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DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF <br /> EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The Arc of the Triangle Inc. <br /> Applicant Organization's Physical Address: 1709 Legion Rd, Suite 100, Chapel Hill NC 27517 <br /> Applicant Organization's Mailing Address: same <br /> Applicant Organization's Web Address: www.arctriangle.org <br /> Executive Director: Executive Director, Jennifer Pfaltzqraff <br /> Telephone Number: 919 942 5119 ext 117 E-Mail: jpfaltzgraff arctriangle.org <br /> Tax ID Number: 56-1214133 <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 Carrboro Chapel Orange Total <br /> -HS Hill -HS Coun -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 /> Community Programs Individual Services for $7,500.00 $12,000.00 $7,500.00 $27,000.00 <br /> individuals with intellectual and developmental <br /> disabilities [I/DD] supplies, materials, salary, rent, <br /> printing, marketing. <br /> Totals $7,500.00 $12,000.00 $7,500.00 $27,000.00 <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 /> i <br /> Signature: L/--a'=)J'/ <br /> E-Abulive Director Date <br /> Signature: ��/ //Z.2/l-Y <br /> Board Chair p rson Date <br /> AGENCY INFORMATION 1/20/2018 3:58:40 PM Page 8 of 24 <br />