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DocuSign Envelope ID:A29AB125-209D-4CB9-854C-789BEC34FODD <br /> COVER PAGE <br /> Applicant Contact Information <br /> Applicant Organization's Legal Name: Dispute Settlement Center Inc. <br /> Applicant Organization's Physical Address: 302 Weaver Street Carrboro NC 27510 <br /> Applicant Organization's Mailing Address: same <br /> Applicant Organization's Web Address: www.disputesettlement.org <br /> Executive Director: Frances Henderson <br /> Telephone Number: (919) 929-8800 E-Mail:fhenderson dis utesettlement.or <br /> Tax ID Number: F56-1216584 <br /> Funding Request <br /> Please list all Fiscal Year 2021 Human Services (HS)funding requested for all programs and the proposed <br /> use of funds (please list program name only) <br /> Program Carrboro- HS Chapel Hill- Orange Total <br /> HS County-HS <br /> Mediation, Conciliation, and referral $10,000 $16,000 $92,000 $118,000 <br /> of Interpersonal Disputes Operations Personnel Personnel <br /> Totals <br /> Briefly explain your proposed use of funds: <br /> For provision of mediation, conciliation and referral services for a wide variety of <br /> interpersonal disputes referred from Criminal District Court, and divorce, Medicaid, <br /> neighborhood, business or workplace disputes. Court-referred cases are provided <br /> without charge. Family/divorces cases have a sliding scale fee. Services include <br /> conflict coaching and referral as well as mediation. <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: /- I- , (� J <br /> Executive Director Date <br /> F <br /> Signature: <br /> Boar Chairperson Date <br /> �' 6 of 23 <br />