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DocuSign Envelope ID:4F676C90-21 E4-4097-A8AC-0087D34EB01 3 <br /> COVER PAGE <br /> Applicant Contact Information <br /> Applicant Organization's Legal Name: Chapel Hill Carrboro Meals on Wheels, INC DBA Meals on Wheels <br /> Orange County, NC <br /> Applicant Organization's Physical Address: 632 Laurel Hill Road, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: PO BOX 2102 Chapel Hill, NC 27515 <br /> Applicant Organization's Web Address: www.MOWOCNC.org <br /> Executive Director: Rachel Sobel Bearman <br /> Telephone Number: 919-942-2948 E-Mail: execdirector@mowocnc.org <br /> Tax ID Number: 59-1721954 <br /> Funding Request <br /> Please list all Fiscal Year 2022 Human Services(HS)funding requested for all programs and the proposed <br /> use of funds(please list program name only) <br /> Program Carrboro- Chapel Hill- Orange Total <br /> HS HS County-HS <br /> Meal cost,delivery+check-In $16,500 $37,273 $54,809 $108,582 <br /> Operations Operations+ Operations <br /> +Personnel Personnel +Personnel <br /> Totals $16,500 $37,273 $54,809 $108,582 <br /> (=1,983 (=4,480 (=6,587 (13,050 <br /> meals meals meals meals <br /> delivered) delivered) delivered) delivered) <br /> Briefly explain your proposed use of funds: <br /> Funds would be used to cover both operational expenses (70%) and personnel (30%). <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: January 10, 2021 <br /> Executive Director Date <br /> Board Chairpe <br /> Signature: January 10, 2021 <br /> Cover Page P a g e 6 o f 2 2 <br />