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t'", r City of Tybee Island Community Services Contract Award
(",,' Fiscal Year 201546
APPLICATION FOR CASH AWARD
This form and all attachments are to be completed and submitted by March 20, 2015
Date: _March 3, 2015,
Organization requesting City of Tybee Island Community Services Contract Award:
Name of Organization: YEEPIES
Contact Person: Bobbie Orr
Address: P. O. Box 2843, Tybee Island, GA 31328
Contact Email: _cborr@bellsouth.net Contact Phone #: 786-7486
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: $_575.00
Describe how these funds will be used and how the City and citizens of Tybee Island will benefit:
$750.00 for supplies, field trips, admission fees, etc., for senior group, packages to soldiers
What percentage of these funds will be matched by your organization? None
Will this event or program bring visitors to Tybee Island in off-peak season or months?_N/A
>>Please attach a detailed budget to this request outlining how the money will be used.
P.O. Box 2749— 103 Butler Avenue,Tybee Island,Georgia 31328-2749
(912) 786-4573—FAX(912) 786-9465
www.cityoftybee.org
YEEPIES Estimated Budget for Fiscal Year 2015-2016
Supplies $ 175.00
Field trips 150.00
Admission Fees 150.00
Packages to Soldiers 100.00
Total Requested $ 575.00
Affidavit Verifying Status
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
• COmTial Ilnily Services Contract Award
for Bobbie Orr (printed name of person applying on behalf of
individual, business, corporation,partnership, or other private entity).
I) 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 Code Section 16-10-20 of the Official Code of Georgia.
Signature of Applicant Bobbie On
2123115_
Date
Bobbie Orr
Printed Name
*Alien Registration Number for Non-citizens
SUBSCRIBED AND SWORN BEFORE ME ON THIS
THE 2 s3 DAY OF ,,-! 2015 ___-
Notary Public (---
My Commission Ex ' s: /0 / & ~/4
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. Quaked aliens that do not have an alien registration number may supply another
identifying number below: