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ori ry City of Santa Ana <br />f' Donation Request <br />City Manager's Office - M-31 <br />20 Civic Center Plaza <br />P.O. Sox 1988 <br />Santa Ana, CA 92702 <br />(714) 647.5200 <br />Name: Dr. Ana Jimenez-Hami <br />Title: Executive Director <br />iAddress: 12215 North Broadway <br />1 <br />;City, State, Zip: 'Santa Ana <br />;Phone: 714-296-2191 <br />Email: lana@occtac.org <br />;Fax: <br />1714-564-9690 <br />Name: !Orange County Children's Therapeutic Arts Center <br />Tax -Exempt Status: Is your organization a non-profit or public tax-exempt organization as <br />1Select One: Yes No <br />defined under Section 501(c)(3) of the Internal Revenue Code? l <br />If No, you will only qualify for a credit for City -related costs for your request i e. permit fees, !staff time, rental rates for facilities or equipment, etc.). for Cify services vary and if If Yes, <br />33-0930891 <br />'approved, credit may or may not cover full cost of requested City services. Tax ID #: <br />r___.___.. <br />City Services Credit $ Date Needed. 06-26-2017 1Mayor/Councilmember Martinez <br />'Amount Requested: <br />.Direct Payment Amount <br />Requested: <br />!$500 1Event Date: (06-30-2017 Event Time: pm <br />! !4:30-7:30 <br />!Event Location: <br />i OCCTAC <br />'Address, Clty, State, Zip <br />2215 North Broadway, Santa Ana, CA 92706 <br />! Once a year we celebrate the students enrolled In our "Youth Employment Program" that completed all the requirements of the <br />Description of <br />! program. We invite the parents and family members to celebrate their accomplishments and do a "GRADUATION" ceremony at our <br />!Event / Purpose: <br />agency. The funds we are requesting would allow us to purchase food to give to the families on that day since the grant does not allow <br />I for us to purchase food for the program. Since this is a special celebration we would love to treat the families and students on that day, <br />j <br />! Our Santa Ana Youth deserve to celebrate their accomplishments with their parents and family members This event celebrates our youth and all the efforts <br />Community Benefit: <br />! they have invested in improving their current life situation, including getting a job and enrolling in college. Many of our youth have great challenges, such as a <br />! disability, parenting teens, basic skills deficiencies, and others. Despite these challenges, they have learned to overcome these barriers, and have improved <br />! <br />significantly. By celebrating their accomplishments we motivate them to continue to pursue bigger and greater things in their lives, especially their education? <br />Applicant Signature: <br />Date: 16-26-2017 <br />Mail: City Manager's Office - M-31 I Email: donationrequest@santa-ana.org <br />! 20 Civic Center Plaza 'Fax: (714) 647-6954 <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />i <br />Donation Request DR <br />xe,v, a rce t? +, Nt ,t to -xv N,"Vc Council Meeting Date: <br />Eligibility Met: YES I NO Approved Amount: <br />City Manager Signature: Date: <br />Revised 01/05/2017 <br />