applicant Organization's Physical Address: 401 NC 54 Bypass, E # 16, Carrboro, NC 27510 <br />Applicant Organization's Mailing Address: PO Box 1025, Carrboro, NC 27510 <br />Applicant Organization's Web Address: www.refugeesupportcenter.org <br />Executive Director: Flicka Bateman <br />Telephone Number: 919) 423 -1478 <br />Tax ID Number: 46- 3944698 <br />E -Mail: fbatemanrsca)-g mail. corn <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 />Agency Administration (rent, utilities, insurance) <br />$6,000 <br />$6,000 <br />$5,000 <br />$17,000 <br />Projected Estimates: Rent - $10,000; utilities - <br />$3,000; insurance - $4,000 . <br />Totals <br />$6,000 <br />$6,000 <br />$5,000 <br />$17,000 <br />c) To the best of nay 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: �`-',- ti- .._✓___ <br />Executive Director <br />Signature* i4) <br />-=- �Boairdl Ch irperson <br />Date - -- <br />/ / 16 ) -/ C� I � -4 <br />Date <br />AGENCY INFORMATION 1/18/2018 1:56:21 PM Page 8 of 26 <br />