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EXHIBIT A <br />AGENCY REQUEST FOR FUNDING FROM Indian River COUNTY <br />FISCAL YEAR 2019/2020 <br />A. Program Cover Page <br />Agency: <br />New Horizons of the Treasure Coast, Inc. <br />Contact Person: <br />George Shopland <br />Title: <br />CEO/President <br />Address: <br />4500 W Midway Rd <br />Ft Pierce, FL 34981 <br />Website Address: <br />www.nhtcinc.org <br />Program Title: <br />Mental Health and Substance Abuse <br />Telephone: (772) 468-5600 <br />Fax: (772) 468-5606 <br />E -Mail: <br />I certify that information contained in this application accurately reflects the activities of this agency and <br />that the expenditures or portions thereof for which County funds are being requested are not reimbursed <br />by any other source. <br />George Shopland, CEO/President <br />Signature Print name and title <br />briet aescription of the Program for which funding is requested: <br />This application is to secure match funding necessary to leverage funding from the Department of <br />Children and Families through their contract with Southeast Florida Behavioral Health Network <br />(SEFBHN). The funds requested will be used to provide services to Indian River County residents <br />ranging from emergency stabilization provided 24/7 to intensive community based programs for children <br />and adults. (A Program Description of all services, locations and service time is attached.) The attached <br />report "Units of Service Report with State Rate" shows the specific services provided and number of <br />residents accessing these services for the period 10/1/2017 to 09/30/2018. The match grant funding <br />provided by IRBOCC for FY17/18 leveraged over $4,482,000 of State funded services. <br />aummary Keport <br />Amount requested from Indian River County for 2019/2020: $319,884 <br />Total Proposed Program budget for 2019/2020: $27,087,206 <br />Percent of total Program budget: 1.2% <br />Current Funding (2018/2019) $310,576.00 <br />Dollar increase / (decrease) in request: $9,308.00 <br />Percent increase / decrease in request: 3% <br />It request Increasea 5-/o or more, brletiv exDlaln <br />The Organization's Board of Directors has approved this application on F <br />Patricia Austin -Novak <br />Name of President/Chair of the Board Signature <br />George Shopland, CEO/President -� <br />Name of Exec. Director/CEO SignatGre <br />EXHIBIT A <br />y 27, 2019: <br />-�-_1i"/�_ <br />