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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 E-Mail: jenny.black@ppsat.org <br />Tax ID Number: <br />Funding Request <br />Please list all Fiscal Year 2023 Human Services (HS) funding requested for all programs and <br />the proposed use of funds (please list program name only) <br />Program Carrboro - <br />HS <br />Chapel Hill - <br />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 />Sexual health education and outreach <br />Personnel <br />$1,000 <br />Personnel <br />$5,000 <br />Personnel <br />$20,000 <br />Personnel <br />$26,000 <br />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 <br />support the 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 <br />application is true and current. The document has been duly authorized by the <br />governing board of the applicant. <br />Signature:12/1/21 <br />Executive Director Date <br />Signature:12/1/21 <br />Board Chairperson Date <br />Cover Page Page 2 of 10 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 70AC09D8-3205-4A8F-BDE0-893B802CD27D