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City Manager's Office - M•31 <br />City of Santa Ana 20 Civic Center plaza <br />Donation Request aa, sox 1909 <br />;, " Santa Ana, CA 92702 <br />(714) 0474200 <br />Name: Trlcla Nguyen ICEO <br />Address: 11618 West First Street <br />(City, state, zip: (Santa Ana, ca 92703 'Phone: 1714-620-7007 <br />jtnguyen@sotathtandintegrated.org !rax: 1714-620-7097 <br />1 Name: (Southland Integrated Services, Inc. <br />!, Tax -Exempt Status: Is your organization a non-profit or public tax-exempt organization as <br />'defined under Section 601(0)(3) of the Internal Revenue Code? <br />If No, you will only quality for a credit for Cityralated costs for yourrequest (i.e. permit fees, <br />staff time, rental rets for facilities or equipment, eto.).Coals for City services vary and if <br />(approved, credit may or may not cover full cost of requested City services. <br />k <br />!Select One; <br />R&/ Yes ❑ No <br />i <br />If <br />Tax10 #. I95-3403526 <br />(Tax ID <br />'Cit Services Credit <br />Amount Requested: (Date Needs d: �MayorlCouncitmembor: Martinez <br />irect Payment Amount Is 1000 (Event Date: 112/16/2017 11ventTime: 110 am t4 -4-pm <br />m <br />Requostod; <br />Event I.onation: 1618 West First Street, Santa Ana, CA 92703 <br />Address, 011 StaPe, Zlp <br />We are hosting a clinic day for anyone to come to our center for citizenship <br />Description of <br />levant I Purpose: application assistance. <br />s <br />�To provide free application assistance to anyone that come to our location. <br />Community Benefit: <br />Applicant Signature: j ..- .. .... .w--- -�---.-v„....Data: ..._...111/21/2017 <br />Mail: City Manager's Office -M-31 <br />20 Civic Center Plaza <br />P.O. Box 11988 <br />Santa Ana, CA 92702 <br />Ooration Requs ii{.... DN <br />j Eliglbl8uy Mot: ! 1'ES /NO <br />City Managsr Sifynatuno; <br />Email: donationrequest@eanta•ana.org <br />Fax: (714) 647-6954 <br />Council Mooting Milw <br />Y` Approved AnnounG <br />1 Unto: <br />EXHIBIT 4 <br />December 19, 2017 <br />$1,000 <br />Revised 0110612017 <br />