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,a City of Santa Ana <br />Donation Request <br />City Manager's Office -M,31 <br />20 Civic Center Plaza <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />(714) 647-5200 <br />amut�e: Roman Reyna/ Mario Rodriguez ase: Lead Advisor <br />�lddresr s. p0 Box 194 <br />fcltystate, z—lp: San Clemente, CA 92674 phone: (714) 865-9118 <br />IEmatl I: mrod262@yahoo.com or roman _reyna@hotmail.comF�; —�— <br />o r. • r s . <br />Name: Hispanic 100 Foundation <br />Tax -Exempt Status: Is your organization a non-profit or public tax-exempt organization as etact One: <br />defined under Section 501(c)(3) of the Internal Revenue Code? Yes ❑ No <br />If No, you will only qualify fora credit for City -related costs for your request (le. permit fees, if Yes, <br />,staff time, rentalrates forfacilides orequipment,etc.).Costs for City services varyandif � 46-1962620 <br />('approved, credit may or may not cover full cost of requested City services. Fax <br />to #: <br />Donattoil a `uesh; a <br />ICtty Services Credit <br />ount Requested: Date Needed: ASAP ayor/counctlmember. i Tiiy� <br />/un1h� <br />Direct Payment Amount <br />Requested: 1i <br />Event Oate: <br />Ori-gOing vent Time: <br />On-going <br />Event Location: <br />Funds will help cover on-going cost for the youth program, but will specifically cover <br />ddress, City, State, Zip <br />the cost of conferences to prep youth for legislation training in Nov., Jan., and Febr. <br />City Manager. Signature: <br />a Ana youth will participate in the Youth & Government program/activities <br />Description of <br />Event/ Purpose: <br />e training on how to create a bill and help it pass. There are three upcoming <br />Fai <br />s that will train youth and help them launch the bills. <br />Santa Ana youth will become empowered by the education, training, and ea ers ip <br />community Benefit: <br />skills, that will learn from the Youth & Government Program. This will also provide <br />insigh n legislation, networking, self-esteem and public speaking skills. <br />AppllcantSignature: <br />i ate: <br />11/6/17 <br />(Mail: City Manager's Office -M-31 IEmail: donationrequest@santa-anamrg <br />20 Civic Center Plaza Fax: (714) 647.6954 <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />11 <br />Revised 01/05/2017 <br />Donation Request #: <br />a,rer�m•, so,, .,n r�r3red oru: <br />DR <br />CCouncilMeeting Date: <br />December 19, 20017 <br />Ellgibliibj Met: <br />YES i No YES <br />Approved Amount: <br />— <br />$1,500 <br />City Manager. Signature: <br />_ <br />_ <br />11 <br />Revised 01/05/2017 <br />