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DocuSign Envelope ID : A 1 EB25D0-1464-44DD-894A-53A04A225D F2 <br />COVER PAGE <br />Applicant Contact Information <br />Applicant Organization's Legal Name: EMPOWERment. INC <br />Applicant Organization's Physical Address: 109 N. Graham Street. Chapel Hill. NC 27516 <br />Applicant Organization's Mailing Address: 109 N. Graham Street. Chapel Hill, NC 27516 <br />Applicant Organization's Web Address: www.empowermentinc-nc~org <br />Executive Director: Delores Bailey <br />Telephone Number: 919-967-8779 E-Mail: empowermentincnc@gmail.com <br />Tax ID Number: 56-1969772 <br />Funding Request <br />Please list all Fiscal Year 2023 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 />$10,000 $15,000 $5,000 $30,000 <br />Operations Personnel Operations <br />Affordable Rental Program $25 ,000 $40,000 $40,000 $105,00 0 <br />Totals $25,000 $40,000 $40,000 $105,000 .. <br />Briefly explain your proposed use of funds: <br />EMPOWERment, Inc. will use these funds to support programs that address the affordable <br />housing shortage. <br />To the best of my knowledge and belief all information and data in this application is true and current. <br />The document has been duly authorized by the governing board of the applicant. <br />~OocuSlgned by: <br />Signature: __ ___.,L_l)_,eliil~iiiBlil'iB~ieiii&1-oro1&~1a1:11,,.~,_4;!1 ______ _ <br />Executive Director <br />lsDocuSigned by: <br />Signature: __ __,L_~-.Q;11a""·g~~a1:..-41.p.;.•1:~a1:~1:~~11A•.-~------- <br />Board Chairperson <br />1/12/2022 <br />Date <br />1 /13 /2022 <br />Date <br />DocuSign Envelope ID: 7E3B840A-729F-4167-AA3E-B7E3D1B7700F