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DocuSign Envelope ID: 2F546B53- F2D1- 407D- A1C7- 26EB823DOFFD <br />I. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: The Exchange Club's Family Center in Alamance <br />Conn <br />Applicant Organization's Physical Address: 200 N. Main Street Graham NC 27253 <br />Applicant Organization's Mailing Address: 240 N. Main Street Graham NC 27253 <br />Applicant Organization's Web Address: www. facebook. com /familycenter!nAlamance0ranaee <br />Executive Director: Sarah E.G. Black, MA, MFT <br />Telephone Number: 336- 227 -5601 E -Mail: sarahblack348@gmail.com <br />Tax ID Number: 56- 2227006 <br />b) Funding Request <br />List all FY18 -19 Human Services IiHS) Funding Being Requested — <br />For All Pry rams and the Proposed Use of Funds (2 -3 lines or less) <br />Program <br />Carr brv,.: <br />Cf�ap@I <br />Cranae <br />Total <br />Count -14 <br />Ex: Yvut <br />AfterStfilol <br />SRO <br />4500 <br />$3o,000 , <br />P'ta1il4 rl <br />Parent Aide Program: salary and benefits of program <br />$2,700 : <br />$20,000 <br />$20,00 <br />$42,700 <br />staff, mileage, supplies/ client emergency funds, <br />rentlutilitieslo pe rations. <br />Children's Parents Parenting Classes: salary and <br />$2,390 <br />$2,390 <br />$4,780 <br />benefits of facilitator, mileage, program/office <br />supplies. ' <br />v <br />Totals <br />$2,700 <br />$22,390 <br />$22,390 <br />$47,480 <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:[) t <br />Executive Director - Date <br />Signature: <br />yard Chairperson Date <br />AGENCY INFORMATION 1122/2018 10:50:53 AM Page 7 of 29 <br />