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DocuSign Envelope ID: F9D83648-635F-47C1-AOC6-CC3370BEF8EA <br />City of Santa Ana <br />Donation Request <br />Name: Mamie Funahashi �itle: <br />Address: 1000 N. Alameda Street, Suite 240 <br />city, State, zip: Los Angeles, CA 90012 (Phone: <br />Email: mfunahashi@CommunityPartners.org Fax: <br />City Manager's Office — M-31 <br />20 Civic Center Plaza <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />(714) 647.5200 <br />Name: ommunity Partners for MASA (Media Arts Santa Ana) <br />($ (Date Needed: (6/28/17 Sarmiento <br />Tax -Exempt Status: Is your organization a non-profit or public tax-exempt organization as Select One: <br />defined under Section 501(c)(3) of the Internal Revenue Code? <br />� Z Yes ❑ No <br />If No, you will only qualify for a credit for City -related costs for your request (i.e. permit fees, <br />$ 1,00 (Event Date: 6/28/17 Event Time: <br />i 7 weeks <br />staff time, rental rates for facilities or equipment, etc.). Costs for City services vary and if If Yes,g <br />4302067 <br />approved, credit may or may not cover full cost of requested City services. Tax ID #: <br />Delhi Community Center, 505 E Central Ave, Santa Ana, CA 92707 <br />(city Services Credit <br />($ (Date Needed: (6/28/17 Sarmiento <br />(Amount Requested: <br />IMayorlCouncilmember: <br />Direct Payment Amount <br />Requested: <br />$ 1,00 (Event Date: 6/28/17 Event Time: <br />i 7 weeks <br />Applicant.Signature: <br />Event Location. <br />Delhi Community Center, 505 E Central Ave, Santa Ana, CA 92707 <br />Address, City, State, Zip <br />—0FX813C0842F468... <br />We are requesting funds to support the 2017 MASA Youth Cinema Camp and to offer free instruction to Santa Ana youth in digital <br />Description of <br />media production and skills that promote creativity, leadership, civic engagement, career skills and community expression. The program <br />Event/ Purpose: <br />will take place from June 26 -Aug 11, 2017 and will include a free community screening of youth -produced works. MASA is a <br />fiscally -sponsored project of Community Partners, a 501(c)(3) non-profit organization. <br />This program will provide free summer media -making instruction, programming and access to Santa Ana youth ages 11-17 by award-winning <br />Community Benefit: <br />artists and media -makers. The MASA Cinema Camp will provide critical digital literacy and production skills that will enable participants to <br />create their own community stories, inspire artistic production and the use of technology, promote equity, provide marketable career skills <br />and also increase the capacity of the community to defend itself by documenting abuses and attacks from anti -immigrant groups. <br />Applicant.Signature: <br />Dacus igned by. <br />` - <br />�4l uutL Y s10605-1-7 <br />IDate: i 0605_ 7 <br />' <br />—_ <br />—0FX813C0842F468... <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@santa-ana.org <br />Fax: (714) 647-6954 <br />I <br />Donation Request #: I DR- <br />Rete, ence V on ali retatexi Dpvs Council Meeting Date: <br />Eligibility Met: <br />I i <br />YES / N0 YES � Approved Amount: <br />1 <br />JUNE 20, 2017 <br />$1,000 <br />I City Manager Signature: Date: <br />EXHIBIT 4 <br />Revised 01/05/2017 <br />