HomeMy Public PortalAbout020_026_Veteran's Monument Committee 1 13V 1 r`'` j$1_.
Jf ,V.
l,` -:-z..; _ :. ! City of Tybee Island Community Services Contract Award
,w „ '' ' Fiscal Year 2015-16
f1Y SiMSy‘.''-
APPLICATION FOR CASH AWARD
This form and all attachments are to be completed and submitted by March 20, 2015
Date: 3 1 i
Organization requesting City of Tybee Island Community Services Contract Award:
Name of Organization: e( X /itct, \J f e tares LLnraeny Cyr m t e
Contact Person: NN in al d o LI e--
Addressr Q$ a_ 7e::,-,-. 1f E.-_-7L 44 `7 -c . '�'_ ,1 tA t3 , s /6.-- ..- `L
( f '� — 37-
Contact Email: ID d Cho if e frA: r. C Contact Phone #: ` (. Y & -�
Is this organization an IRS approved 501(C) 3 Non-Profit? Yes No
If"yes", please attach your most recent audited financial statement, and a copy of your IRS
determination letter. 1
Amount of funds requested: y5`ee �r-c.Ae c 6'1 7. )
Describe how these funds will be used and how the City and citizens of Tybee Island will benefit:
Sec a+1--- J -
What percentage of these funds will be matched by your organization? ° C cc4-r, ---int el _
Will this event or program bring visitors to Tybee Island in off-peak season or months? _
>>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.rityoftybee.org
Tybee Island Veteran's Monument Committee
Fiscal Year 2015-2016
Through fundraisers, brick sales, and donations, the Tybee Island Veteran's
Monument Committee has raised and spent approximately $60,000 on the
Monument since 2007. The following is an estimated budget that is needed
to complete this monument. Also, included: the cot of electricity that has
to be paid monthly and the cost of flags and hardware that have to be
replaced quarterly because of wind and salt air.
Expenses:
Materials (c.,-,ranite) and installation for the centerpiece: 29,226.00
Installation of the third sidewalk: 5,000.00
Electric bill ($100 per month): 1,200.00
Flags and hardware: 1,500.00
Expense Total: $36,926.26
We lost a member of our committee to cancer and another one is the
hospital and may not make it to see the completion of the monument. As a
result, brick sales, donations, and fundraisers for the past year total
approximately $5000.00. We will be working on numerous fundraisers in
2015-2016. Your support would be greatly appreciated in our effort to
complete this monument for all the veterans.
Describe how these funds will be used and how the City and citizens of
Tybee Island will benefit.
Funds will be used to:
l . Complete the center piece of the monument
2. Installation of the third sidewalk
3. Pay the electric bill
4. Replacement of all flags and hardware every three months
The Veteran's Monument brings visitors to the island which means more tax
revenues for the City which in turn benefits all citizen city services. There
are a lot of veterans on our island who take pride in the monument that is
being built. The completion of this monument will be a memorial to all
veterans that everyone on Tybee can be very proud of for generations to
come.
What percentage of these funds will be matched by your organi7.ation?
It is hard to say what percentage of these funds will be matched by the
organization. It is difficult to measure because the committee depends on
fundraisers, brick sales, and donations. There has been a lot of support from
the Tybee community with monetary donations, some very large and some
small. A lot of general contractors from Tyhee have also donated time,
equipment, and materials that were needed to g<<t it to the point it is today.
Whatever the donation, our community has pulled together to show their
support for this monument.
• '' Affidavit Verifying Status
for City Public Benefit Application
..,_j ',
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:
a Business License or Occupational Tax Certificate,
▪ Alcohol License,
(circle all that apply)
■ Taxi Permit,
▪ Contract
▪ Community Services Contract Award
for .. ,e 'ii 41 1)41-71 e (printed name of natural person applying on behalf of individual,
business, corporation,partnersh or other private entity),
1) v lam 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 violatio Code Section 16-10-21 ,f the Official Code of Georgia.
`
t.-.-1)--'4„9c.....,7 w it
Signature of Applicant
3 Jo //
Daat1e
Li 41 i'` L'i /Cl/ ear"y te----
Printed Name
* Alien Registration Number for Non-citizens
SUBSCRIBED AND SAO'N BEFORE ME ON THIS
THE T:IDAY F i_,'ru a _ R ,20 I, .
- / / SHARON S. SHAVER
Notary Put+lid �t(' v Notary Public,Chatham County, GA
My Commission xpu-es; My Commission Expires Dec, 5, 2015
Note: O.C.G.A. , 50-36-1(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
identring number below:
Form W-9 Request for Taxpayer Give form to the
Tiny October 2004) requester. Do Il o f
Ddpartmant of the TreaMIr'y identification Number and Certification send to the iRS_
II rt. ■e1 Revenue Sxrfce _
oi Name( a reported on your Income+ ro r ) i )
e E c nc k.4er-115 Moil Lt khe6� 'nm [`7'
�e e- et r pe rC ` , �
0- Bu eINC name,if different from above
0
0
o p individual/ Exempt from bocl up
-7.v Check appropriate box: II Sole proprietor i` Corporation ❑ Partnership ❑ Other ■ ❑ Withholding
a` ?
