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Applicant Contact Information <br />Applicant Organization's Legal Name: Club Nova Community. Inc. <br />Applicant Organization's Physical Address: 103 D West Main Street, Carrboro, NC 27510 <br />Applicant Organization's Mailing Address: 103 D West Main Street, Carrboro. NC 27510 <br />Applicant Organization's Web Address: clubnova.org <br />Executive Director: Karen Kincaid Dunn <br />Telephone Number: 919-968-6682 E-Mail: karendunn@nc.rr.com; kdunn@clubnova.org <br />Tax ID Number:-- <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 Cha~el Hill -HS Orange County-HS <br />Critical Safety Net-$22,000 Personnel $22,000 Personnel $15,000 Personnel & <br />Livelihood Security & Operations & Operations Operations <br />& Improved Health <br />Outcomes <br />Transportation $65,000 Personnel & <br />Operations <br />Employment $22,000 Personnel & <br />Operations <br />Psychiatric $18,000 Personnel & <br />Rehabilitation Operations <br />Services -ACTT <br />Members <br />Totals $22,000 $22,000 $120,000 <br />TOCH -Impact $50,000 <br />Award- <br />Comprehensive <br />Integrated Critical <br />Safety Net <br />Briefly explain your proposed use of funds: <br />The Outside Agency funding will provide for staffing and other costs to operate Club <br />Nova, an accredited Clubhouse Model. The Clubhouse Model is one of the most <br />comprehensive, integrated, effective, community-based approaches in addressing <br />the health, safety, social, and economic risks of serious mental illness and provides <br />a critical safety net for individuals living with serious mental illness. <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 />Total <br />$59,000 <br />$65.000 <br />$22,000 <br />$18,000 <br />$164,000 <br />$50,000 <br />Cover Page Page 6 of 35 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: D48DD7FB-D87E-4B89-8F49-216C48CF34E2