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City of Santa Ana <br />Donation Request <br />City manager's office— M-31 <br />20 Civic Center Plaza <br />A.0_ Box 1988 <br />Santa Ana, CA 92702 <br />(714) 847-5200 <br />Name: ';Michelle Chan <br />Address: :2101 E. 4th Street, Suite A220 <br />city, state, zip: !Santa Ana Phone: 1714-510-3846 <br />Email: mchan@hoalthysmilesor.org Fax: <br />Name: Healthy Smiles for Kids of Orange County <br />Tax -Exempt Status; Is your organization a non-profit or public tax-exempt organization as <br />defined under Section 501(c)(3) of the Internal Revenue Code? <br />If No, you will only qualify for a credit for City -related costs for yourrequest (i.e. permit fees, <br />sluff time, rental rates for facilities or equipment, etc.). Costs for City services vary and if <br />Approved, credit may or may not cover full cost of requested City services. <br />Select Onal I <br />Yes ❑No <br />If x <br />ID ill 38-3675065 <br />I I <br />City Services Credit <br />Amount Requested: <br />!.n <br />I � V note Needed: October 5,201 -1 MayorlCouncilmember: TinaJero <br />Direct Payment Amount fl000 voint Date: October 21, 20 'Event Thaw 6prin <br />:Requested: <br />I <br />,Event Location: <br />!,Bowers Museum, 2002 North Main Street, Santa Ana, CA 92706 <br />'.Address, City, State, Zip <br />[Funding will contribute to ongoing program success and help Healthy Smiles for Kids of Orange County (Healthy Smiles) <br />Description of <br />!expand its services, reach, and Impact. As a community-based nonprofit organization, Healthy Smiles Is dedicated to <br />Event / Purpose: <br />!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: <br />Mobile Program (dental clinics on wheels that travel to Title I schools), Outreach Program (childre ages 0-5), <br />Teladongstry Program treatment at our 2 clinics (Garden Grove and CHOC Children's <br />Hospital of Orange Case <br />Applicant Signature: <br />,Date: 19-20-17 <br />l� 1 111 1 1 <br />1 1 <br />Z <br />Mail: City Manager's Office — M-31 Email; donationrequest@sorsta-ana.org <br />20 Civic Center Plaza Fax: (714) 647-6954 <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />Do I nation R e I ques ; t z DR Council Meeting Date: NOVEMBER 7,2017 <br />Eligibility 11110t: yrs i NO YES Approved Amount: $1,000 <br />City Manager Signature: Date: <br />Revised 01/0512017 <br />EXHIBIT 15 <br />