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DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.} <br /> a) Apelicant Contact Information <br /> Applicant Organization's Legal Name: A Helping Hand <br /> Applicant Organization's Physical Address: <br /> 1502 West NC Highway 54 Suite 405 Durham NC 27707 <br /> Applicant Organization's Mailing Address: <br /> 1502 West NC Highway 54 Suite 405 Durham INC 27707 <br /> Applicant Organization's Web Address: www.ahelpinghandnc.org <br /> Executive Director: Jennifer Ashley <br /> Telephone Number: 919-403-5555 E-Mail: jennifer,ashle ahel in handnc.or <br /> DUDS Number: <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Pro ect/Proctram Contact Information <br /> Project/Program Name: Senior Companion Care Program <br /> Project/Program Primary Contact and Title: Jennifer Ashley. Executive Director <br /> Telephone Number: 919-403-5555 E-Mail: Jennifer.ashleyOahelping hand nc.gM <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $ Total Amount of Funds Requested: $ 16,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Provide non-medical independent living <br /> services for senior citizens and adults with disabilities, regardless of their ability to pay. <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package for each funding source. *The Participating Jurisdiction reserves the right to <br /> fund projects from any funding source, subject to eligibility and funding constraints. <br /> ❑ CDBG Non-Construction (CH) $ ❑ Grant ❑ Loan <br /> ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan <br /> ❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan <br /> ❑ HOME Other (OC) $ ❑ Grant ❑ Loan <br /> F� Human Services: Carrboro $4,000 ® Chapel Hill $4,000 ® Orange County $8,000 <br /> d) 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: + f <br /> E� t i v Dir ctor Date <br /> Main Application 1/25/201 6 1:23:46 PM Page 3 of 26 <br />