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DocuSign Envelope ID:94DODA4A-83C1-42A4-8FB2-44BO273OE7D2 <br /> .=..it.;�Y,��.'�.'--•'.'»9:.4•G c. '!•'s iC�IP�Y'1r:.='�5�?ws .�r- .. •a�.Y!'a.'a, 'Y. .a. <br /> Applicant Contact Information <br /> Applicant Organlzation's Legal Name:The Exchange Club's Family Center in Alamance <br /> Coun <br /> Applicant Organization's Physical Address:200 N_ Main Street Graham, NC 27253 <br /> Applicant Organization's Mailing Address:200 N. Main Street Graham, NC-27253 <br /> Applicant Organization's Web Address:www.facebook.comifamil CenterinAiamanceOran e <br /> Executive director;Sarah E.G. Black M.A., MFT <br /> Telephone Number:336-227-5601 E-Mail:sarahbi_ack(cr exchangefcp.org <br /> Tax ID Number:56-2227006 <br /> i <br /> Funding Request <br /> Please list ail Fiscal Year 2020 Human Services(HS)funding requested for all programs and the <br /> proposed use of funds(please list program name only) <br /> Program Carrboro : Chapel Or.aneg Total <br /> H5 Hill-HS Count t_HS <br /> Ex. Youth Afterschool Program _ $10,000 $15,000 $5,000 $30,000 <br /> Parent Aide Program: salary and benefits of $2,000 $23,327 $23,377 $48,654 <br /> program staff, mileage, supplies/client <br /> emer ency funds, rentlutilitieslo erations, <br /> Children's Parents Parenting Classes: salary $0 $1,000 51,000 $2,000 <br /> and benefits of facilitator, mileage, <br /> pro ramloffice supplies. <br /> Totals $2,0W $24,327 $24,327 $50,654 <br /> To the best of my knowledge and belief all information and data in this application is true and <br /> current. The document has been duly authorized by the governing board of the applicant. <br /> Signature: °7, q <br /> Executive Director Date <br /> _ I <br /> Signature: ' — <br /> Board 8iairperson Date <br /> Cover Page <br /> I <br />