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EXHIBIT A <br />INDIAN RIVER COUNTY NONPROFIT / QUASI AGENCY REQUEST FOR FUNDING <br />A. Program Cover Page <br />Agency: <br />New Horizons of The Treasure <br />Coast, Inc. <br />Contact Person: <br />William Wims <br />Title: <br />President/CEO <br />Address: <br />4500 W Midway Road <br />Website <br />nhtcinc.org <br />Address: <br />Program Title: <br />Mental Health and Substance <br />Abuse Services <br />Telephone: 772-672-8350 <br />Fax: 772-468-5606 <br />E -Mail: wwims0i)nhtcinc.onmicrosoft.com <br />I Agree - By checking the "I Agree" box and entering your name below, you certify that information <br />contained in this application accurately reflects the activities of this agency and that the expenditures or <br />portions thereof for which County funds are being requested are not reimbursed by any other source. <br />Name: William Wims Title: William Wims, President CEO <br />tsneT aescripuon OT the vrogram Tor wnicn Tunaing is requestea: <br />The purpose of this application is to secure match funding necessary to leverage funding from the Department <br />of Children and Families through their contract with Southeast Florida Behavioral Health Network (SEFBHN). <br />The funds requested will be used to provide services to Indian River County residents ranging from <br />emergency stabilization provided 24/7 to intensive community based programs for children and adults. (A <br />Program Description of all services, locations and service time is attached.) The attached report "Units of <br />Service Report with State Rate" shows the specific services provided and number of residents accessing <br />these services for the period 10/1/2019 to 09/30/2020. <br />OU1111FIdUy MU Urt <br />Amount requested from Indian River County for 2021/2022: $329,490.00 <br />Total Proposed Program budget for 2021/2022: $25,617,270.00 <br />Percent of total Program budget: 1.29% <br />Current Funding (2020/2021) $329,490.00 <br />Dollar increase / (decrease) in request: $0.00 <br />Percent increase / decrease in request: 0% <br />f request increased 5% or more, briefly explain why: <br />The Organization's Board of Directors has approved this application on (date): 05/01/21 <br />Name of President/Chair of the Board <br />Name of Exec. Director/CEO: <br />EXHIBIT A <br />Greg Pickett <br />William Wims <br />