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City of Santa Ana <br />Donation Request <br />* "a <br />City Manager's Office— M-31 <br />20 Civic Center Plaza <br />P.O. Bar 1086 <br />Santa Ana, CA 82702 <br />(714) 547.5200 <br />!Name: Mary H. Lana <br />Title: <br />Director <br />Address: P.O. Box 28541 <br />!Event Location: <br />Jerome Center, 726 S. Center, Santa Ana, CA 92704 <br />;city, State, zip: 'Santa Ana, CA 92799 <br />Phone: <br />(714) 336 -3361 <br />Email: mary.lara813aiyahoo.com <br />Fax: <br />jevent / Purpose: <br />Name: TKO Boxing Club <br />communityBenetlt: <br />the City. We offer at -risk youths a safe and structured place to meet after school. <br />Tax - Exempt Status: is your organization a non -profit or public tax - exempt organization as <br />dernad under Section 601(0)(3) of the Internal Revenue Code? <br />Select one: <br />Yes ❑ No <br />If Ito, you will only qualify for a credit for City- ralated costs for your request (i.e. pennit fees, <br />M Yes <br />- <br />�stafftime, rental rates forfaci8ties or equipment, etc.). Costs for CiTyservkes vary andif <br />full City <br />Tax ID #: <br />_+�3087✓�050 <br />0.J C,? / G <br />;approved credit may or may not cover cost of requested sets Ices. <br />Santa Ana, CA 92702 <br />a3 a? lJ Li <br />laity Services Credit <br />Amount Requested: <br />.$ Date Neoded: 3/15/17 'Mayor /Councilmembor. -; Sarmlento <br />Direct IRegUe PaymentAmount <br />!f? °quested: <br />$500 OQ ;Event Dato: 'Event'nma: <br />!Event Location: <br />Jerome Center, 726 S. Center, Santa Ana, CA 92704 <br />.Address, Uty state, 2rp <br />iDescrip#ion <br />For ongoing expenses, i.e, equipment, supplies, travel to competitions. <br />of <br />jevent / Purpose: <br />TKO serves as a gang - prevention program in one of the most troubled areas of <br />communityBenetlt: <br />the City. We offer at -risk youths a safe and structured place to meet after school. <br />'Applicant Signature:` <br />Dated <br />Mail: City Manager's Office —M -31 Email: donationmquest@santaana.org. <br />20 Civic Center Plaza Fax: (714) 047 -6954 <br />P.O. @ox 1088 <br />Santa Ana, CA 92702 <br />Donation Request 9: <br />., ,, _. <br />.� <br />_. DR- <br />, _ Council [100ting Dais: <br />Eligibility Met <br />0c, <br />YES 1 NO Approved Amount: <br />City Manager Signature: <br />Data: jVl �Ii�l <br />f <br />Revised 11116/2015 <br />24X-3 <br />