HomeMy WebLinkAboutOA Application FY 202220231
OUTSIDE AGENCY FUNDING REQUEST
FOR CHARITABLE CONTRIBUTION Application
(Exhibit A)
Fiscal Year 2022/2023
Return complete Application packet to the City of Palm Desert by Mail, Hand Delivered or Email.
(Reference Section V. FILING INSTRUCTIONS for a complete list of required information)
Mail/Hand Delivered: Email:
City of Palm Desert pleon@cityofpalmdesert.org
73-510 Fred Waring Drive
Palm Desert, CA 92260 Questions:
Contents: Outside Agency Funding Application Call Patty Leon or the Finance Department
Attention: Patty Leon 760-346-0611, EXT 349
I.GENERAL INFORMATION
Date: Amount of Funding Request: $
Organization Name:
Organization President
Or Equivalent:
Mailing Address:
Physical Address:
Organization Phone: Contact Phone:
Email: Website:
II.ORGANIZATION INFORMATION
1.DESCRIPTION OF ORGANIZATION AND ITS SERVICES:
2.Number of Years in Community: Date organization was established:
(Minimum 5 years required)
OUTSIDE AGENCY FUNDING REQUEST FOR CHARITABLE CONTRIBUTION
Application FY 2022-2023
Page 2 of 3
3. Are volunteers used by this organization? Yes No
If Yes, please indicate the number of annual hours and duties performed
III. STATEMENT OF PURPOSE
1. PROGRAM/SERVICE TO BE FUNDED BY THIS REQUEST (Specific line-item details
regarding your reason for request and how those funds will be spent. Funds are considered
per line item, and appropriate information should be provided to assist the Committee’s review
and decision. Add additional rows if necessary):
2. Explain the benefit to the Palm Desert community as a whole:
3. Total number of persons that benefit from this program:
4. Of the total number benefitting, give an estimate of the percentage (%) of Palm Desert citizens
that participate in said benefit:
Residents: Non-Residents:
Item Description Amt requested
Example:
Group support
Counseling for two low-income families for six months ($500 per
family per 6 month period)
1,000
OUTSIDE AGENCY FUNDING REQUEST FOR CHARITABLE CONTRIBUTION
Application FY 2022-2023
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IV. SOURCES OF FUNDING
1. Palm Desert, Local Government and Community Support : List any and all funding requested
from the City of Palm Desert, Local Government and Community Support (i.e. Berger Foundation,
RAP Foundation, Rotary Club, Agua Caliente Band of Mission Indians, etc.) for the CURRENT
(2021/2022) fiscal year and UPCOMING (2022/2023), including type of request (Community
Development Block Grant (CDBG), UNITE Palm Desert Local Economic Relief Program
(UPDLERP) funds, grant, sponsorship, donation, fundraiser, etc.), the actual amount received, and
a description of the funding request. (The City will usually not provide an additional contribution to
those organization already receiving CDBG and/or UPDLERP funds) (if necessary, attach a
separate sheet)
V. FILING INSTRUCTIONS DEADLINE: FRIDAY, MARCH 18, 2022
See Submission Instructions and Contact Information at the top of this form
Application packet must contain the following:
One (1) Application with original signature (electronic signatures are acceptable)
Tax Status Verification letter from IRS
Current Roster of Board of Directors, Executives, Trustees or Committee Members
Federal W-9 Form
Current IRS Form 990*
*If your organization is not required to file Form 990, please explain
Packets that do not include all required information and/or are incomplete will be considered unresponsive and will not
be reviewed further by the Committee.
VI. SIGNATURE AUTHORIZATION
Signature of authorized official, as identified in Section I, General Information, Organization
President or Equivalent:
The undersigned does hereby confirm that the information herein is true and correct; that the applicant
organization meets the guidelines set forth in the Funding Criteria for Non-profit Agencies and
PTO/School Organizations published on the City’s website; and that the applicant’s organization will
make these programs available to all eligible participants, without regard to race, sex, political
persuasion, religion, national origin, or age.
SIGNATURE: DATE:
Fiscal FROM/Entity
Type of
Request
Approved Funds
Received
Description of Funding Request
(dinner, sponsorship, contribution)
Example
2021/2022 City of Palm Desert Outside Agency $1,000 Counseling for two low-income families for six
months ($500 per family per 6-month period)
Total Palm Desert, Local Government &
Community Support received: $