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HomeMy Public PortalAbout020_016_Irish Heritage Celebration City of Tybee Island Community Services Contract Award f ,f Fiscal Year 2015-16 APPLICATION FOR CASH AWARD This form and all attachments are to be completed and submitted by March 20, 2015 Date: 0 1 5 Organization requesting City of Tybee Island Community Services Contract Award: f cL Name of Organization: I�°be� .�(cuv�c� �c Z�L �� i,°�� � r-c?-11(6rN Contact Person: U -k Address: P. 0 . 0 k` o3 /L I-- Contact Email:3 FtLx ke6S e l f l" I.Contact Phone #: 142. L 7r -3 r- Net- Is this organization an IRS approved 501(C) 3 Non-Profit? Yes i/ No If"yes", please attach your most recent audited financial statement, and a copy of your IRS determination letter. Amount of funds requested: $ �� 6-0 b Describe how these funds will be used and how the City and citizens of Tybee Island will benefit: Used _ f -re '{ �..�...._!�c u.I!`Q l'1 L f �' � i �' j(-- ci`t`r 7-- eArt S hex-)€:-Co I i brh inCreq s e d X re,k)cn t£F?.s ( b crl� es5e � . Pd What percentage of these funds will be matched by your organization? • Will this event or program bring visitors to Tybee Island in off-peak season or months? i ° S DA- >>Please attach a detailed budget to this request outlining how the money will be used. P.O.Box 2749—403 Butler Avenue,Tybee Island,Georgia 31328-2749 (912) 786-4573—FAX(912) 786-9465 www.eityoftybee.org 1, - City of Tybee Island Community Services Contract Award \ � Fiscal Year 2015-16 APPLICATION FOR WAIVERS Name of Organization: T bee . 51 _t r't S 1 Cdr( �- Provide detail on any waivers (i.e. free or reduced parking, rent or utilities) or City services (i.e. number of hours of security, city worker clean-up, trash and/or recycle bins, building maintenance and upkeep, etc.) that you plan to request for your event(s): ]e\- Lica r - No C-Ikce.AA , 5 E r, r7 a ea/1r reres4 1 eT -1--+ -e d 62- c f C e cf. ( ? c))�. r te` NI 0 a.r i r, e riS r can-1-1 ( Q f+e-Y- ` r d"am /A-2) `; fr r C- r I ! /".9 ! - , AF`19 rrerill "r:. 'j J c . Value of the waivers requested: $ F.O.Box 2749—403 Butler Avenue,Tybee Island,Georgia 31328-2749 (912)786-4573—FAX(912) 786-9465 www.cityoftybee.org re Affidavit Verifying Status i1,,. for City Public Benefit Application By executing this affidavit under oath.as an applicant for a City of Tybee Island,Georgia, Business License or Occupation Tax Certificate, Alcohol License,Taxi Permit,Contract, or other public benefit as referenced in O.C.G.A. Section 50-36-1,I am stating the following with respect to my application of a City of Tybee Island: • Business License or Occupational Tax Certificate, • Alcohol License, (circle all that apply) ■ Taxi Permit, • Contract • Community Services Contract Award for J a � t.t_.1+ °c _ (printed name of natural person applying on behalf of individual, business, cnrboration,partnership, or other private entity). 1) If 1 am a United States citizen. OR 2) I am a Legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non-immigrant under the Federal Immigration and Nationality Act, 18 years of age or older and lawfully present in the United States. * In making the above representation under oath,I understand that any per •n who knowingly and willfully makes a false, fictitious,or fraudulent statement or representation in an affidavit shall be guilty of a violation • Code Section -10- of the Official Code of Georgia. 6 at of Applicant / Date f2- /(5 . Printed/Name *Alien Registration Number for Non-citizens SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF { 4-4_47 ,20.-i_- — 7 i i SHARON S.SHAVER ,, .,-, t .--4 Notary Public, Chatham County, GA Notary Public .. ,. rY Y My Commission 1 �cpires: My Commission Expires Dec. 5, 2015 Note: 0.C.G.A. sr S0-36-1(e)(2) requires that aliens under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, provide their alien registration number, Because legal permanent residents are included in the federal definition of"alien", legal permanent residents must also provide their alien registration number. Qualified aliens that do not have an alien registration number may supply another identiiing number below: Tybee Island Irish Heritage Celebration March 12, 2016 Estimated Budget and Expenses EXPENSES: Insurance: 1 500.00 Advertisement 1500.00 Bands/Travel 2000.00 I Tospitalitylr'ood 1000.00 Misc. Expenses 300.00 Expense Total: $6,300.00 INCOME: Entries: 1600.00 Sponsors: 2250.00 City of Tybee Island 1500.00 Shirt/Hat Sales 950.00 Income Total: $6,300.00 These are the estimated Expenses and Income for the 14th Annual Tybee Island Irish Heritage Parade to be held on Tybee Island Saturday, March 12, 2016. /1)7'5/ 03-Q5-'15 15:48 FROM- 1-379 P0002/0002 F-607 AC nk CERTIFICATE OF LIABILITY INSURANCE DATE(MUM DIYYYY) kr....1 03/05/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREI S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLDER, . IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the poiicy(ies)most be endorsed. If SUBROGATION IS WAIVED,subject to the terMS and conditions Of the policy,certain policies may require an endorsement A Statement On this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 912-920-0278 912-356-8450 FL1NrCT Deborah Bowen Advantage Insurance Agency t.,-r , cNM.rim:912-920-0278 FAX NO 912-356-8450 820 E. DeRenne Avenue \---s). ADO s:advarltage_ins@a bellsauth,nef Savannah, GA 31405 ,-r 0 PRODUCER ID t INSURERS)AFFORDINQCOVPRAGE I NAIC# INSURED IRSURRRA:NAUTILUS INSURANCE COMPANY 117370 Tybee Island Irish Heritage Celebration Parade INSURER a: PO Box 2314 INSURER C: Tybee Island, OA 31328 INSURER D: INSURER E: MN INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF ' POUCY EXP LTR INSR UIVD POLICY NUMBER I rlAWOeY VYI.IlwuuonmYVL LIMITS GENERAL RAL uAEIU!Y I EACH OCCURRENCE $1.000.000 A F4 coMMERCIAL E AL LIASILnv P lrsES Fa DocianentaI I 3100,000 UCLIUME-MADE 1 V I OCCUR NLED EYCP[w+u one F'e�sC41)3 0.0. NN407278 03/14115 03/15/15 PERSONAL SADVIN-JURY $1,0D0.000 • GENERAL AGGREGATE s 7 000 000 GEN'LAGOREGATELIMIT APPLIES PER_ PRODUCTS-COMMA AGO s INCLUDED T POLICY 11 JjEECOT 1 1 LOC 5 AUTOMGt}ILE LIAWUTY COMBINED SINOLE LIMIT E (Es weitIera) ANY AUTO BODILY INJURY(Per person) $ ■ ALL•OwNED AUTOS BODILY INJURY(Per accident)) 5 U SOHEOuLED AUTOS PROPERTY CAMAGE HIRED AUTOS (Perawidsnt) S NON-OWNED AUTOS U $ M6AIB.LA MB EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE _ RETENTION & I S. WORKERS COMPENSATION NC STATU• OTH. AND EMPLOYER&LIABILITY r r H TORY LIAIrr$� ) ER ,wur PROM/VON/PARTNER/EXECUTIVE 0 E EACH ACCIDENT S C7>=Mette.,MINEER EXCLUDED?LUDED? N I A (Mandalay In NH) EL DISEASE,-EA EMPLOYEE $ IF vas descr be under ` DESCRIPTION pc OPERATIONS baI w EL DISEASE-POLICY LIMIT 1$ 1 _ j ., DESCRIPTION Dr OPERATIONS I LOCATIONS I VEHICLES(Adaah ACORS 101,Additional Rer M$chcd'uk,If mom space r5 mom) CERTIFICATE HOLDER CANCELLATION City of Tybee Island SHOULD ANY OF THE ABOVE DESCRIBED POLICIES ME CANCELLED BEFORE 403 Butler Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Tybee Island GA 31328 AUTI• REPRESENTATIVE ©1988-2009 t•RD CORPORATION. All rights resorved. ACORD 25(2009109) The ACORD name and logo are registered marks of A * -D Fotrn W.9 Request for Taxpayer Give torn, to the ( .October 2004) identification Number and Certification requester. Do not Department at the Treasury send to the IRS.. Internal Revenue Service c^.r Narrre as reported on your incarne tax refs, n) ' Q. Business name,if different from above O CA /// indWduaif Exempt from backup y Check appropriate box: Bole proprietor ❑ Corporation ❑ Partnership ❑ Other 1 ._. ❑ withholding O a s Address y . strew d apt.or egte no.}/ Requester's name and address(optional) City,state P code m List a t number(s)hero(optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on Line 1 to avoid .sry7ial security number backup withholding. For individuals, this Is your social security number(SSN). However,for a resident t � `� ' ,4 ,r I } 1 •" I- alien,sole proprietor, or disregarded entity.see the Part I instructions on page 3. For other entities, it is f your err/player identification number (SIN). If you do not have a number, see Now to get a TN on page 3. Or Note.ff the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identification number to enter. i fi Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or(b) I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that 1 am no longer subject to backup withholding, and 3. )am a U.S. person (including a U.S. resident alien). Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to sport all interest and dividends on your tax return. For real estate transactions. item 2 does not apply. For mortgage interest paid, acquisitio +or abandonment of secured property,.cancellation of debt, contributions to an individual retirement arrangement(IRA). and generally. , ants other than Interest and dividends,you are not required to sign the Certification, but you must provide your correct TiN.(See the ", - ction 'on 4.) Sign Signature of Here U.S..person ■ Date i• 3(7-O k t'`