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2016-06-08 Mizel Grant Applications
APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY { FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. Civic ❑Arts Grant Request Amount: $5,000 Free of Charge: ❑ Yes No (Not to exceed$5,000) Program Title: American Legion Post 416 Architectural Plans ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt orqanizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: American Legion Post 416 (Must match name filed under the Tax/Employer Identification Number) Street Address: 210 W F Street Encinitas, CA 92024 Mailing Address: 210 W F Street Encinitas, CA 92024 Doing Business as (dba)Name: American Legion Please list the names and titles of the organization's Board of Directors: Steve Lewandowski George Barlow Brian Hall Jay O'Keefe Bob Wilson Rolf Ohnstad 0 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): American Legion Post 416 requests the City of Encinitas and Mizel Family Foundation grant in the amount of$5,000 to pay for architectural plans for American Legion Post 416. Organizational History: American Legion Post 416 was founded in Encinitas, CA in 1930. The American Legion is a non-profit veterans organization. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: 210 W. F Street Encinitas, CA 92024 Total Est. Cost: $10,000 Time Frame: 6 months Number of Encinitas Residents Served: 2,500 Fundraising Activity: ❑ No 0 Yes If yes, please explain: Naming rights, fundraising events, grants, direct mail, & dedication plaques CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Steve Lewandowski, Commander Mailing Address: 210 W. F Street Encinitas, CA 92024 Telephone Number: (858) 699-5545 Email Address: seewandowski@hotmail.com ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Steve Lewandowski Title: Commander (Please print) Signature: Date: 13 April 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed & dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 _ ....�4" CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: American Legion Post 416 PROJECT TITLE: American Legion Post 416 Architectural Plans PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Secured Dane Chapin Matching Funds Secured $5,000 INCOME TOTAL*: 1$10,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Services DZN Partners Architectural Plans $ 10,000 EXPENSE TOTAL*: $10,000 Budget Form *Your Total Income and Total Expenses should be equal. THE AMERICAN LEGION NATIONAL HEADQUARTERS OFFICE OF THE NATIONAL JUDGE ADVOCATE P.O.BOX 1055 INDIANAPOLIS,IN 46206 September 15, 2015 Mike Lindsey, Finance Officer American Legion San Dieguito Post No. 416 210 West F Street Encinitas,California 92024-3525 Dear Finance Officer Lindsey: In reply to your recent request,The National Organization of The American Legion was granted its exempt status by the Internal Revenue Service in 1934. In February of 1946,we submitted to the central office of the Internal Revenue Service a complete listing of all Departments and Posts extant in the Legion up to and including December 31, 1945. With our submission we requested a group ruling which would extend exemption from the payment of federal income tax for those Departments and Posts designated in our listing. Each year since 1946 supplemental listings have been transmitted to the Internal Revenue Service for an over-all group ruling covering those Departments and Posts chartered during the previous year. Group rulings have been issued yearly by the Internal Revenue Service covering those Departments and Posts. Since San Dieguito Post No. 416 was chartered on June 22, 1931, it was included in our original listing. Post No. 416 does not appear on the IRS list of revoked organizations. Enclosed is a copy of the original ruling. Section 101(8) referred to in the exemption letter corresponds to Section 501 (c) (4) of the 1954 Code. The American Legion, its component Departments and Posts, were exempt from the payment of federal income tax under this Section up to and including the year 1972. By virtue of the passage of Public Law 92-418 on August 29, 1972, veterans' organizations were given a separate classification under the Code,Section 501(c)(19). A copy of that ruling is also enclosed. Also enclosed please find a copy of a letter we received from the Internal Revenue Service dated February 17, 1976, wherein the National Organization, Departments and Posts were instructed to use the number 0925 as their Group Exemption Number(GEN)when filing their Form 990. In addition, the status of The American Legion and its Departments and Posts may allow acceptance of charitable gifts and bequests. The following might be of assistance to you. Deductability of Contributions to The American Legion is governed by 26 U.S.C. 170 (c) (3) Internal Revenue Code of 1954,as amended. Deductibility for bequests is established by 26 U.S.C. Section 2055 (a) (4). September 15,2015 Page#2 Section 170(c)(3) reads as follows: "Section 170. Charitable,etc.,contributions and gifts (a) Allowance of deduction (1) General Rule.