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1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization’s Legal Name: Planned Parenthood South Atlantic <br />Applicant Organization’s Physical Address: 1765 Dobbins Drive, Chapel Hill, NC 27514 <br />Applicant Organization’s Mailing Address: 1765 Dobbins Drive, Chapel Hill, NC 27514 <br />Applicant Organization’s Web Address: www.ppsat.org <br />President & CEO: Jenny Black <br />Telephone Number: 919-833-7526 x6140 E-Mail: jenny.black@ppsat.org <br />Tax ID Number: 56-1282557 <br />b) Funding Request <br />List all FY18-19Human Services (HS) Funding Being Requested – <br />For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br />Program Carrboro <br />-HS <br />Chapel <br />Hill-HS <br />Orange <br />County-HS <br />Total <br />Ex. Youth Afterschool Program <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />$10,000 $15,000 $5,000 $30,000 <br />Sexual Health Education and Outreach $1,000 $2,500 $20,000 $23,500 <br />Totals $1,000 $2,500 $20,000 $23,500 <br />c) To the best of my knowledge and belief all information and data in this application is <br />true and current. The document has been duly authorized by the governing board of <br />the applicant. <br />Signature: 1/12/18 <br /> President & CEO Date <br />Signature: 1/19/18 <br />Board Chairperson Date <br />Exhibit A: Provider's Outside Agency Application <br />DocuSign Envelope ID: ED368FB6-6FB1-45A7-A8CA-9AB3EAEB624E