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COVER PAGE <br />Applicant Contact Information <br />Applicant Organization's Legal Name: Planned Parenthood South Atlantic <br />Applicant Organization's Physical Address: 1765 Dobbins Dr, Chapel Hill, NC 27514 <br />Applicant Organization's Mailing Address: 100 S Boylan Ave, Raleigh, NC 27603 <br />Applicant Organization's Web Address: ppsat.org <br />Executive Director: Jenny Black <br />Telephone Number: 919-833-7526 X6140 E-Mail: jenny.black@ppsat.org <br />Tax ID Number: <br />Funding Request <br />Please list all Fiscal Year 2022 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 Coun�-HS <br />Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br />Operations or Personnel Operations Personnel Operations <br />Sexual health education and outreach $1,000 $5,000 $20,000 $26,000 <br />Personnel Personnel Personnel Personnel <br />Totals $1,000 $5,000 $20,000 $26,000 <br />Briefly explain your proposed use of funds: <br />PPSAT requests $26,000 from the collective Human Services funding opportunities to support the <br />personnel costs for one full-time community health educator in Orange County. <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 />Signature: --��--�0 __ � _________ _ <br />Executive Director <br />Signature: K� JV\ -,Mr.Fl� <br />Board Chairperson <br />Cover Page <br />12/17/2020 <br />Date <br />I l.../ 1"1 / ·2-01--0 <br />Date <br />Page 6 of 20 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 3B9D32F2-BCE5-494E-B2DF-78A17389E8BA