-There shall be allowed as a deduction any charitable contribution (as defined in sub-section (c) payment of which is made within the taxable year. A charitable contribution shall be allowable as a deduction only if verified under regulations prescribed by the Secretary or his delegate. (c) Charitable contribution defined. For purposes of this section the term 'charitable contribution' means a contribution or gift to or for the use of- (3) A post or organization of war veterans, or an auxiliary unit or society of, or trust or foundation for, any such post or organization- (A) organized in the United States or any of its possessions, and (B) no part of the net earnings of which inures to the benefit of any private shareholder or individual." According to the records at The American Legion National Headquarters,your Post EIN is 23-7169704. I trust the foregoing information is what you needed. If there are any questions, please do not hesitate to call me. Sincerely, 1'. B. Giw11]F.It DON K JR. National Judge Advocate cc: Dept. Commander-California Dept. Adjutant Dept.NECman Dept. Judge Advocate TREASURY DEPARTMENT I _r -- W14 WASHINGTON 25 OFFICE OF COMMISSIONER OF INI ER NAL 14EVENUE ^00WVJ5 ftcft� 19V OCVIC"M 00MM11,5;k#ML0•OF JNTL� Amu ocrx"To IT:P:T:1 L L'.r' The American Legion c/o Donald G. Glascofr, Ecktional Adjutant National neadquarterB IrLdi!uiripolic 6, Indiana Gentleman: Reference is made to the information submitted for use in do- tem.ining the 'status of the departmentc and -posts under your juris- diction for Pederal income tax purposes. In Bureau ruling dated February 26, 1934 it was hole that you aro entitled to exemption from Federal income tax under the pro- visionG.of* section 163(8) of the Revenue Act of .1932 and corre- sponding provisions of prior revenue acts. Such ruling was affirmed July 8, 1938 under the hievenue Act of 1936 and is appl i eabl e"under the provisions of section .101(6) of the Revenue Act of 1958 and the Internal Revenue Code. Based upon the evidence presented, it is held thet your de- partments and posts appearing on the lists submitted with an af- fidavit dated February 27, 1946 of your National Adjutant are entitled to exemption from Federal income talc under the provisions of section 101(6) of the Internal Revenue Code and corresponding provisions of prior revenue acts.. . Accordingly. your departments and posts appearing on the I-Lati sorhitted will not be required to file income tax returns unless there is a change in their character, purposes or method of. oper- ation. Any such changes should be reported inonediately to this Bureau in order that their effect upon the exempt status of the departments and posts undior your jurisdiction may be deter:,:inea. You should furnish the Bureau annually, on the calendar year basis, lists in a-uadruplieate showing cray the riames, numbers and addresses of any re.vt dopartments and poste vil:ich were chartered by you during the cala-ridar year and the names, ntunbers and addresses of !u;y departments and loost:7 which for any reason Ahave --,eaccd to exist. Such annual lists should be accompanied by a statement swom to by one of your principal officers as to whether the it-for- nation heretol'ore submitted by you and on which this ruling is based 2 - The. American Legion i I is applicable in all respects to the c:cpartments and posts appear- ing on the lists and should be for-aurded so as to reach this of- fice not later than .February lb of the following year. f Gontributions made to you and your departments and posts are deductible by the donors in arriving at their taxable net income � in the spanner and to the extent provided ty section 23(o) and (q) of the Internal Revenue Code, as amended. . However, under section 54(1'), as added to the internal Revenue Code by section 11.7 of the Revenue Act of 1943, you and your de- partments and posts are required to file annually information re- turns on Form 99D (Revised May 1944) with the collector of internal revenue for the respective districts in rrrioh located 'so long as the exemption remains in effect. This form may be obtained from the collector and is required to be filed on or before the fifteenth day of the fifth month following the close of the respective annual accounting periods. Your departments may file annually in addition to a separate annual return, a group return on Form S90 for two or more of the local posts which are affiliated Frith such department. Group returns on Form 990 shall be filed in accordance