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4/7/2020 North Carolina Division of Emergency Management - Designation of Applicant’s Agent Page 1 of 2
<br />DESIGNATION OF APPLICANT'S AGENT
<br />AND APPLICANT ASSURANCES
<br />FOR PUBLIC ASSISTANCE
<br />ORGANIZATION NAME (HEREAFTER NAMED ORGANIZATION)
<br />PRIMARY AGENT SECONDARY AGENT
<br />AGENT’S NAME AGENT’S NAME
<br />ORGANIZATION ORGANIZATION
<br />OFFICIAL POSITION OFFICIAL POSITION
<br />MAILING ADDRESS MAILING ADDRESS
<br />CITY ,STATE, ZIP CITY ,STATE, ZIP
<br />DAYTIME TELEPHONE DAYTIME TELEPHONE
<br />FACSIMILE NUMBER FACSIMILE NUMBER
<br />PAGER OR CELLULAR NUMBER PAGER OR CELLULAR NUMBER
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<br />35,17('217+(6(&21'$77$&+('3$*(
<br />CHIEF FINANCIAL OFFICER CERTIFYING OFFICIAL
<br />NAME OFFICIAL’S NAME
<br />ORGANIZATION ORGANIZATION
<br />OFFICIAL POSITION OFFICIAL POSITION
<br />MAILING ADDRESS MAILING ADDRESS
<br />CITY ,STATE, ZIP CITY ,STATE, ZIP
<br />DAYTIME TELEPHONE DAYTIME TELEPHONE
<br />FACSIMILE NUMBER FACSIMILE NUMBER
<br />PAGER OR CELLULAR NUMBER PAGER OR CELLULAR NUMBER
<br />APPLICANT'S STATE COGNIZANT AGENCY FOR SINGLE AUDIT PURPOSES (IF A COGNIZANT AGENCY IS NOT ASSIGNED, PLEASE INDICATE):
<br />APPLICANT'S FISCAL YEAR (FY) START
<br />MONTH: DAY:
<br />APPLICANT'S FEDERAL EMPLOYER'S IDENTIFICATION NUMBER
<br />-
<br />APPLICANT'S STATE PAYEE IDENTIFICATION NUMBER
<br />- -
<br />CERTIFYING OFFICIAL’S SIGNATURE
<br />Orange County
<br />Pascal Moore Sarah Pickhardt
<br />Finance and Administrative Services Emergency Services
<br />Accountant EOC Manager COVID-19
<br />405 Meadowlands Dr 510 Meadowlands Dr
<br />Hillsborough, NC 27278 Hillsborough, NC 27278
<br />919-245-2455 919-245-6138
<br />David Hunt
<br />Board of County Commisioners
<br />Deputy Clerk to the Board
<br />919-245-2126
<br />56-600327
<br />3
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