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, F,x,. City M1lanager's Office - IVY-31 <br />N-4 City of Santa Ana 20 Civic Center Plaza <br />Donation Request P.O. Cox <br />Santa Ana, CA 92702 2702 <br />1 C14) 647.5200 <br />Name: (` Title. <br />Address: N C.`� } 4 <br />City, state, Zip: 1 ('- - '- ,_ . Phone: < z-j` (✓'- I V <br />Email; fi <br />,. pax: <br />r. <br />Name: ' U Lw -'-1 L(. UQ <br />Tax - Exempt Status: Is your organization a non- prog�t or public tax-exempt organization as Select One: <br />defined under Section 501(c)(3) of the Internal Revaa``nue Code? Yea No <br />If No, you will only qualify for a credit for City- related costs for yourrequest (i.e. permit fees, If Yas, q ) —b. [ � 6j 660 <br />staff time, rental rates for facilities or equipment, etc.). Costs for City services very and if o(V <br />approved. credit may or may not cover full cast of requested City services. Tax ID M <br />City Services Credit � - - -- -. -... / 1 f ) , <br />Amount Requested: Data Needed: ! i / MayoriCaunatlmembar; { <br />J �`tcc t r t i <br />Direct Payment Amount <br />Requested: S Event Date: 2� I EventTlme: 6­11 ��� � t <br />Event Location: <br />AddMai CO, State, ZIP , <br />�} � 7 �f. , � � �{ (� Cc t � � lrt ✓t t«.ps't �e C Ui -, G `� �it t c-s eix -�-i <br />Description of <br />Event t Purpose: Q »-� �E `c I �„ y Oyl C P f . <br />,r <br />Community Benefit:' ur n_j L& U cx C 5¢ C., « e �� <br />Applicant Signature: a -- i Date: f C/ <br />Mail: City Manager's office -M-31 <br />20 Civic Center Plaza <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />Email: donationrequest §santaana.org <br />Pax: (714) 647 -6954 <br />Revised 11!1612015 <br />