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city manager's office -IW-31 <br />City ®f Santa A�� <br />20 Civic <br />oCe ionPlaza <br />I aza <br />Donation Request P.98 <br />Santa Ana, CA 92702 <br />(714) 647.5200 <br />4 0 <br />!IName: Maria Paz <br />Policy Analyst I <br />Iddress: 12040 Camfield Ave <br />ICdty, state, zip: I,I Los Angeles CA 90040 ;Phone: !323-889-7892 <br />Einad: 'I�mpmoreno@altamed,org ;Fax: ;323-889-7855 '.. <br />IName: 'AltaMed Health Services Corp <br />Tax -Exempt Status: Is your organization a non-pro0t or public tax-exempt organization as aelect One: I <br />(defined under Section 501(c)(3) of the Internal Revenue Code? 1 ® Yes ❑ No <br />If No, you will only qualify fora credit for City -related costs for your request its. permit fees, If Yes <br />;Staff time, rental rates for facilities or equipment, etc). Costs for City services vary and if 1952810095 <br />;approved, credit may or may not cover full cost of requested City services, Tax ID M <br />I <br />City Services Credit <br />I I al„�„e., <br />$ Aate Needed: !08/17/2017 Mayor/Counciimember. BENAVIDES <br />Amount Requested: <br />(Direct Payment Amount <br />$ [HventDate: <br />108/17/2017 Event Time; 2pm-5pl't1 <br />Requested: <br />$500 approved <br />Event Location: <br />1400 N. Main St Santa Ana CA 92701 <br />(Address, City, State, Zip <br />r,'bandfliy, the second week of August is dedicated to acognlvng the servlet and ctnthballont of had Ith tenders affect] Health Center Man, Sauguat 13-19, 2017) Micas us to detaches the ' <br />! <br />!Description Of <br />long modal of focuses and delMory of high quality, spot offers ve, and acewdblt care..tufo the ovish. America§ Hough Contare newsav9 ovor2S million IhdlAduala In 9,000 cotmmllNllea in <br />IS United Status Including the D18oct alCalumbin Puerto Rlm,US,Vl Oinlslandsand G,Itrrt TblS....Slh.sc.In Itdfpbhdflafi Amada'. Hoollh Congo. The Key to financier G parunitlos,' <br />Event/Purpose; <br />As part the Wc.u.n, Wlabrepary AhaMedwill be bidding an Olen Heads In aur Septa And. Man dlnlc(located at 1400 N. Main St Santa Ane, GA 92701) fron12 pra to 5 pin oft Thuradfy, ' <br />1 <br />I August 17th. This oventwlll to stand to the public and llTaSM fee tooth teachings, nation and plans, and healta peace "In mal.'rWe tad infmmetlon. <br />Provide free health screenings to the Santa Ana community, provide information about the health and <br />'Community Benefit: <br />wellness services AltaMed offers to the community, and encourage and motivate Santa Ana residents to <br />engage in healthy activities as well as healthy eating. <br />;Applicant Signeturo:.... <br />/ <br />Date: '. 7117 <br />r • ^ m <br />s <br />(Mail. City Manager's Office -M-31 Email: donationrequest@santa-ana.org <br />20 Civic Center Pima Fax: (714) 647.6954 <br />J P.O. Box 1988 <br />Santa Ana, CA 92702 <br />Donatlon Request 4: <br />DF¢ - <br />Council Mi76tlnCq Date: AUGUST I, 20I % <br />Eligibility Met: <br />YES i Ado YES Approved Annotmt: $500 <br />City Manager Signature: <br />Date: <br />Revised 01/05/2017 <br />29A-12 <br />