with the regulations promulgated under the income taut chapter of the Internal Revenue Code and the instructions on Form 990 end shall be considered- the return or each of the' loeal posts included therein. The collectors of internal revenue- for the districts in which . you and your departments and posts are located are being advised of this action. By direction -of the Commissioner. Very truly .j ours,. �o. 1 _k Deputy Commissioner { !r' 0-ply rthir 1973 i T.MS:EO-R:1 f The American Legion National Headquarters Indianapolis, Indiana 46206 EIN 35-0144250 DO 52 Gentlemen: This refers to your letter dated January 2, 1973' in which you ask that your ruling letter of March 14, 1946, be modified to show that you are recognized to be exempt from Federal income tax under section 501(c)(19) of the Internal Revenue Code. You state, and the information furnished shows, that membership in your organization is limited to persons who served in the Armed 'Services of the United States during a period of war. ' Our records show that on March 14, 1946, you and your subordinate departments and posts were recognized to be exempt from Federal income tax under section 101(8) of the- 1939 Code (this now corresponds to section 501(c)(4) of the 1954 Code). Based on the irifozmation furnished, we rule that you and your subordinate departments and posts are recognized'as being exempt under section 501(c)(19) of the Code. You are required to file the annual return, Form 990, on or before the 15th day of the 5th month after the end of your annual accounting period if your annual gross receipts are normally more than $5,000. Failure to file the Form 990 by this date may subject you to a penalty of $10 for each day during which such failure continues, up to a maximirn of $5,000. Your subordinates will have to file an annual infor- mation return, Form 990, if their gross receipts in each taxable year are normally more than $5,000. The American Legion If you do not include the subordinates in a group ret-a-rn, each mist file an annual return by the 15th day of the 5th month after its annual accounting period closes. You and your subordinates are not required to file Federal income tax returns unless you or your subordinates are subject to the tax on unrelated business income under section 511 of the Code, if so, you and your subordinates must file an income tax return on Foam 990-T. In this Letter we axe not determi ni`gig whether any or your, or your subordinates' , present or proposed activities is unrelated trade or -business as defined in section 513 Q the Code. Unless specifically excepted, you and your sibor- dinates..are liable for taxes under the Federal Insurance Contributions 'Act (social security takes). Also, i unless excepted, you and your subordinates are liable for tax under the Federal UnemploT_ent Tex Act if during the current or preceding calendar year, you have one or more- employees at any time in each of 20 weeks, or you pay wages of $1,500 or more in any calendar quarter. Any questions concerning excise, employment, or other Federal taxes should be submitted to you= key District Director in Baltimore, ` a y'land. Contz-ibations made to your exempt subordinate units are deductible as provided by section 170 of the Code. You should advise each of the subordinates of the provisions of this ruling, including the requiremenzt I or filing information or other returns. Each year within 45 days after the close of your anzzual accounting period, please send the following l to the Philadelphia Service Center, 11601 Roosevelt Boulevard, Philadelphia, Pennsylvania 19155, Attention: FOR,Branch; -3- The American Legion 1. A statement describing any changes during the year in the purposes, character, or method of operation i of your subordinates. 2. A list of the names, mailing ad- dresses including ZIP Codes, and 73-f loyer identification numbers required for group exemption letter purposes) of subordinates on your group eNemption roster that during the year: i a. changed names or addripsses; b. were deleted from the roster; c. were added to the roster. An aanotat.ed directory of subordinates will not be* accepted for this purpose. 3. For subordinates added to the roster, a letter signed by one of your principal officers coot im-i g or attaching a. a statement that the information which your present group exemp - tion letter is based applies to the new subordinates; b. a statement that each has given you, w-ritten authorization to add its name to the roster; i c. a list of those to which the Service previously issued rulings or determination letters relating to exemption. -4- The American Legion 4. If applicable, a statement that your group exemption roster did not change during the year. To the extent that this ruling is inconsistent with it this ruling modifies our rling issued to you on March 14, 19 46. Your key District -Director is being advised of this action. Sincerely yours, Director, Miscellaneous and Special Provisions Tax Division I Internal Revenue Service Department of the Treasury Washington, D.C. 20224 Date: Person to Contact: Mr. Charles E. McLaughlin Telephone Number: (202)964-6197 3 —01 4250EE 0925 Q� QQ 19 Refer Reply to: 7g+ORNaRiNHLPGIUN NATIONA HEAuuOUARTERS E:EO:O:R PENNSYLVANIA 5TREET Date; INDIANAPOLIS IN 46206 February 17, 1976 Group Examption Number; 'j7Lam Dear Officer or Trustee: We are contacting all group central organizations because the 1975 Form 990 and instructions require each central organization and its subordinates to show their group exemption number (GEN) in Part I, item 18(b), of Form 990. Your group exemption number is shown above. Please advise any of-your subordi- nates that are required to file an annual information return, Form 990, to place your group exemption number on their return. Church central organizations are not required to file an annual information return. However, any of their subordinates that do not qualifytas "integrated auxiliaries" of a church are required to file an information return, Form 990, and should include on that return the appropriate group exemption number. We are preparing a proposed amendment to the Income Tax Regulations which will define an integrated auxiliary of a church. When that amendment is published, we will send an information copy to holders of group exemption rulings under section 501(c) (3) of the Internal Revenue Code. (Organizations exempt under other provisions will not receive a copy.) If you have any questions, please contact the person whose name and telephone number are shown above. Thank you for your help in this matter. Sincerely yours, edesco, Director pt Organizations Division M-0088 (2-761 San Dieguito Post 416 210 West F Street Encinitas,California 92024 April 13,2016 4 ., w SAN DIEGUITO POST 416 RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION Resolution of the Board of Directions of American Legion Post 416 WHEREAS,the American Legion Post 416 is a legally constituted corporation or public/governmental entity,under the laws of the State of California,and is complete control of its affair though its own officers and members, NOW THEREFORE,BE IT RESOLVED,that the Board of Directors of the American Legion Post 416 hereby approved the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 13th day of April,2016 f Jay O'Keefe Secretary,Board of Directors American Legion Post 416 Post 416: (760)753-5674 ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: American Legion Post 416 TITLE OF GRANT PROGRAM: American Legion Post 416 Architectural Plans UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000)for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Steve Lewandowski Title: Commander Ifs) ` 13 April 2016 Signature: Date: APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM :ATEGORY: Grant requests are classified into two categories: Civic or Arts proqram. Choose only one option_ 0 Civic ❑Arts Grant Request Amount: $5000 Free of Charge: K Yes ❑ No (Not to exceed$5,000) Program Title: Operation School Bell ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0556542 9 IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Assistance League of Rancho San Dieguito (Must match name filed under the Tax/Employer Identification Number) Street Address: 1542 Encinitas Blvd. Encinitas 92024 Mailing Address: 270 F North El Camino Real, Box 368, Encinitas 92024 Doing Business as(dba)Name: Fabulous Finds, An Assistance League Thrift Shop Please list the names and titles of the organization's Board of Directors: Lois Green, President Roberta Waterman,VP Resource Development Judy White, Recording Secretary Pat Talmon, VP Philanthropic Programs Brenda Seitz, Treasurer Stella Ramos, VP Membership Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program(Limit to the space provided): Operation School Bell is the premier program of National Assistance League. Our program began in 1998 to meet local needs. It has continued to serve low income families since then. Each year we host shopping events for these children at a local retail store in Encinitas. Each qualified child is given $70 tax-free to spend on school clothes and shoes. Assistance League members participate by helping at the registration table, in the boys and girls' departments and at the checkout. The families and the children know we care. Research indicates that children who wear clothes that fit and are new no longer seem different from their more affluent peers. We seek to diminish the outward signs of poverty so that children can focus confidently on learning. Another facet of Operation School Bell, in addition to Clothing Children, is Science Camp Scholarships. In 2010 we learned of an unmet need in Encinitas. Schools were challenged to maintain the 6th grade science camp. In 2015 we provided partial camp scholarships to 30 Encinitas students. Organizational History: We became a guild of the national organization in 1993 and a chapter in 1997. We are 100% volunteer. Our philanthropic programs are dedicated to making a positive difference in the lives of children and adults affected by trauma,violence, and poverty. Application Form, Page One of Two 't APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRA110 ,'ROGRAM INFORMATION: Location: Our shopping events are held at the Encinitas Target store. Total Est.Cost: $27,500 Time Frame: October 2016 for shopping events/Spring 2017 for camp scholarships Number of Encinitas Residents Served: 375 Target Fundraising Activity: E No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Kathy O'Leary Mailing Address: 317 Village Run West, Encinitas, 92024 Telephone Number: 760-753-1319 Email Address: kathyclaire @yahoo.com ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: CL4- ( C-' 't-et;(.t^i� Title: Grant Chairman (P.Jdase print) Signature: � --� = L i�� 7,.- Date: April 13, 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM -GANI ATION !NAME: Assistance League of Rancho San Di guito PROJECT TITLE: Operation School Bell PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership feesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT _'..i t.,% $ 5,000 Grant Neighborhood Reinvestment Grant, District 3,County of San Diego Pending $8,000 Grant Mazzerini Trust,Wells Fargo Advisors Secured $5,000 Fundraiser Spring 2016,portion alloted to Operation School Bell Pending $4,500 Thrift Shop Store surplus, portion alloted to Operation School Bell Pending $5,000 INCOME TOTAL: $27,500 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Target Gift Cards Target gift cards for Assistance League members to use in payment for clothing and shoes $24,500 Camp Scholarships Funding by check for partial payment of tuition for Encinitas sixth graders camp experience $3,000 Note: Additional information available through chapter website at www.airsd.org. EXPENSE TOTAL*: $27,500 Budget Form *Your Total Income and Total Expenses should be equal. 9:58 PM Assistance League of Rancho San Dieguito 07/27/15 Accrual Basis Budget June 2015 through May 2016 Jun'15-May 16 Income 4000• Contributions Wells Fargo Credit Card Rebate 2,500.00 Amazon Smile 150.00 Community Newsletter 2,000.00 Fabulous Finds 175.00 Make a Difference Day 1,000.00 OSBI Clothing Children 2,500.00 OSBIPendleton 1,000.00 Unrestricted to Use 2,000.00 Total 4000•Contributions 11,325.00 4100-Grants Grants-Other 500.00 Operation School Bell City of Solana Beach 3,000.00 Berkshire Hathaway Charitable 1,500.00 City of Encinitas 4,000.00 Masserini Fund 5,000.00 Neighborhood Reinvestment 5,000.00 Carlsbad Rotary 1,500.00 Sundt 1,000.00 Wells Fargo Foundation 2,500.00 Total Operation School Bell 23,500.00 Total 4100•Grants 24,000.00 4201 - Fabulous Finds Resale 4202•Sales 155,000.00 Total 4201 •Fabulous Finds Resale 155,000.00 4300•Special events Chico's 1,100.00 Holiday Boutique 400.00 San Diego County Fair 700.00 Spring Fundraiser 40,000.00 Total 4300•Special events 42,200.00 4500• Investment Income Wells Fargo Savings 130.00 Total 4500•Investment Income 130.00 4600• Member-Only Annual Meeting/Luncheon 100.00 Christmas Luncheon 100.00 Holiday Party 100.00 Member dues 8,850.00 PALS Dues 360.00 Total 4600•Member-Only 9,510.00 Total Income 242,165.00 Gross Profit 242,165.00 Page 1 of 3 9:58 PM Assistance League of Rancho San Dieguito 07127/15 Accrual Basis Budget June 2015 through May 2016 Jun'15-May 16 Expense 5100• Philanthropic Programs Assault Survivor Kits 3,500.00 Hug-a-Bear 2,500.00 Knifty Knitters 800.00 Make A Difference Day 2,000.00 Operation School Bell OSBIClothing Children 65,000.00 OSBIScience Camp Scholarships 5,000.00 OSBIPendleton 11,000.00 Total Operation School Bell 81,000.00 Optional Charitable Program 1,000.00 PREP 150.00 Stand Up for Kids 400.00 Storage Rental 2,254.00 Total 5100. Philanthropic Programs 93,604.00 5200 • Fabulous Finds Resale. Advertising 500.00 Business license 21.00 Chamber Membership 175.00 Cleaning 3,640.00 Delivery Charges 1,500.00 Fees-Franchise Tax Board 25.00 Furniture&Fixtures 1,000.00 Insurance 3,000.00 Merchant Services 2,500.00 Printing 300.00 Refurbish&Repairs 1,000.00 Rent 88,625.00 Storage 865.00 Supplies 1,800.00 Utilities Electric 2,500.00 Security 420.00 Telephone 1,200.00 Total Utilities 4,120.00 Total 5200• Fabulous Finds Resale. 