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Page 5 PART I - FACESgEET APPLICATION FOR FEDERAL ASSISTANCE 2. DATB SUBMITTED TO CO] NATTONAL SERVICE (CNS): 03-25-2002 5. APPLICANT INFORMATION LEGAL NAME: ORANGE COUNTY GOVERNMENT 3. a DATE RECEIVED BY STATE: 4. a. DATE RECEIV-ED BY CNS: ADDRESS (give street address, city, county, state and nip code): Orange County Government Department on Aging P. O. Box 8181 Hillsborough, NC 27278 6. EMPLOYER IDENTIFICATION NUMBER (EIN): 8. TYPE OF APPLICATION (Check appropriate box): ^NEW ®CONTINUATION QREVISION ^ ^ Tf Revision, enter appropriate letter(s) in box(es): A. Increase Awazd B. Decrease Award G Increase Duration D. Decrease Duration E. Other (specify): 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: RSVP: 94.002 _ FGP: 94.011 9 4 0 0 2 SCP: 94.016 Senior Dcmonstiration: 94.015 12. AREAS AFFECTED BY PROJECT (List Cities. Counties. States, etc.): TOWNS OF: HILLSBOROUGH, CI3APEL HILL, AND CARRBORO ORANGE COUNTY, NORTH CAROLINA 1. TYPE OF SUBMISSION: Application ®Non_Ccns¢uction 3.b. STATE APPLICATION IDENT>F1EF: SCH# 00-C-0000-0505 CFDA~94.002 4.b. CNS~GRANTNUMBER: 02SRSNC034 _ Np,ME AND CONTACT INFORMATION FOR~VPORO~G ,~~C~T ~C~.IR'ION PERSON TO EE CONTACTED ON MATTERS area codes): NAME: KATHERINE L. PORTER TEL.EPxoNENUMEER: (919) 968 - 2054 F~NIJMBER: (919) 968 - 2093 7. TYPE OF APPLICANT: (enter appropriate letter in bos) ~ State g Indepe~ent School District L State ControIled Institution of Higher Learning B. County C. Mrwicipal J. Private UmversitY D. Township K. Indian Tube E. Interstate L.. Individual F. Interrnunicipal 1vL Profit Organization G. Special District N. Private Non-Profit Organization O. Other (specify) 9. NAME OF FIDERAL AGENCY: Sei'V1Ce Corporation for National & Community 11. DESCRIPTIVE TT1ZE OF APPLICANT' S PROJECT: RETIRED & SENIOR VOLUNTEER PROGRAM 13. PROPOSED PR0JL3Cf: START DATE: O7/O 1/ZUUj 15.y IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE 14. ES'TIMATID FUNDING: ORDER 12372 P1tOCESS? a. ~~ S 170,073 a. YES. THIS PREAPPLICATION/APP ORDER ~ 2 PgpCESS FOR ~~ TO THE STATE EXECUTIVE b. APPLICANT S 150,000 REVIEW ON: DATE /08 03 c. STATE S b. NO. ^ PROGRAM IS NOT COVERED BY E.O.12372 d. LOCAL S 40,431 ^ O~R~OWGRAM HAS NOT BEEN SELECTED BY STATE FOR e. OTHER S 16. IS THE APPLICANT DELINQUENT ON ANYFEDERAL- D ®NO 360,504 ^ YES If "Yea,° attach an explanation. £TOTAL S ___ ...______ _ __ _ _ HAS BEEN DULY 17. TO THE BEST OP MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION/PREAPPLICATION AItfi TRUE AND CORRECT, '~ DOG'IJMENT AUTHORIZED BY THE rpVERNING BODY OF THE APPLICANT AND THE APPLICANT WILI. COMPLY WITH THE ATTACI~D ASSURAN~I'EL¢EPxONE INUMBER: AWARDED. a. TYPED NAME OF AUTHORIZED gEpgESENTATIVE: Margazet Brown -- d. SIGNATURE OF AUTHORIZED REPRESENTATIVE: b. TITLE: (,'hair, Orange County Boazd of Commissioners 919-245-2300 e. DATE SIGNED: 04/01/2003 Modified Standard Form 424-NSSC (Rev 4/01)