HomeMy Public PortalAboutAmerican Legion (2) City of Tybee Island Communky Servfces Contmct Awnrd
Fiscal Ye2fr 2012-ll3
APPLICATION FOR CASH AWARD
This form is to be completed and submitted to Finance with your budget request.
Date: if 30 l
3
Organization requesting City of Tybee Island Community t Services Contract Award:
Cin4v2
Name of Organization: 1 frc t Pte— tS{
Contact Person: Dcon Cr e4--
Address: U Cb t-2 2-- fit - tS 61..vj 6et- 'i 3 2.,‘''v
Contact Email: P -1 s'f e Contact Phone #: 611'7, -LC?-B 9° Z-
Is this organization an IRS approved 501(C) 3 Non-Profit? °° Yes No
If"yes", please attach your most recent audited financial statement, a copy of your IRS
determination letter and a copy of If= current budget detailing the planned use for the
awarded funds.
Amount of funds requested: $ i -_—
Describe how these funds will be used and how the City and citizens of Tybee Island will benefit:
V V
n /i /l
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What percentage of these funds will be matched by your organization? /L e
Will this event or program bring visitors to Tybee Island in off-peak season or months? 10/9-a a 9-a
>>Please attach a detailed budget to this request outlining how the money will be used.
P.O. Box 2749—403 But➢er Avenue, Tybee Island, Georgia 31328-2749
(912) 786-4573—FAX(912) 786-9465
www.eityoffybee.org
c.4 City of Tybee Island Community Servces ces ®n r ac AwErd
\\..11\ )2/41
Fiscal Year 2012-13
APPLICATIOIN FOR WAIVERS
Date: q 5o - ( 3
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):
a '- q (3 -(,c� C L tis L am, ce - -- CL. ,
U
(,1. tc J) ,140
Value of tie waivers requested: $ (cn , ')3
P.Q . Box 2749—433 Butler Avenue,Tybee Island,Georgia 31328-2749
(9E2) 786-4573—FAX(912) 786-9465
www.cityoftybee.org
City of Tybee Island Community Services Contract Award
Y.
l. . ' Fiscal Year 2012-13
4
Community Services Contract
PROJECT EVALUATION f�
Organization Name: _ t€cca _ S'( ii: T
Individual Completing Evaluation: �Orw ! Eiv(
Name of Event / Project: LI o.► -c LA c -(7
Date(s) of Event I Project: v
Date of Evaluation Submission:
Within thirty (30) days of the completion of your project/ event, please complete the following and return
as indicated. The completed project evaluation is required for compensation / verification of services
provided, as well as, for consideration of future funding/service request(s).
*Attach additional pages as necessary, *
1) Describe each goal of the event / project`and how each oat was achieved:
L- i cit ery cc-44A G h I t r v6 k i F' U C. ` $ itto-o,
I %,
2) Indicate the percentage of attendees/ participants that...
Reside on Tybee Island 7 e
Reside within Chatham County '8' ,,,,
Are considered visitors* .,`?,,
*i.e. persons residing outside of Chatham County's corporate limits
3) What was the average age of attendees/ participants? '' )
4) Number of volunteer hours spent for the event/ project: v 5 nn , n ,
5) Who benefited from this event/ project? Please describe the benefit. tiJ � el i1� _�j
,
6) How did the City of Tybee/Tybee Residents benefit? AA call) t � L.co /20
s
(z`e°3— (a4-` c 91(1) 0 cal-- i : '(..__'?C2 4
I / r
7) Additional Comments:
*Upon completion, return two(2)copies of the evaluation to Tybee Finance Department, PO Box 2749, Tybee Island,
GA 31328;ATTN: FUNDING EVALUATION.
P.O. Box 2749-403 Butler Avenue, Tybee Island, Georgia 31328-2749
(912) 786-4573-FAX(912) 786-9465
www.cilyoftybee.org
is *;.
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 Aw rd
for 70,1a c(
�,,r✓l (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 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 16-1 oft - i cial : •
Georgia.
Signature of ApplicafrF°—
-6o - 13 —
Date
Printed Name
* Alien Registration Number for Non-citizens
SUBS : 9P AND SWO BEFORIi ON THI
THE :. OF I i 7 ,20
Notary Public Nola rq PusCHC �t hTSI ®��lyy, ��
Nly COIT1U 90S On P Taa Dec. � 2015
My Commission Expires:
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 identing number below: