NGO Funding Request

The recipient entity's full legal name:  Capitol City Family Health Center Inc. dba CareSouth

The recipient entity's physical address:
           3140 Florida St., Baton Rouge, LA 70806

The recipient entity's mailing address (if different):
           3140 Florida St., Baton Rouge, LA 70806

Type of Entity (for instance, a nonprofit corporation):  Non-Profit Corporation

If the entity is a corporation, list the names of the incorporators:

The last four digits of the entity's taxpayer ID number:  5500

What is the dollar amount of the request?  $500,000

What type of request is this?  Capital Outlay Appropriation

Is this entity in good standing with the Secretary of State?  Yes

Provide the name of each member of the recipient entity's governing board and officers:
           Edmond Jordan, President, 425 Lejeune St, Brusly, LA 70719
Elaine Patin, Vice-President, 12130 Lake Estates Ave, Baton Rouge, LA 70810
Brian Bernard, Treasurer, 5525 Bennington Ave, Baton Rouge, LA 70808
Ruth Franklin, Secretary, 704 Vatican Dr., Donaldsonville, LA 70346
Edwin Walker, PO Box 12566, Baton Rouge, LA 70813
Kerry Auzenne, 680 Sharp Lane Apt. 416, Baton Rouge, LA 70815
Dalton Honore II, 17503 Lake Vista Drive, Greenwell Springs, LA 70739
Darrin Dixon, 7200 Gregory Street, Shreveport, LA 71108
James Llorens, 5542 S. Woodchase Ct., Baton Rouge, LA 70808
Debra Butler, 1138 Columbus Dunn Dr., Baton Rouge, LA 70802
Keisha Lacour, 13317 Ector Drive, Baker, LA 70714
Susan Rogers, 12735 Lariat Avenue, Greenwell Springs, LA 70739
Joshua Hollins, PO Box 80143, Baton Rouge, LA 70810
Terrence Lockett, 9711 Van Drive, Baton Rouge, LA 70815
Jody Davis, 1187 Bayberry Ave, Baton Rouge, LA 70807
Murlonda Webb, 13810 Sunshine Road, Baton Rouge, LA 70811
Achilles Williams, 17918 Jefferson Ridge Dr., Baton Rouge, LA 70817
Matthew Valliere, Chief Executive Officer, 2441 Creek Hollow Ave., Zachary, LA 70791

Provide a summary of the project or program:
           CareSouth Clinic at LOTUS Village will be the beacon of light to serve the local community‚Äôs health and wellness needs. The clinic will be located on Scenic Highway providing patients and visitors ease of access to site by bus, bike and vehicles. This three-story 35,000 square foot medical facility will provide jobs (approximately 25 new positions) for local residents. The facility will provide a multitude of services such as dental, primary care, hearing and vision, pharmacy, phlebotomy, podiatry, cardiology, dermatology, behavioral health and a therapeutics gym including a therapy pool. The building will also be equipped with a large training room which will be multi-purposed to provide a place to host meetings.
As a reinforcing element to the health and healing focused function of the clinic sustainable strategies and concepts will be utilized in the design. Sustainable landscape design will aid in storm water management. Energy efficiency is accommodated with a continuous thermal break in the construction of the exterior wall and roof, with insulation values to meet International Energy Code requirements.
The overall cost of construction inclusive of furniture, fixtures and equipment is $19.5 million.

What is the budget relative to the project for which funding is requested?:
          Salaries. . . . . . . . . . . . . $0
          Professional Services. . . $0
          Contracts . . . . . . . . . . . $500,000
          Acquisitions . . . . . . . . . $0
          Major Repairs . . . . . . . $0
          Operating Services. . . . $0
          Other Charges. . . . . . . $0

Does your organization have any outstanding audit issues or findings?  No

If 'Yes' is your organization working with the appropriate governmental agencies to resolve those issues or findings?

What is the entity's public purpose, sought to be achieved through the use of state monies?
          The purpose of these state monies will be to assist in the construction of a healthcare facility that will provide comprehensive healthcare services to the individuals over the age of 60. There are variety of services offerings that will be beneficial to this patient population in improving access to services and improving overall health outcomes of our aging population in East Baton Rouge Parish and surrounding areas. The services include primary care, dental, behavioral health, cardiology, dermatology, podiatry, physical therapy and an in-house pharmacy. Free transportation will also be provided for patients to get to and from appointments.

What are the goals and objectives for achieving such purpose?
          The goals and objectives that CareSouth plans to achieve are as follows:
1) Provide an affordable option for the aging population to receive services in one location.
2) Increase access to specialty services for our aging population
3) Alleviate transportation barriers to patients seeking healthcare services

What is the proposed length of time estimated by the entity to accomplish the purpose?
           18 months

If any elected or appointed state official or an immediate family member of such an official is an officer, director, trustee, or employee of the recipient entity who receives compensation or holds any ownership interest therein:
     (a) If an elected or appointed state official, the name and address of the official and the office held by such person:
                 Edmond Jordan
425 Lejeune St.
Brusly, LA 70719

     (b) If an immediate family member of an elected or appointed state official, the name and address of such person; the name, address, and office of the official to whom the person is related; and the nature of the relationship:

     (c) The percentage of the official's or immediate family member's ownership interest in the recipient entity, if any:

     (d) The position, if any, held by the official or immediate family member in the recipient entity:
                  Board President

If the recipient entity has a contract with any elected or appointed state official or an immediate family member of such an official or with the state or any political subdivision of the state:
(a) If the contract is with an elected or appointed state official, provide the name and address of the official and the office held by such person: 

(b) If the contract is with an immediate family member of an elected or appointed state official:
          Provide the name and address of such person:

          Provide the name, address, and office of the official to whom the person is related:

          What is the nature of the relationship?  N/A

(c) If the contract is with the state or a political subdivision of the state, provide the name and address of the state entity or political subdivision of the state:

(d) The nature of the contract, including a description of the goods or services provided or to be provided pursuant to the contract:

Contact Information
name:  Matthew Valliere 
                                       address:  3140 Florida St.
Baton Rouge, LA 70806

                                       phone:  225-301-1585
                                       fax:  225-415-8156
                                       relationship to entity:  Chief Executive Officer