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�t : City Manager's office - M•3t <br />3 City of Santa Ana 20 Civic Center Plaza <br />;'' <br />Donation Request N -2017-248-A P.a,CAx2702 <br />. .,-�' , Saraa Ana, CA 82702 <br />(714) 647.6704 <br />R R R <br />Name:. _.._ Off hii:ik <br />--�*(✓0�..P1/ 'J^ tfgr�".i�Y1U ..i.. �" Title: <br />Address: 196) 5' ' 0 � rlLii IN it (1`70-7 <br />/ ^l J-�7T <br />City, State, ZIP:. J p.�(/J','tf�. /"17p�Ucd�1.. �C /, (c7 70 / ;Phone: <br />Email: IP,/V14P.1( �:.71p}.P0(),Co/p. Fax: /. ..... .t(.,lr.. <br />Name: Charitable Ventures of Orange County as Fiscal Sponsor for Wilshire Square Neighborhood Associat <br />Tax -Exempt Status; is your organization a non -prom or public tax-exempt organization as Setect One: {-� f ,- <br />defined under Section 561(c)(3) of the Internet Revenue Code? Q Yes ] i No <br />1f No, you will only qualify for a credit for City -related costs for your request (la, permit fees, �� Yes <br />staff time, rental rates for facilities or equipment, etc.). Costs for City services vary and if <br />approved, credlfmay ormay not cover full cost ofrequested City service& Tax 1DIt. ::�Q-$756660 <br />ServicesCredit <br />Amount Date Needed: �inGcillmember, Mayor Fulido <br />-a5-1� <br />ou <br />€)iteok Payment Amount <br />$$1,000 Event Date:Requested: -3 J EvX P;,) : <br />- <br />Event Location: M./ Ok Al"11,,60;-:t UP !!2/i [ /� C� 9w'�f'� ,40t J` , /Un P,44 IA1)6 , <br />`Address, 00, State, zip � l /hf7. {,ittl re -P E }, <br />% o Ca1}�/� DSS f�/v C� ,�� 107'0eeyC, <br />/ OZIC're Z7M <br />Description of f7'N✓t`�j''/�`G t�7JL,rry?p4-y a/i/f rev <br />_..... <br />Event I Purpose: C4116 Cay4V&' "S ,j_'I).dJ71 ".d1W 1.116:11, e7A467d& '-_ (14G.C,1rj <br />��lJ?�)G/�L'�'��1C /f Na�.S.9d✓r'�3����i�.-ij G,G' �'/r�.�' _ i <br />Community Benefit: ��%?% T%N� y dry/ir}/CTi / r y✓}' 9`1� �i i <br />/"/ZFr!rl?S1i/U /T}L/l ij Clime/ SCtGAS' <br />Applicant Signature: q - Date: <br />Mag: City Manager's Otflce r M-31 . Email: donationrequestgsanta-ana.org <br />20 Civic Center Plaza -. Fax: (714) 847.6$84 <br />Ro. Box 1888 <br />Santa Ana, CA 82702 <br />Donotinn <br />NO YES <br />ci k ML8id)g4n' <br />r,<,unc�i tri _#erg Date: 'NOVEMBER 7, 2017 <br />`p,,iov a -lrnowiU $1,000 <br />Revised 01105/2W <br />EXHIBIT 1 <br />