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p.-. City Manager's Office—M-31 <br />City of Santa Ana <br />_�. <br />20 Civic Center Plaza <br />i) Donation Request P.O. Box 1986 <br />Santa Ana, CA 92702 <br />_ (714) 647-5200 <br />Name: Michelle Chan—�— <br />Title: CommuNcallonsd Devebpmenl Maruger <br />Address: 12101 E. 4th Street, Suite A220 <br />city sstate,zi: [Santa Ana - l — --- <br />P Phone: 714-5103846 <br />Email: mchan@healthysmilesoc.org i [Fax; f <br />—. <br />o . <br />Name: Healthy Smiles for Kids of Orange County <br />Tax-Exempt Status: Is your organization a non-profit or public tax-exempt organization asSelect One: <br />defined under Section 501(c)(3) of the Internal Revenue Code? <br />a <br />Yes No <br />❑ <br />If No, you will only qualify for a credit for City-related costs for your request (i.e. permit fees, 1 <br />staBtime, rental rates for lacUities or equipment,efc.).Costs for City services vary and if �f Yes, <br />- <br />(3g_3675065 <br />approved, credit may ormay not cover full cost of requested City services. [Tax ID #: <br />De <br />Clry ces Credit 1$--�—�� <br />Amount Requested: IS (] ate Needed: 5,ZO1 I [Mayor/Councilmember: Tinajero <br />'rOCtOber <br />�Dlre—ct Payment Amount s100 Eve t^ D eat: [October 21, 20 EVent Time: Grp. <br />Requested: IOpjtj <br />Event Lc cation: Bowers Museum, 2002 North Main Street, Santa Ana, CA 92706 <br />Address, C8g State, Zip <br />Funding will contnbute to ongoing program success and help Healthy Smiles for Kids of Orange County (Healthy Smiles) <br />Description of expand Its services, reach, and Impact. As a community-based nonprofit organization, Healthy Smiles is dedicated to <br />Event / Purpose: empowering all children to live healthy and happy lives. To realize this vision, our mission is to reduce oral disease in <br />children through collaborative programs aimed at prevention, education, treatment, and advocacy. <br />Healthy Smiles serves over 100,000 low-Income children and parents each year through the following programs: Smile <br />Community Benefit: Mobile Program (dental clinics on wheels that travel to Title 1 schools), Outreach Program (childre ages 0-5), <br />TeledenlistryProgram ('Cla oo t try"), and treatment at our 2 clinics (Garden Grove and CHOC Children's <br />Hospital of Orange Coun <br />_ __—I <br />7 —— <br />-- -- — —.I atm— 9_20_1 <br />Applicant Signature- <br />— -- — __ —_ • --_—_ __ —_J <br />ity Managers Office—M-31 Email: donatlonrequest@santa-ana.org <br />Civic Center Plaza Fax: (714) 647.6954 <br />n2P.O. <br />Box 1966 <br />—0 <br />Santa Ana, CA 92702 <br />De^aOonRegaeat#: I DR- <br />Rekra:mc d en nil retstccl nFVs Council Meeting Date: NOVEMBER 7, 2017 <br />Eligibility Met: YES/NO YES $1,000 <br />i Approved Amount: <br />City Manager Signature: Date: <br />j <br />Revised 01/0512017 <br />EXHIBIT 15 <br />29A-33 <br />