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DocuSign Envelope ID:4CB52244-A26D-418A-B4AE-8C84440B4D81 <br /> COVER PAGE <br /> Applicant Contact Information <br /> Applicant Organization's Legal Name: El Centro Hispano, Inc <br /> Applicant Organization's Physical Address: 2000 Chapel Hill Road,Suite 26A, Durham NC 27707 <br /> Applicant Organization's Mailing Address: 2000 Chapel Hill Road,Suite 26A, Durham NC 27707 <br /> Applicant Organization's Web Address:www.elcentronc.org <br /> Executive Director: Pilar Rocha-Goldberg <br /> Telephone Number: (919) 687-4635 Ext. 125 E-Mail: procha@elcentronc.org <br /> Tax ID Number:56-2011661 <br /> Funding Request <br /> Please list all Fiscal Year 2021 Human Services (HS)funding requested for all programs and the <br /> proposed use of funds(please list program name only) <br /> Program Carrboro- Chapel Orange Total <br /> HS Hill-HS County-HS <br /> Ex. YouthAfterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Operations or Personnel Operations Personnel Operations <br /> Education(PreK-12&Adult)-personnel&operations $15,938 $18,304 $5,361 $39,603 <br /> CommSupport&Engagement-personnel&operations $6,000 12,156 $23,759 $41,915 <br /> Health&Wellness-personnel&operations $3,062 6,000 $11,211 $20,273 <br /> Totals $25,000 $36,460 $40,331 $101,791 <br /> Briefly explain your proposed use of funds: <br /> Funds will be used to expand services and reach in the Orange County,Carrboro-Chapel Hill area, <br /> and surrounding municipalities for ECH's Education,Workforce Development, and Health and <br /> Wellness Initiatives (community support, health screenings,outreach, etc. Funds are used to <br /> support staff time, rent, mileage, and other program related expenses. <br /> To the best of my knowledge and belief all information and data In this application is true and <br /> current. The document has been duly authorized by the governing board of the <br /> applicant-P0 <br /> Signature f"`-/• WO I f <br /> Executive Director Date <br /> Signature: _ <br /> BowdiXalirperson Date <br /> Coven Page P a g e 6 o 1 2 3 <br />