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{ fr+CAp <br />I <br />City of Santa Ana <br />Donation <br />Name:.(<...pl <br />Address:/g� . 5- r7' 0 r6 %. ,,ala /Rew sy <br />City, state, zip: �y",0}}cv TJf3 l/� N A II/,7(- ,9 7,4-70-7 <br />Email: 1p,P14 _ Coe YRJq.0 0o <br />City Manager's Office - M-31 <br />20 Civic CentorPlaza <br />P.O. Box 1968 <br />Santa Ana, CR 92702 <br />(714) 847.6200 <br />Title: /l;096w ' <br />:Phone: 7 1 —006 - &3 & <br />Pax: <br />Name: Charitable Ventures of Orange County fiscal sponsor for Wilshire Square Neighborhood Association <br />Tax -Exempt Status: Is your organization a, non-profit or public tax-exempt organization as Select One: F] I <br />defined under Section 501(e)(3) of the Internal Revenue Code? � Yes No <br />If Na, you will only qualify for a credit for Ciiy-related costs for your request (e. permit fees, 1f Yes, <br />staff time, rental rates for facilities or equiument, etc.). Costs for CRy services vary and if <br />approved, credit may or may not cover full cost of requested City services, Tax ID#: <br />Am unt Req Credit ( Date Needed: Ma ouncllmember:) VILLEGAS <br />Amount Requested: 11-W-17 �Oir.0 Ll + <br />Direct Payment Amount $ 504 Event Data: E Jt -'i <br />Requested: <br />Event Location: Chi oic Al"116o4ljoD)7 rel�r, <br />;Address. CNy, state, zta <br />i f�✓vTl�- �� mt���,��r-�.,� <br />Description of d�FvG/3� % IL�a�a/ /s�G9�Orc / ✓U �G�/o� ' crcf i7 j%C <br />event iPurpose: LJtffG G !ll/f' f/}s/% vU?7 ✓f16rXl5ellerr4. 5_ (14L6��- Y1 <br />4402 Rig #(4-- <br />CommunityBenefit: �,C���r> i fit/G' CYC?r`i✓�U�l�l� /r,"1f/��'�.%�f.�+ F--c,v` <br />Applicant Signature: - Dater <br />Mail City Manager's Office -M-31 <br />20 Civic Center Plaza <br />P.O. Box 1988 <br />Santa Ana, CA 92702 <br />City <br />YES <br />Email: donationrequastQsanta-ana.org <br />Fax: (714) 647-6984 <br />NOVEMBER 7, 2017 <br />$500 <br />EXHIBIT 12 <br />Dotter: <br />Revised 01105/2017 <br />