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City Manager's Office - M-31 <br />City of Santa Ana 20 Civic Center Plaza <br />Donation Request P.O. Box 1988 <br />Santa Ana, CA 92702 <br />(D (714) 647-5200 <br />Name: 1 RITA CRUZ GALLEGOS <br />Address: 1400 K Street, Suite 204 <br />city, State, 7jp: <br />Sacramento, CA 95814 <br />jPhomn <br />1951.468.5712 <br />Email: <br />rita@harbageconsulting.com <br />Fax: <br />:916.662.7982 <br />Name: <br />California Department of Health Care Services <br />Tax-Exempt Status: Is your organization anon -profit or public tax-exempt organization <br />rga as <br />defined under Section 501(c)(3) of the Internal Revenue Code? <br />iselect One: <br />❑ Yes <br />(Direct Payment Amount <br />Requested; <br />No <br />If No, you wig only qualify for a credit for City-related costs for your request (i.e. permit to <br />Yos' <br />sslaff time, rental rates for focliffles or equipment, etc.).Costs for City services vary and if <br />of <br />approved, credit may or may not cover full cost of requested City servica& <br />Tax to <br />City Services Credit <br />Amount Requested: <br />i f I <br />375.80 Date Needed: MayoriCounclimembor: Tinajero <br />(Direct Payment Amount <br />Requested; <br />Event Data: 06.04.16 Event Timoz ;Sam 'I pm <br />!EventLocation: <br />The Salgado Community Center, 706 N. Newhope St., Santa Ana, CA 92703 i <br />Address, City. State, Zip <br />�Descrlptlon <br />!Town Hall Resource Fair for The Senior Community <br />of <br />!Event/ Purpose: <br />Educational Seminar on The Coordinated Care Initiative/OneCare Connect for <br />I <br />CommunityBorlefit: <br />Medicare & Medk al Services For The Senior Community <br />Applicant Signature: <br />DOW May 17, 2016 <br />!Mail: City Manager's Office --M -31 Email: done I tionrequest I @son - to-ana.or 11 g <br />20 Civic Center Plaza Fax: (714) 647-6954 <br />P-O. Box 1988 <br />Santa Ana, CA 92702 <br />Donation Requestit: DR Council Meeting Date: <br />4'f'd"dVr1V�; I <br />Eligibility Mot: YES I NO Approved Amount: <br />City Manager Signature: Date: <br />Revised 1111612016 <br />