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DocuSign Envelope ID:BE69D0F4-65F9-4511-85C7-BCBB1 0605A1 1 <br /> COVER PAGE <br /> Applicant Contact Information <br /> Applicant Organization's Legal Name: Boomerang Youth, Inc. <br /> Applicant Organization's Physical Address: 825A N. Estes Drive, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 825A N. Estes Drive, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: https://boomerangyouth.org <br /> Executive Director:Tami Pfeifer <br /> Telephone Number: (919) 968-2146 E-Mail:tami.pfeifer@boomerangvouth.org <br /> Tax ID Number: 47-4660452 <br /> Funding Request <br /> Please list all Fiscal Year 2021 Human Services(HS)funding requested for all programs and the proposed <br /> use of funds(please list program name only) <br /> Program Carrboro- Chapel Orange Total <br /> HS Hill-HS County-HS <br /> STRIVE—alternative to suspension and school re- $8,000 $16,000 $24,000 $48,000 <br /> engagement Personnel Personnel Personnel <br /> Totals $8,000 $16,000 $24,000 $48,000 <br /> Briefly explain your proposed use of funds: <br /> Funds will be used to pay living wage salaries to qualified staff that provide direct services to middle <br /> and high school students. <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 applicant. <br /> j� P+ --- <br /> Signature: 1-13-2020 <br /> Executive Director Date <br /> Signature: 1-14-2020 <br /> Board Chairperson Date <br /> Cover Page P a g e 3 o f 18 <br />