HomeMy WebLinkAboutFY 1617 application for PTO and school organizations
OUTSIDE AGENCY FUNDING REQUEST
FOR CHARITABLE CONTRIBUTION
Application
(Exhibit A)
Fiscal Year 2016/2017
City of Palm Desert
FINANCE DEPARTMENT
73-510 Fred Waring Drive
Palm Desert, CA 92260
760-346-0611, Ext. 382
Fax: 760-341-4564
2016/2017 Outside Agency Funding Application
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INTRODUCTION
Thank you for your interest in the Outside Agency Funding Committee’s funding process for
nonprofit, school and community-based organizations. The Committee’s goal is to provide for
unmet needs and improved services that serve the City of Palm Desert. The Outside Agency
Funding Committee is comprised of a five-member Board: two City Council Members, City
Manager, City Treasurer and City Attorney.
CRITERIA
1. The agency or group (“Applicant”) requesting funds must be in existence for a minimum of five
(5) years in order to be considered for funding by the Outside Agency Funding Committee. The
Agency must also be of verifiable non-profit status and presently providing charitable, public
benefit, public welfare or educational services to persons residing in the City of Palm Desert or its
sphere of influence (the “City”); and
2. The applicant has an existing program in place and a staff that is ready and willing to provide
services to the City for the benefit of its residents. Funds will not be contributed to any agency or
group for “startup” costs; and
3. The applicant has submitted to the City an application setting forth in detail its request for
funding, including a statement of purpose detailing specifically the services it intends to provide
for the City, how and where the contribution from the City will be allocated, and the quantity and
quality of such proposed service; and
4. The funds contributed to the applicant will be donated for the purposes of providing services
to the City of Palm Desert, or its sphere of influence, to the extent possible. Said funds are not
designated for salaries, dinner/golf events or capital improvement projects; and
5. The applicant agrees to use the funds granted by the City to provide only the services
represented in its application for funding. Additionally, the applicant will explain how the services
will benefit the City’s residents; and
6. The City desires to have the services as detailed in the applicant’s application performed for
the City and its residents by the agency or group; and
7. The City has reviewed the applicant’s application and tax exemption certification and, upon
review and discussion, has determined that the expenditure of funds for these services is in the
public’s interest; and
8. The City will not provide public funds to private individuals or corporations unless there is
either: a) full consideration; or b) an overriding public need; and
9. Where the applicant is an audited entity, the applicant’s independent auditor will need to make
a footnote in the financial statements confirming the use of the City’s contribution in the manner
set forth above, as well as the executed agreement; and
10. Where the applicant received funding for Fiscal Year 2015/2016, all documents must be
submitted and agreement terms complete prior to funding disbursement for FY 2016/2017; and
11. Application and all supporting documents are to be submitted to Niamh Ortega, Finance
Department, City of Palm Desert, 73-510 Fred Waring Drive, Palm Desert, California 92260, NO
LATER THAN 5:00 P.M. ON FRIDAY, APRIL 29, 2016 to be considered for funding for FY
2016/2017.
2016/2017 Outside Agency Funding Application
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12. FILING INSTRUCTIONS
1. PREPARE YOUR APPLICATION PACKET containing the following:
One (1) application with original signature, single sided, 8 ½ x 11, white paper,
unbound, unstapled, 3-hole punched. Color copies may be included if desired for
clarity.
Six (6) black & white copies, double-sided, 8 ½ x 11, white paper, unbound, unstapled,
3-hole punched
Tax Status Verification letter from IRS
Current Roster of Board of Directors, Executives, Trustees or Committee Members
Attachments as necessary for further explanation of application content
2. RETURN COMPLETE APPLICATION PACKET in a sealed envelope via mail or hand
delivery to:
City of Palm Desert
Finance Department
73510 Fred Waring Drive
Palm Desert, CA 92260
CONTENTS: OUTSIDE AGENCY FUNDING APPLICATION – Attn: Niamh
Ortega
3. SUBMIT ON OR BEFORE DEADLINE. Application packet must be received in the
Finance Department no later than 5:00 p.m. on Friday, April 29, 2016. Packets which
do not include all required information and/or are not completed in their entirety will be
considered unresponsive and will not be reviewed further.
