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DocuSign Envelope ID: 17COF518- 9238 - 480E- 96E6- 77F FCC C2626B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Senior Care of Orange County; Inc. <br />Applicant Organization's Physical Address: 105 Meadowland Drive Hillsborough, NC 27278 <br />Applicant Organization's Mailing Address: 105 Meadowland Drive <br />Hillsborough, NC 27278 <br />Applicant Organization's Web Address: soltysadultday.org <br />Executive Director: Swayzene Rigssbee <br />Telephone Number- 919 -245 -2017 E -Mail: sri sbee Oran ecount nc. ov <br />Tax ID Number: 56- 2460614 <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 />Carrbora <br />Chapel <br />Oran.:de <br />Total <br />HS <br />Hill - HS <br />Count HS •.' <br />The Adult Day Health Program Operations <br />$1;500 <br />$2 540 <br />35,000 <br />$39 000 <br />programming supplies and the days of servlcds for <br />alcl ant:who.atkends ;`ro rani..... <br />Totals <br />411500 A <br />$2,500 <br />$35,000 <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: <br />E uti "ripctor li Date <br />r <br />Signature: _ � 1 K v Ll <br />Board ai'person Date <br />— - -- - - - -- .... ... .... ... ...-----— <br />AGENCY INFO R ATION 1/23/2018 4:21:18 PM Page 8 of 25 <br />