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HomeMy Public PortalAboutTybee DAC O 7 a4(4 ') Cflty n rI'yhee 1slEnd Co munarrgity Se vfces CContrEic AwEnl 'ussc El {czu 2© t2 1$ APPLICATION FOR CASH AWARD This form is to be completed and submitted to Finance with your budget request. Date: 41301 a°1 Organization rr_Alluesting City of Tybee Island Community Services Contract Award: Name of Organization: l "Di\c '(Id S l vAL, Contact Person: 00 nc0 rc�,e Address: v Bo L a f 4 ,`i Li ln oo L 5 I er D G 1 313 al Contact Email: kki b ee cki..0 Co Clod Contact Phone #: q t —1 CQ (( ( SCE1C cc Is this organization an IRS approved 501(C) 3 Non-Profit? des )( No '-" -- If eyes", please attach your most recent audited f nEndal statemer tt, a copy of your IRS (2a termination letter and a caps' of your current Fzu sell detaiiing the piannrcl use for the awarded funds. Amount of funds requested: $ Aim Describe how these funds will be used and how the City and citizens of Tybee Island will benefit: F L-v-)iJ • tic)l o_,In o cam` "Pt S,, l i,c. 6Ccrn e n p ar-Vc.c<< Od:G_. n ®(1�'c 2 -4- o (.31. khn e) r/0-4q-(S b ca c C'—Lc t ei1�-fr1 A COO J h e€ cc, )S •ar t e� What percentage of these funds will be matched by your organization? t O Wiii this event or program bring visitors to Tybee Island in off-peak season or months? ✓1 O >a?0e :is- EMEch da alied t u get this request outiininci [how the money All used. e - P.O. Box 2749–403 Butler Avenue, Tybee Island, Georgia 31328-2749 (912) 786-4573–FAX (912)786-9465 www.cityoftybee.org E it f ALEdfavL VerfiTy'mg Stztans for City IFublic Bcuncf Applinc alt i_ .4gorr� By executing this affidavit under oath,as an applicant for a City of Tybee Island,Georgia, gusiness 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 (printed name of natural person applying on behalf of individual, business, corporation,partnership, or other private entity). 1) { 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 Fede 1 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 fraud lent statement or representation in an affidavit shall be guilty of a violation of Code Section 16-10-20 of the Official Code of Georgia. c� rucc, Signature of Applicant 3oaok3 Date refe A2 L Printed Name * Alien Registration Number for Non-citizens SUBSCRIB D AND SWO BEFORE ME ON THIS THE,3amDAY OF A,/ ,20 /3 / /J Notary Public � a JERRIS A. 3RYANT e Notary Public,Chatham County GA My Commissis: My Commission Expires May 22,2016 Note: O.C GA. §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 identifying number below: 041/20/2007 11:a Fa. 215 5ia 1043 --13nN 1001 a - ■ - Identification� Enukr 4/20/07 i No.of Fagg: 'internal ?�.�.-, lob u . r (EIN) Cover a I 1 of 1 Sent= Philadelphia A 4t'O Managene t Cs T O: FRO yda:1s ia$r3 Tame; ;,Ohil ,O7 iziont 1 A.IISLENE NICHOLS IFhl 4 Ac.o' ..?5 M"a fi . PHONE: 9'12-726-a752 1-800- 29)-4-933 At Yi.,+ NT Nr-a DC—ae t y T3 DACEu S WC EN Nu 1 m 33-a 2er c) . Name OfEntaly :' ',whir: Nama Of Entity EIN Number: This caversheet is used so verification of the (riquesied ED:.For any question regarding the application for Employer Identification Nun aer(SS-4) use the c o 7 toll-fr a number, all other non-related question, please con!act 8 i. ►a '3294040 This o mmunicetion is intended for the sole use of the individual to whom it is ad *ad and rnly=lain ivrar=tion that is privileges, confidential,and exempt from disclosure under applicable law. r t e reader of this commun,cation is not the intended recipient or the employee or agent responsible for delivering the coax titivation to the inter recipient, dis © of this comma-ication may be strictly prohibited. you are hereby�Ailed that any.di.ya..:.s:•w»on, � copying tely telephone, and return the f you have --lived this communication in err n please notify the sender ' ' y ommunication. &fax at the number given above.Thoth you n•;s://cgov.sos.state.ga.us/Accou iaspx/MiewEi thyDaiia?entntyi[d=2249318 Georgi . ._ _ 1,1 At, jh _1• -;� Secretary of Stat- t' i' M Corporations thruon - Home TYBEE "DAC" KIDS, INC Control Number: 07034614 Main Reports Officers Filing History Entity Info Entity lid 2249318 Key Ind oators Model Type Corporation Locale Domestic • alifier Non-Profit Business Name TYBEE°DAC"KIDS,INC Registration Data 3/26/2007 Entity Status Active/Noncompliance Entity Status Date 3/21/2011 Foreiem Mame Date or Ca-esnbzat6on State Georgia Coamtry PPri nxiipa9 Citoce Addax PRINCIPAL Lime. P 0 Box 1214 Li e2 172 Lewis Ave City Tybee Island State Georgia Zip 31328 Agent Is non-comov osial Registered Agent? Yes Mame Nichols,CP,Arelene L Address Lime/. 172 Lewis Ave P 0 Box 1214 Line2 City Tybee Island State Georgia Zip 31328 Ent ii ll of 2 4/30/2013 9:49 AM