Please complete all areas of this report. Please note that numerical numbers are REQUIRED for all demographic information. DO NOT USE PERCENTAGES! If items for dissemination were purchased, you can include the quantity in the non-demographic section. If you have any additional questions, you may e-mail Anna at agasinski@bhcare.org.

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* 1. Applicant Agency

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* 2. Contact Person

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* 3. Total Amount Spent