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DocuSign Envelope ID:2F348727-C96D-44CB-A423-F125131FB250C <br /> COVERPAGE <br /> Applicant Contact Information <br /> Applicant Organization's Legal Name: Charles House Association <br /> Applicant Organization's Physical Address: 7511 Sunrise Road Chapel Hill NC 27514 <br /> Applicant Organization's Mailing Address: 7511 Sunrise Road Chapel Hill NC 27514 <br /> Applicant Organization's Web Address: www.charleshouse.or� <br /> Executive Director: Paul Klever <br /> Telephone Number: 919-967-7570 E-Mail: paul@charleshouse.org <br /> Tax ID Number: 58-1582881 <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- Chapel Orange Total <br /> HS Hill-HS County-HS <br /> Ex. Youth�Iftemchool Program $10,000 $15,000 $5,000 $30,000 <br /> Operations o)�Personnel operations Personnel Operations <br /> Charles House Daytime Program $1500 $7000 $24,000 $32.500 <br /> Personnel <br /> Totals $1500 $7000 $24,000 $32.500 <br /> Briefly explain your proposed use of funds: <br /> The Outside Agency Funding is used to financially support families enrolled in the Daytime Eldercare <br /> Program at Charles House through scholarship funds and offsetting Orange County agencies (DSS, <br /> DoA) discounted purchase of services for specific clients. <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; !Z <br /> Executive Director Date <br /> Signature- /G� 1 <br /> UA <br /> Chairp <br /> erson erson Date <br /> p <br /> Uove Page P a g e 6 o 1 2 0 <br />