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DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. OVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Table Ministries, Inc. <br /> Applicant Organization's Physical Address: 209 E. Main Street Carrboro 27510 as of 211117 <br /> (previously 205 W. Weaver Street, Carrboro, NC 27510) <br /> Applicant Organization's Mailing Address: Same <br /> Applicant Organization's Web Address: www.tablenc.orq <br /> Executive Director: Ashton Tippins <br /> Telephone Number: 919-636-4860 E-Mail: infoatablenc.orq <br /> Tax ID Number: 26-1471735 <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - HS County-HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Food for Weekend Meal Backpack Program $7,500 $7,500 $7,500 $22,500 <br /> Partial payment of program staff $2,000 $2,000 $2,000 $6,000 <br /> Assistance with cost of new rental space(90% $2,000 $2,000 $2,000 $6,000 <br /> program) <br /> Program Equipment $500 $500 $500 $1,500 <br /> Totals �12,C�uC� 6 QP,,C, �1�a wo 5} fCcr <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 /> ' r <br /> Signature: <br /> Executive Director Date <br /> Signature: <br /> �86 rd Chairperson Date <br /> AGENCY INFORMATION 1/30/2017 4:15:08 PM <br />