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City Manager's Office ='M-31 <br />R City of Santa Ana 20 Civic Center,Plaza <br />P.O. Box 1988 <br />" . Donation Request Santa Ana, CA 92702 <br />(714) 847.5200 <br />Name: Tricia Nguyen itle: CEO <br />Address: (1618 West First Street <br />Icily, st Santa Ana, ca 92703 Phone; 714-620-7007 <br />[Email. Far x — 714-620-7097 <br />Name: <br />Southland Integrated Services, Inc: <br />Tax-Exempt Status: Is your organization —anon-profit or public tax-exempt argarkatlon as Selec�-- t One: as ❑ No <br />defined under Section 501(c)(3) of the Internal Revenue Code? <br />If No, you will only qualify fora credit for City-related costs feryour request (i.e. permit fees, <br />"f Y"' <br />staff time, rental rates farfacililies or equipment,etc.). Costs for City seMces vary and If <br />approved, credit may or may not cover full cost of requested City services. ' ax ID #: F95--8403526 <br />?.Tr M am <br />-- <br />City Servlce� s Credit <br />Date NeededF <br />—IMayorlCouncilmember. Madinoz <br />PmountQequested: <br />'Direct Payment Amount tour $1 — <br />OOO <br />1112211612017 <br />Event Tima: <br />1 O aril to 4P <br />(Requested; I <br />IEvenl_Date; <br />Event Location: <br />1618 West First Street, Santa Ana, :CA 92703 <br />Address, City, State, Lp <br />We are hosting a clinic day for anyone to come to our center for citizenship <br />Description of <br />application assistance. <br />Event/Purpose: <br />Community Benefit: <br />To provide free application assistance to anyone that come to our location. <br />(IA�pplicant Signature: <br />��--.�,�. jb ie. : 11/21/2017 <br />Mail: City Manager's Office—M31 <br />Email; donationrequest@santaana.org <br />20 Civic Center Plaza <br />Fax: (714) 647.6954 <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />Ph <br />Donation Request N: <br />nafervnca R on an related bPVs <br />DR Council Meeting Date: December 19 2017 <br />Eligibility Met:YESINO <br />YES Approved Amount: $1,000 _ <br />City Manager Signature, <br />Date: <br />Revised 01/0512017 <br />EXHIBIT 4 <br />29A-11 <br />