2018-509-E Finance - El Centro Hispano outside agency agreement

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DocuSign Envelope ID: A899BE5E- BAEC- 40F3 -91 E1- A9D77FC4C488 1. a) Applicant Contact Information PAGE Applicant Organization's Legal Name: El Centro Hispano Applicant Organization's Physical Address :201 West Weaver Street, Carrboro NC 27510 Applicant Organization's Mailing Address: 2000 Chapel Hill Road, Durham NC 27707 Applicant Organization's Web Address: www.elcentronc.o_rq Executive Director: Pilar Rocha- Goldberq Telephone Number: (919) 687- 4635_ Ext. _43 E -Mail: procha(a_)_elcentronc.orq Tax 1D Number: 56- 2011661 b) Funding Request List all FYI 8-19 Human Services HS Funding Being Requested — For All Programs) and the Proposed Use of Funds (2 -3 lines or less) Pro ram Carrboro Ch. apel Hill -. HS Orange County-HS Total - HS Ex. Youth Afterschool Program Afterschool Program Coordinator salary and materials for youth activities and projects $10,000 $15,000 $5,000 $30,000 Community Support Services (salaries, rent & utilities, communications, supplies, equipment, forums) •5,000 15,000 25,000 45,000 Center for Employment and Leadership (salaries, rent & utilities, supplies, program expenses) 10,000 10,000 10,000 30,000 Education Services: Tutoring /Summer Program (staff salaries, supplies, program expenses) 5,000 5,000 10,000 Totals 20,000 30,000 35,000 85,000 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the apnlicant. Signature: au ;, a"k Executive Director 1/22/2018 Date Signature: i -%�- 1/22/2018 Voard Chairperson Date AGENCY INFORMATION 1122/2018 10:14:21 AM page H of 3