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Cover Page P a g e 3 o f 17 <br /> <br />COVER PAGE <br /> <br />Applicant Contact Information <br /> <br />Applicant Organization’s Legal Name: El Centro Hispano, Inc <br /> <br />Applicant Organization’s Physical Address: 2000 Chapel Hill Road, Suite 26A, Durham NC 27707 <br /> <br />Applicant Organization’s Mailing Address: 2000 Chapel Hill Road, Suite 26A, Durham NC 27707 <br /> <br />Applicant Organization’s Web Address: www.elcentronc.org <br /> <br />Executive Director: Pilar Rocha-Goldberg <br /> <br />Telephone Number: (919) 687-4635 Ext. 125 E-Mail: procha@elcentronc.org <br /> <br />Tax ID Number: 56-2011661 <br /> <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 - <br />HS <br />Chapel <br />Hill - HS <br />Orange <br />County-HS <br />Total <br />Ex. Youth Afterschool Program <br />Operations or Personnel <br />$10,000 <br />Operations <br />$15,000 <br />Personnel <br />$5,000 <br />Operations <br />$30,000 <br />Carrboro Office Services: Community Support, Adult <br />Education, PreK – 12 Tutoring & Summer Camp <br />(Salaries, rent, supplies, mileage, program materials) <br />25000 30000 38000 93,000 <br /> <br />Totals 25,000 30,000 38,000 93,000 <br /> <br />Briefly explain your proposed use of funds: <br /> <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 /> <br /> <br />Signature: 1/14/2021 <br /> Executive Director Date <br /> <br /> <br />Signature: 1/14/2021 <br /> Board Chairperson Date <br /> <br />Fund will be used to support salaries, rent, and materials need to support Community Support, <br />Education, and Health initiatives offered to Orange County / Town of Chapel – Carrboro residents <br />Exhibit A- Provider’s Outside Agency Application <br />DocuSign Envelope ID: 19D4C255-6C4E-420A-B8D1-63E97B864BA9