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City of Tybee Island Community Services Contract Award
Fiscal Year 2013 -14
APPLICATION FOR CASH AWARD
This form is to be completed and submitted to Finance with your budget request.
Date: March 6, 2013
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, a copy of your IRS
determination letter and a copy of your current budget detailing the planned use for the
awarded funds.
Amount of funds requested: $
Describe how these funds will be used and how the City and citizens of Tybee Island will benefit:
$1,000 for Supplies, field trips, admission fees, etc. for senior group, packages to soldiers
$1,500 for Tybee Island Mailing Directory
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.
Yeepies Estimated Budget for Fiscal Year 2013 -2014
Supplies $ 250
Field trips 150
Admission Fees 300
Packages to soldiers 300
Tybee Island Mailing Directory 1,500.00
Total Requested $ 2,500.00
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City of Tybee Island Community Services Contract Award
Fiscal Year 2013 -14
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APPLICATION FOR WAIVERS
Date:
Provide detail on any waivers (Le. 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):
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Value of the waivers requested: $
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
• Community Services Contract Award
for Bobbie Orr (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 Code Section 16 -10 -20 of the Official Code of
Georgia.
/72/
Signature of P.phcant — Bobbie Orr
March 6, 2013
Date
_Bobbie Orr
Printed Name
* Alien Registration Number for Non - citizens
SUBSCRIBED AND SWORN BEFORE ME ON THIS
THE 7 DAY OF March , 2013
Notary Public \
My Commission L xpires: /0/ /6 / (,.„
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 identifidng number below: