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Home My Public Portal About020_019_SEABAR Mardi Gras k ! 'f 1(\\...,........,___ g City of Tybee Island Community Services Contract Award r Fiscal Year 2015-16 ot2. APPLICATION FOR CASH AWARD This form and all attachments are to be completed and submitted by March 20, 2015 Date: March 18, 2015___.. Organization requesting City of Tybee Island Community Services Contract Award: Name of Organization: TYBEE SEABAR INC. (Tybee Mardi Gra Feb 6, 2016) Contact Person: Steven Kellam Address: P.D. Box 1970 Contact Email: tybeepiratefest@aol.com_ Contact Phone #: _(912) 713-5466 Is this organization an IRS approved 501(C) 3 Non-Profit? Yes X No If"yes", please attach your most recent audited financial statement, and a copy of your IRS determination letter. Amount of funds requested: $ 0 Describe how these funds will be used and how the City and citizens of Tybee Island will benefit: What percentage of these funds will be matched by your organization? N/A Will this event or program bring visitors to Tybee Island in off-peak season or months? Yes >>Please attach a detailed budget to this request outlining how the money will be used. Y.Q.Box 2749—403 Butler A%enue, Tybee island,Georgia 31328-2749 (912) 786-4573 — FAX(912)786-9465 www.cityaftybee.org , ,;,:.-,V)AlLifii 1„... ( ; j City of Tybee Island Community Services Contract Award \.!.4-1: ' - J1 ' r , Fiscal Year 2015-16 APPLICATION FOR WAIVERS Name of Organization: TYBEE SEABAR INC. 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): 1. Waiver any Building and Zoning fees that may occur. (Tents, Stage, etc.) 2. Seabar request free use the Roundabout and 20 parking Spots in the South End Parking Lot 3. Waiver DPW fees for 10 trash cans, 10 Recycling containers, Barricades, and roping off for parade. Clean streets after parade and event. 4. Waiver all Tybee Police fees for parade and street patrol. Value of the waivers requested: $ $6,000.00 P.O.Box 2749—403 Butler Avenue,Tybee Island,Georgia 31328-2749 (912)786-4573—FAX(912) 786-9465 www.cityoftybee.org t Affidavit Verifying Status Ifor 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 50-36-1,1 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_Steven Kellam (printed name of natural person applying on behalf of individual, business, corporation,partnership, or other private entity). 1) X I 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 person who knowingly and willfully makes a false,fictitious,or fraudulent statement or representation in an affidavit shall be guilty of a violation of .+ec '•• 6-I 1-20.0 - s vial Code of Georgia. Siguataie r Applican - March I8,2015 Date Steven Kellam Printed Name *Alien Registration Number for Non-citizens SUBSCRIBED AND SWORN BEFORE ME ON THIS THE r._ J lyAY sF j 20 /ter Na Public „ /'` '. r '', {. I^ ' /'t/1. t_—__ SHARON S. .m count M Notary Expires: .- = Notary publ'sc,Chatham Goa1y,GA Y P rtes DSC- , gp15 my commission EXP Note: 0.C.G.A. §5O-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 identing number below: For, W-9 Request for Taxpayer Give Form to the (Rev,December 2014) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank. - TYBEE SEABAR INC. ni 2 Business namefdisregarded entity name,if different from above a a- 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to certain entities.not individuals;see ° []individuaVsole proprietor or ❑ C Corporation IU S Corporation ❑ Partnership ❑Trust/estate instructions on page 3): IS. c single-member LLC Exempt payee code(f any) 0,, []Limited liability company.Enter the tax classification(C=C corporation,S=S corporation.P=partnership)• L Exemption from FATCA reporting p 2 Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box in the line above for C m the tax r-+,wsification of the single-member owner. code(if any) ❑Other(see instructions)• (Applies'to.a=ounts m:NrtlaIwS outtalk?the US) a. ra S Address(number,street,and apt or suite no.) Requester's name and address(optional, 0 . P.U.Box 1970 y6 City.state,and ZIP code Tyre island Georgia 31328 7 List account number(s)hers(optional) WU Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid I Social security number backup withholding.For individuals,this is generally your social security number(SSN).However,for a - - resident alien,sole proprietor,or disregarded entity,see the Part 1 instructions on page 3.For other - - entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN on page 3. or Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number guidelines on whose number to enter. 4 6 - 3 1 5 7 7 0 3 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)f 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 I am no longer subject to backup withholding;and 3. I am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. 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 report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and divi ids,you are not required-to sign the certification,but you must provide your correct TIN.See the instructions on page 3. Sign Signature W f - ` r e Here u_s.person■ ,_ ,.-r Date• �r , General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T (tuition) Section references are to the Internal Revenue Cade unless otherwise noted. •Form 1099-C(canceled debt) Future developments.information about developments affecting Form W g(such •Form 1099-A(acquisition or abandonment of secured property) as legislation enacted after we release it)is at www.irs.govlfw9. Use Form W-9 only if you are a U.S.person(including a resident alien),to Purpose of Form provide your correct TIN_ An individual or entity(Form W-9 requester)who is required to file an information ffyou dry not return Form W-9 to the requester with a T7N,you might be subject return with the iRS must obtain your correct taxpayer identification number(11N) to backup withholding.See What is backup withholding?on page 2. which may be your social security number(SSIV),individual taxpayer identification By signing the filled-out form,you: number(ITIN),adoption taxpayer identification number(AT1N),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number identification number(EIN),to report on an information return the amount paid tea you or other amount reportable on an information return.Examples of information to be issued], returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or •Form 1099-I NT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee-If •Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of any partnership income from a U.S.trade or business is not subject to the •Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and •Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on •Form 1099-S(proceeds from real estate transactions) page 2 for further information. •Form 1099-K(merchant card and third party network transactions) Cat_No_10231X Form W-9(Rev.12-2014) 1:05 AM Tyhee SeaEbar Inc. 03/19115 Profit & Loss Accrual Basis January through December 2014 Jan-Dec 14 Ordinary Income/Expense Income 157.288.40 Cost of Goods Sold 13-484.15 Gross Profit 143.804.25 Expense Administrative Cost 5,658.67 Advertising and Promotion 1771.75 Automobile Expense 400.00 Charitable Contributions 3,141.00 Childrens Activities 7,500-00 Entertainment 34,035.00 Event Cost 18,581.38 Insurance Expense 5.138.80 Miscellaneous Expense 438.78 Postaga and Delivery 85.59 Rent Expense 630.00 Site Prep 71,226.46 Total Expense 148,607.43 Net Ordinary income 4803.18 Net Income -4,803.18 Page 1 2016 MARDI GRAS BUDGET INCOME Sponsorships 5,000.00 Merchandise/T-Shirts 2,500.00 Beer/Food 3,000.00 Parade 750.00 TOTAL INCOME 11,250.00 COST OF GOODS SOLD T-Shirts/Hats/rnisc_ 1,000.00 Beer/Food 1,500.00 TOTAL OF COST OF GOODS SOLD 2,500.00 GROSS PROFIT 8,750.00 EXPENSES Entertainment and Stage Cost 6,500.00 TOTAL ADMINISTRATIVE 1,500.00 TOTAL MISC. EXP. 500.00 TOTAL EXPENSES 8,500.00 SURPLUS/DEFICIT 250.00