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City of Santa Ana CiManager's00 Civic Center Plaza <br />31 <br />�'� Donation Request P.O. Bon 1988 <br />4 Santa Ana, CA 92702 <br />(714) 647.5200 <br />r <br />(Name: IMariaPazties: Policy Analyst <br />llAddress: 12040 Camfield Ave <br />City, State, zip: LOS Angeles CA 90040 Phone: i323-889-7892 <br />;Email: mpmoreno@altamed.org Fax: 1323-889-7855 <br />IName: 'AltaMed Health Services Corp <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? FV_1 Yes ElNo ! <br />i <br />I If No, you will only qualify for a credit for City-related costs for your request file, permit fees, i <br />i <br />!staff time, rental rates for facilities or equipment,etc.). Costs for City services vary and if If Yes, jg52810095 1 <br />reproved, credit may or may not cover full cost of requested City services !Tax 10 0: <br />80 M-1 ^r <br />'City Services Credit '$ <br />Date Needed 108/17/2017 Mayor/Councilmember: Martinez <br />Amount Requested: ; <br />Direct Payment Amount 0$/17/2017 Event Time; <br />,Requested: I$+I+dew— 1Even4 Date: I 12pm-spm <br />_.. $500 approved _ <br />(Event Location: '.1400 N. Main St Santa Ana CA 92701 <br />(Address,, City, State, Zip <br />Nglonally theemnd weok M August is dedicadef to mcoanerng the senno and Contdbutionof health eenlrs Ntlal Health Cater Vessel, (August 1110201 alflowa us (a unlearned the <br />!long ossund ofoucaevo and delvaly slash quality Cort agodlva ntl olble cpreor smo natlon. Am hH IIM1C mors 9 r25 mIWO Ind!Itl I hr 9.000 11 In <br />IDeseriptlon of Iha Oallotl Slolao MCludlnOlha Gkidcl of Columbia, Pusan Rleo, LLB targln Islands and Guam This y.a,.$be.leC.O.W.lig Amercn4 Health Centers. Th.la"WHouniluConeoushlorl <br />i Event Purpose: As pad argue week long oolobradon, AIWMad Wil behaells, on Olson House In our Santa Ano, Main dlnie(locarsd at 1400 N. Main St Santa Ann, CA 92701) home pm to S pm on Thurs&y. <br />i Augud 17th. TFiv event WII bo upon to the publicnnd IndWe free health scraonings, rpmoa and pnxos, antl heollh etlucallvn matenale end Inlormalion, <br />i <br />Provide free health screenings to the Santa Ana community, provide information about the health and <br />community Bennet: 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 Signature:IN <br />�r 'Date: I7117 <br />I Mail: City Manager's Office - M-31 Email: donationrequest@santa-ana.org <br />20 Civic Center Pima I Fax: (714) 647-6954 <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />Donation Request: rs: DR AUGUST 1, 2017 <br />- CouncilMaetfncq Dat'o: <br />Eligibility Nlet: YEs l Rio YES Approved Amount: $900 <br />City Manager signature: Date: <br />Revised 01/05/2017 <br />29A-4 <br />