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x-� =' City of Santa Ana <br />1_77 <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) 847.5200 <br />Contact Information <br />Name: J Y' <br />I Vl� -Gv � �.t�cj.,�Lf �qy� c,t- I <br />it Title: fC t fo1 <br />{� <br />Address: <br />�d <br />Y t �t '1 ('7 <br />City, State, Zip: <br />Phone: / L/ <br />_ <br />Email: 1 �(' �% V.UU - L.C9v�il <br />v <br />Fax. �l y <br />organization Information <br />Name: V" l `iSiv� xe <br />Tax - Exempt Status: Is your organization a non -profe or public tax - exempt organization as <br />defined under Section 501(c)(3) of the Internal Revenue Code? <br />Select One: yes No <br />If No, you will only qualify for a credit for Clty-related costs for your request (i. e. permit fees, <br />staff time, rental rates for facilities or equipment, etc.). Costs for City services vary and if <br />if Yes, <br />approved, credit may or may not cover full cost of requested City services. <br />Tax 10 #: <br />bonation Request <br />City Services Credit $ pate Needed: j MayodCouncilmember. PLIfido <br />Amount Requested: �� {� <br />Direct Payment Amount 9 Event Date: '�� U , Of r_ Event Time: — 7 uo w" <br />Requested: <br />Event Location: <br />Address, GM, state, Zrp <br />I1,4 %4 'C . � -1 �`i�• -l' _��t7 �dO �t� it � C4 —L" �l? �J i G P5 4 <br />lv 1s�n.�p c� ti�cfQ �t�, k 6 -tC1- i~ntkt' Sj <br />Description of �V Y.` 5 � �Q S ct 'C �C <br />Event/ Purpose: <br />Community Benefit: S fv i Vt E�lr,bW ocC S �A,�.�S IA -:re -S V -Q <br />Applicant Signature: �--� �_ Date: <br />Mail: City Manager's Office -M31 <br />20 Civic Center Plaza <br />P.O. Box 1986 <br />Santa Ana, CA 92702 <br />i,_ <br />^J <br />Email: donatlonrequest@santaana.org <br />Fax: (714) 6478884 <br />EXHIBIT 1 e n. <br />Revised 11116=15 <br />