.,Tn dress(n er, street,and apt.or sul no.) Requester's name and address&(optional)
a Mate,and ZIP coda r 3
t
0 i ocount number(s)he-re{optional)
re
r
Part 1 Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on Line 1 to avoid Social security number
backup withholding. For individuals this is your social security number(SSN). However, for a resident I I + 1 + 1 I l
alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is '
your employer identification number (FIN). 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 chart on page 4 for guidelines on whose number Employer identification number
to enter. I , -i 1-5i IaI&1:-1g
Part 11 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 I am no longer subject to backup withholding, and
3. i 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 report all interest and dividends on your tax return. For real estate transactions, items 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 ,rid dividends,you are not required to sign the Certification,but you must
provide your correct TIN. (See . instructions an -ge •.)
Sign Signature of / AI /J
Here u.s.person b.4.11,. ��I��._ _ '��j L Date B. 3 r,
„
t ' IRS,DEPARTMENT OF THE TREASURY
INTERNAL REVENUE SERVICE
CINCINNATI OH 45999-0023
Date of this notice: ¢I2-2¢9-no7
Employer Identification Member:
61-1520628
Era: SS-4
Mumber of this notice: CP 575 0
TYBEE ISLAND V'9 ERANS MONUMENT
JAMES NOTTIPti5HAM CARTTR For assistance you may ca.il.l us at;
PO BOX 2714 1-800-829-4933
TYBEE ISLAND -1■8 3 328
871 IF VDU WRITE, A- AC11 THE
11i; OF THIS NOTICE.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER
Thank you for applying for an Employer Identification Number (EIN) . We assigned
you EIN 61-1520628. This EIN will identify your business account, tax returns, and
documents, even if you have no employees. Please keep this notice in your permanent
records.
When filing tax documents, please use the label we provided. If this isn't
possible, it is very important that you use your_EIN and complete name and address
exactly as shown above on all federal tax forms, payments and related correspondence.
Any variation may cause a delay in processing, result in incorrect information in your
account or even cause you to be assigned more than one EIN. If the information
isn't correct as shown above. please correct it using tear off stub from this notice
and return it to us so we can correct your account.
Based on the information from you or your representative, you must file the
following form(s) by the date(s) shown.
Form 1120 03/15/2008
If you have questions about the form(s) or the due dates(s) shown, you can call
or write to us at the phone number or address at the to of the first page of this
letter. If you need help in determining what your tax year is, see Publication 536,
Accounting Periods and Methods, available at your local. IRS office or you can download
this Publication from our Web site at www.irs.gov.
We assigned you a tax classification based on information obained from you or
your representative. It is not a legal determination of your tax classification,
and is not binding on the IRS. If you want a legal determination on your tax
classification, you may request a private letter ruling from the IRS under the
guidelines in Revenue Prccedeee 2004-1,2004-1 I.R.B. 1 (or superseding Revenue
Procedure for the year at issue.)
s
R a + � *�'��- _a�� -k��_� - =sue.�_�'--�:� �,'��._ -��«� " [ i1
Control No. 070 97 ,j I
. ,
, .,. , STATE OF GEORGIA . ,
,,
. ,
, ,, . Secretary f State
)1
Corporations Division
- 315 Vlist Tower I
#2 Martin Luther King, Jr_ Dr. I
=fi Atlanta, Georgia 30334-1530 3
CERTIFICATE
z R f
11 O
1 F ,$l
i 41 EXISTENCE F I
L Karen C Handel, Secretary of State and the Corporations Commissioner of the state of Georgia, 1
hereby certify under the seal of my office that
1 i
TYBEE ISLAND VETERANS MONUMENT COMMITTEE CORPORATION 4
Domestic Non-Profit Corporation
4. was formed or was authorized to transact business on 04/0312007 in Georgia. Said entity is in
compliance with the applicable filing and annual registration provisions of Title 14 of the Official E ra
Code of Georgia Annotated and has not filed articles of dissolution,certificate of cancellation or .)
any other similar document with the office of the Secretary of State.
This certificate relates only to the legal existence of the above-named entity as of the date issued. It
F does not certify whether or not a notice of intent to dissolve,an application for withdrawal,a )j
' . ' statement of commencement of winding up or any other similar document has been filed or is k
3 pending with the Secretary of State. 1
I
A This certificate is issued pursuant to Title 14 of 41 a Official Code of Georgia Annotated and is t
prima-facie evidence that said entity is in existence or is authorized to transact business in this a
state.
.T, WITNESS my hand and official seal of the City of Atlanta and
. la {�.� ' i° ,
4,_, _ .,*�,��} r� the State of Georgia on 12th day of April,2007 . �
il.:_. , 1 -# 1.
s
lib_ 74 '4-1.(14,,e-e. )
Iaren C Handel
F Secretary of State
Certification Number:12658624 Reference:
if Verify this certificate online at 1Ctpar/caag sa _ga.xsfcaapJscskbAri fy.as E p
ro,-,„.„.......4.„..„,,,,,..„,__„._.,,____...„-,,,.......,,,-,..-.,. .,„„_,...,,...2.„,,u ,
__ ____ _____ ___ . _ _
ire SS-4 Application ,,,r Employer ldentificati¢on Number
OMB Na.7545-0003
(Rev.February 2Qt16) (For use by employers,corporations,partnerships,trusts,estates,churches,
government agencies, Indian tribal entities,certain individuals,and others.)
