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County of a.wai`i Nonprofit Grant Appli s ati®n. 7)(2019-20 <br /> Agency Name: 1,I®It a Independent Living Hawaii <br /> Program Name: I! dependent Living Program <br /> Agency Director::,.:. <br /> Roxaoxa I a U. Bolden Phone N o.: (808) 497 — 7996 <br /> Contact Person: Roxa a Ll. Bolden Phone No.: (808) 497 — 7996 <br /> Mailing Address: ddress: P.O.Box 283 <br /> ddess: <br /> Ci,,,ST{Zip Pearl City, HI 96782 <br /> Facility Address: ddress: 1055 Kino'ole Street Unit 202 <br /> ddr�ess: <br /> Cir ,ST Zip Hilo, HI 96720 <br /> Email Address: rubolden(?alofailhawaii.org Fax No.: (800 ) 385 — 2454 <br /> Darrell) im _._--- - Phone NO: (808) 522 8833 <br /> Accountant CPA: II <br /> Firm (if applicable): Dar 4I Lim and Comany, Inc. <br /> Mailing Address: ^ddress: 81 South Hotel Street#300 <br /> ddress: <br /> Cit(,Si,,Zip Honolulu, HI 96813 <br /> If+IrUARE ESP* V xrZa_E T*, ..� a 1 111)4' Hillla,, k11AliON€ QUA RE ?AND TO <br /> P';'OMPTLY NOTI Y THE F!;-A cE DEPAi`ti Td ME- T AND U/\+CBL OF A;'°+Y CHANGES <br /> Amount of Request for 0.unt Nonprofit Grant Y p Program Funds: $10,000 <br /> Gew graphical Areas To Be Served: (One or more c:n be checked) <br /> 0 Puna Q Hamakua d North Kona <br /> 0 South Hilo 0 North Kohala V South Kona <br /> © North Hilo E]South Kohala V Ka`u <br /> rvices or Activities To Be Provided: (One or m«+re can be checked) <br /> ❑ Educational co cerns ®Youth $ Victims of Crimes <br /> ❑Culture and the arts 0 Aged . R Victims of Health or Social Crises <br /> ® Needs of the p'l.r ® Physical/Emotional Disabilities <br /> ❑ Public Health a d Welfare of the People and the Environment <br /> EXHIBIT A <br /> NONPROFIT GRANT APPLI TION FY 2019-2020 Page 1 of 8 <br />