Please complete and return by October 31st.

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* 1. General Information:

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* 2. Program Name:

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* 3. Program Start and Finish Dates:

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* 4. Amount funded by Baptist Health:

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* 5. Purpose of funding:

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* 6. Have you had any changes in your organizational leadership since this investment was awarded or do you anticipate any changes? If yes, please explain:

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* 7. Have there been any changes to your organization’s IRS 501(c) (3) nonprofit status since you were awarded this funding? If yes, please explain:

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* 8. What date was your organization's executive leadership succession plan approved by your board of directors?

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* 9. Please attach the succession plan here.

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* 10. I certify information in this report is true and accurate. Typed name indicates signature.  

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