Please complete and return this form, along with the narrative, by October 31st.

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* 1. Contact Information:

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* 2. Project/Program Name:

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* 3. Program Dates:

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* 4. Program Dates (Start/Finish):

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* 5. Amount funded by Baptist Health:

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* 6. Purpose of funding:

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* 7. Number of people served through funding?

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

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* 9. Does your organization have a succession plan for the ED/CEO that has been approved by the Board of Directors? If yes, please attach the plan to this report.

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* 10. 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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* 11. I hereby certify that the above and attached statements are true and accurate.
Signature of Executive Director or Authorized Person

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* 12. Attach your leadership succession plan here.

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