�lN
Department of rye 2006)
Interrei Revenue$e vrce le See separate instructions for each line. i Keep a copy for your records.
1 Legal name of entity(or individual)for whom the ON rs being requested
a TYBEE ISLAND,VETERANS MONUMENT COMMITTEE
t Trade name of business(if different from name on line 1) 3 Executor,administrator, trustee,"care of"name
4)
JAMES NOTTINGHAM CARTER
O 4a Mailing address(room, apt..suite no.and street,or P.O.box) 5e Street address(if different)(Do not enter a P.O. box.)
PO BOX 2714 2 HODGES ST(PO BOX 2714)
Q 4b City,state,and ZIP code
5b City,state, and ZIP code
o TYBEE ISLAND, GA.31328 TYBEE ISLAND, GA.31328
to C County and state where principal business is located
C.
CHATHAM,GEORGIA 31328
78 Name of principal officer, general partner,grantor,owner,or tnrstor 7b SSN,MN,or ON
JAMES NOTTINGHAM CARTER
APPLIED FOR
tla 'Type of entity(check only one box
❑ Estate(SSN of decedent)
❑Sole proprietor(SSN) ❑ Plan administrator(SSN)
❑Partnership ❑ Trust(SSN of grantor)
m Corporation(enter form number to be filed) it. 1023 ❑ Nat)onai Guard
❑ State/local government
❑Personal service co
rporation ❑ Farrmers'cooperative 0 Federal govemmenf/military
❑Church or church-controlled organization ❑ REMiC
s ec' ■ Indian tribal governments/enterprises
❑Other nonprofit organization CI ( p '} Group Exemption tvumber(GEN) ■
Other•(Specify} ■
8b If a corporation, name the state or foreign country State
(if applicable)where incorporated Foreign country
i
9 Reason fora
applying(check only one box) 23 Banking purpose(specify purpose) ■ DEPOSIT&Wl T HDRAWLS
❑Started new business(specify type) i ❑ Changed g type of organization(specify new type) ■
❑ Purchased going business
Hired employees(Check the box and see line 12.) ❑ Created a trust(specify type) i
❑Compliance with IRS withholding regulations - ❑ Created a pension plan(specify type) le
_ ❑Other(specify) 0 _
10 Date business started or acquired(month,day,year). See instructions. 11 Closing month of accounting year
'12 First date wages or annuities were paid 1 .
p (month,day,year).Note,If applicant is a withholding agent, enter date income will first be paid to
nonresident alien. (month,day, year)
ta. Hest number of employees expected in the next T2 months(enter-0-if none). Agricultural ' Household Other
Do you expect to have $1,000 or less in employment tax liability for the calendar
year? 0 Yes ❑ No.(if you expect to pay$4,000 or less in wages,you can mark yes.)
14 Check one box that best describes the principal activity of your business. 0 Health care&social assistance ❑ Wholessilr-3gent/broker
Li Construction ❑ Rental&leasing 0 Transportation&wareho
❑ Real estate warehousing 0 Accommodation&food service ❑ Wholesale-other 0 Retail
❑ Manufacturing ❑ Finance&insurance ❑ Other(specify)
15 Indicate principal line of merchandise sold,specific construction work done,products produced, or services provided.
16a Has the applicant ever applied for an employer identification number for this or any other business? . ❑ Yea 71 No
Note.if"Yes,"please complete lines 16b and 16c.
16b If you checked"Yes"on tine 16a, give applicant's legal name and trade name shown on prior application If different from line 1 or 2 above.
Legal name i Trade name i
Vic Ap'prexiirsate date when,and city and state where, the application was filed. Enter previous employer identification number if known.
Approximate date when filed(mo., day,year) City and state where tied I Previous EN
Compete this section only it you want to authorial the named individual to receive the entity's EIN and answer Questions shout the completion of this forth,
Third Designee's name -
Party ALFRED D.
Designee's area cods)
Designee Address and ZIP code 972 7$6-0$78
PD BOX 1925 TYKE 15LANlo,GA.31328 Designee's fa).number{include area code)
Untie'penalties of �- ��' 7864828
penury,I a=; :that i have exarrelr s .' .y,+ and to the best of my knowledge and bailee,it is true,carract,and complete. i
tespi-crierts-rter B141(+rrhdearm
Name and tine •= pant clean .JAMES N.CARTEfZ; O— _ j ( 912 ) 786-8141
Si r nature f / Applicant's fax number!include area code)
.c ./ `ate r Date Is.
( )
For ., - Act and Pepei'work Reduction Act Notice,see separate instructions.
Cat. No_ 16055rf Form SS— (Rev.2-2006)