2016/2017 Outside Agency Funding Application
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Application
(Exhibit A)
I. GENERAL INFORMATION
Date of Request:
Amount Requested: $
Name of Agency:
Agency President or
equivalent:
Agency Secretary (or primary
contact if other than President):
Mailing Address:
Physical Address:
Contact Phone Number:
Date Established:
E-mail address:
No. of Years in Community
(minimum 5 years required)
Federal Taxpayer I.D. No:
Type of Agency:
Public ̀ Private Non-Profit
Other (specify): ________________
Tax Status (verification must
be attached):
501(c)3: ̀ Yes ̀ No
Other class (specify): ___________
Most Recent Year Taxes were
Filed:
If not filed, please explain:
_____________________________
______________________________________
______________________________________
______________________________________
______________________________________
FOR CITY USE ONLY
Date Received: _______________ (due 4/29/16)
Original Application
Six Copies B&W
IRS Tax Status letter
Board of Directors or Committee roster
Complete – forward to Committee
- OR -
Incomplete – return to Applicant
2016/2017 Outside Agency Funding Application
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II. STATEMENT OF PURPOSE
1. DESCRIPTION OF AGENCY AND ITS SERVICES (Background and general
description of organization):
2. 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. Attach additional sheets if necessary):
Item Description Amt requested
Example:
Field Trip
Bus transportation for 30 children to Living Desert (Life Science
study section)
1,000
3. Confirm that these programs are available to all eligible participants, without regard
to race, sex, political persuasion, religion, national origin, or age:
4. Total number of persons that benefit from this program: ______
5. Of the total number benefitting, give an estimate of the percentage (%) of Palm
Desert citizens that participate in said benefit:
____ Resident ____ Non-Resident
6. Explain the benefit to the Palm Desert community as a whole:
III. AGENCY INFORMATION
1. How long has this program been in existence? ____/____ Year(s)/Month(s)
2. Are volunteers used by this Agency? ̀ Yes ̀ No
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3. If volunteers are used, please indicate the number of annual hours and activities
and/or duties performed.
4. Describe the alternative funding sources (dinners, golf events, fashion shows, etc.)
that have been approached during the last year.
5. What type of alternative funding or fundraising activities do you intend to pursue in the
upcoming fiscal year?
IV. AGENCY BUDGET
1. Source of Funding:
A. Community Support List all sources of funding excluding anticipated
contributions from the City of Palm Desert and other valley city governments for
NEXT (2016/2017) fiscal year. (If necessary, attach a separate sheet):
Agency providing funds Reason for contribution Amount (A)
Total Funding Sources excluding City Governments - FY 2016/2017: (A)
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B. Government Support List any local government funding that will be requested in
the NEXT (2016/2017) fiscal year from each of the following city government
agencies:
City
Projected
Request
Amount (B)
Additional Funds Anticipated From
Other Fundraising (dinner/golf
sponsorships [specify type of
fundraising activity]) (C)
Cathedral City
Desert Hot Springs
Indian Wells
Indio
La Quinta
Palm Springs
Palm Desert
Rancho Mirage
Other city:
Total Government Funding
requested – FY 2016/2017: (B) (C)
Total of ALL funding sources anticipated for FY 2016/2017 (A+B+C): $
C. List any local government funding received for the CURRENT (2015/2016) fiscal
year, including the amount your agency requested and the actual amount received,
from each of the following city government agencies:
City
Requested
Amount
Approved Amount
(funds received)
Received from Other Fund-raising
(dinner/concert/golf sponsorships)
Cathedral City
Desert Hot Springs
Indian Wells
Indio
La Quinta
Palm Springs
Palm Desert
Rancho Mirage
Other city:
Total Government Funding
received – FY 2015/2016:
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2. List amounts requested or received from Community Development Block Grant
(CDBG) funds through the City of Palm Desert. (The City will usually not provide an
additional contribution to those agencies already receiving CDBG funds.):
FY 2015/2016: Amount requested: $______________ Received: $______________
FY 2016/2017: Amount requested: $______________ Received: $______________
3. EXPENDITURES: (Be as detailed as possible. If necessary, attach a separate sheet.)
GRAND TOTAL OF EXPENDITURES: $ _________________
V. SIGNATURE AUTHORIZATION
1. Identify the principal (President or equivalent) of the parent-teacher group
responsible for the group’s activity:
NAME:
TITLE:
ADDRESS:
PHONE:
E-MAIL:
2. A. Signature of authorized official, as identified in Item V, 1:
The undersigned does hereby confirm that the information herein is true and correct
and is submitted in support of and as part of the application for funding. The
undersigned hereby confirms that the applicant agency meets the criteria set forth
herein and agrees to comply with all requirements.
Signature: Date:
B. Signature of School Principal, indicating review and concurrence with proposed
expenditures, and confirming that these expenses are not covered by school or district:
Signature: Date:
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