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City of Santa Ana <br />Donation Request <br />Name: <br />Address: I �Q -p �G� <br />City, State, zip: SSC A Pin, c q� <br />Email: o <br />l c w.a <br />City Manager's Office - M•31 <br />20 Civic Center Plaza <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />(714) 847.5200 <br />WSNAy .V _ <br />1 <br />coqk43 <br />,Phone: <br />7/y 6 0 6 _0 Yv <br />,Fax: 71y <br />Name: <br />Tax -Exempt Status: Is your organ a ton anon -profit r public tax-exempt organization esSelect One;i <br />defined under Section 501(c)(3) of Cie Internet Revenue Code? -Yes ❑ No <br />lf No, you iW11 only quarify for a credit for City -related costs foryour request (i.e. permit fees. �tYesn <br />staff time, rental rates for facilities o•equipment, etc.).Costs for City services vary and A , <br />approved, credit may ormay not coier NO cost of requested City services. .Tax ID P. ,7[ <br />Amount Req Credit $ Dale Need¢d: MayorlCouncilmember: 'Please Choose From the List Below ' <br />Amount Requested: -- - 17 ._`.(-'(� <br />Direct Payment Amount S1 $500 Event Date: 1 II PULIDO <br />Requested: �( Event Time• <br />Event Location: <br />aedm54 Cft,sr,ra. zo <br />Description of <br />Event I Purpose: <br />Community Benefit: <br />Applicant Signature: <br />n 0/00 s) (-`�ac) W) <br />tlli�S�n re Sc�kaaerS 1—�vlvl"ct( 5`uII,0V4Q-r Pi <br />