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DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC <br />'I. GONER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Orange Congregations in Mission Inc <br />Applicant Organization's Physical Address: 300 Millstone Dr. Hillsborough, NC 27278 <br />Applicant Organization's Mailing ,Address: 300 Millstone Dr. Hillsborough,_ NC 2 72 78 <br />Applicant Organization's Web Address: www.ocimnc.orq <br />Executive Director. Rev. Sharon S. Freeland <br />Telephone Number. • 919 -732 -6194 ext. 10 <br />Tax ID Number. 58- 1563438 <br />E -Mail: ocimexecdi §embargmail. com <br />b) f=unding 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 />Ex. Youth Atierschool Program - - - - <br />Af#erschooi Program Coordinator salary and materials <br />for youth activities and projects <br />Carrbaro <br />Clrapei <br />Hill - HS <br />Orange <br />Cohn -HS <br />Total <br />$30,000 <br />- HS <br />$10,000 <br />15,000 <br />$5,01010 <br />Meals on Wheels - <br />Catered meals for Meals on Wheels and a part -time <br />employee to assist with distributing meals to the rural <br />parts of Orange County <br />34,000 <br />34,000 <br />Totals <br />34,000 <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 />F <br />Signature; ( ) { <br />Executive {director Date <br />c i. <br />Signature: �� &3 <br />Board Chairperson Date <br />AGENCY INFORMATION 112312018 12:17:33 PM Page 3 of 25 <br />