109,071.00 5300• Fundraising Grants 150.00 Total 5300• Fundraising 150.00 5600• Special Events Expense Spring Fundraiser 17,000.00 Total 5600.Special Events Expense 17,000.00 5800 • Management&General Page 2 of 3 9:58 PM Assistance League of Rancho San Dieguito 07127/15 Accrual Basis Budget June 2015 through May 2016 Jun'15-May 16 Bank Charges 50.00 Board Expenses Board expense-other 50.00 Corresponding Secretary 75.00 President's Expense 150.00 Recording Secretary 50.00 Treasurer 100.00 Total Board Expenses 425.00 Chapter Marketing 2,000.00 CPA Audit/Review 4,000.00 Education Board Development 100.00 National Conference&Meetings 5,000.00 Total Education 5,100.00 Government Fees& Licenses 100.00 Insurance Director&Officer 1,300.00 Total Insurance 1,300.00 Storage Rental 864.00 W ebsite 400.00 5800• Management&General-Other 1,500.00 Total 5800• Management&General 15,739.00 5900• Membership expense Chapter Directory 25.00 Chapter Scrap Book 50.00 Circle Donation 225.00 Hall Rental 1,200.00 Hospitality 200.00 Meeting Materials 25.00 Membership Development 400.00 NAL Dues 4,400.00 Name Badges 200.00 Newsletter 100.00 Total 5900•Membership expense 6,825.00 Total Expense 242,389.00 Net Income -224.00 Page 3 of 3 assistance league" October 24, 2009 Good Day: This letter is to confirm that the Assistance League of the Rancho San Dieguito is registered with the Internal Revenue Service as a 501(c)(3) under Group Exemption Number 4176. The parent organization is the National Assistance League. Parent and the subsidiary organizations are registered as follows: Parent: National Assistance League 3100 W Burbank Blvd. Ste 100 Burbank, CA 91505-2348 EIN: 95-1945908 GEN: 4176 Subsidiary: Assistance League of Rancho San Dieguito 132 North El Camino Real Box# 368 Encinitas, CA 92024 We are providing the Internal Revenue Service determination letter for the parent organization group exemption number. The Internal Revenue Service recognizes Assistance League of San Dieguito as a subordinate organization. As such, the Assistance League of Rancho San Dieguito may use the enclosed tax exemption status and Federal Identification Number. Donors to the Assistance League of Rancho San Dieguito may deduct contributions to the chapter under this number as provided in section 170 of the code. If you have further questions, please contact me at the National Assistance League 3100 W Burbank Blvd Burbank, CA 91510 or by phone at(818) 346-3777 or by email at Deanna@ assistanceleague.ora. 1Vitl7 regards, L(n erD14Q ova P.O.Box6637 National Financial Services Director Rurbank,C,91510_663;dational Assistance League L(818)lab-3rn7 fax(819)a46-3535 wwwassist zJ,r,„u-.3r.- caring & conurdtrnent in c1.C: 1 it ims De irineni of the Treasury IRS Internal Revenue Servic P.O. Box 2508 In reply refer to : 0248162349 Cincinnati OH 45201 Aug. 07, 2009 LTR 4167C EO 95-1945908 000000 00 00015740 BODC: TE NATIONAL ASSISTANCE LEAGUE 3100 W BURBANK BLVD STE 100 BURBANK CA 91505-2348 k 02 Employer Identification Number : 95-1945908 Group Exemption Number : 4176 Person to Contact : Mr. Crouch Toll Free Telephone Number : 1-877-829-5500 Dear Taxpayer: This is in response to your July 29, 2009, request for information about your tax-exempt status. Our records indicate that you were issued a determination letter in May 1994, and that you are currently exempt under section 501 (c) (3) of the Internal Revenue Code . Based on the information supplied , we recognized the subordinates named on the list you submitted as exempt from Federal income tax under section 501 (c) (3) of the Code. Donors may deduct contributions to you as provided in section 170 of the Code . Bequests, legacies , devises, transfers , or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106 and 2522 of the Code. If you have any questions, please call us at the telephone number shown in the heading of this letter . Sincerely yours, Michele M. Sullivan, Oper. Mgr . Accounts Management Operations I ASSISTANCE LEAGUE®OF RANCHO SAN DIEGUITO MOTION FORM Date: April 7, 2016 Subject: Authorization of Kathy O'Leary to Seek Grant Funding for Assistance League of Rancho San Dieguito Presented at: _ Committee Meeting Board Meeting Regular Meeting MOTION: Whereas,the Board of Directors of Assistance League of Rancho San Dieguito is a legally constituted nonprofit organization, under the laws of the State of California,and is in complete control of its affairs through its own officers and members. Now therefore, be it resolved that the Board of Directors of Assistance League of Rancho San Dieguito hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on the 8th day of April 2016 RATIONALE: Kathy is a member in good standing and is experienced and qualified to seek this grant funding. ZApproved Signature: , Disapproved Position: ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION _ 1 COMMUNITY GRANT PROGRAM 11 ORGANIZATION NAME:Assistance League of Rancho San Dieguito TITLE OF GRANT PROGRAM: Operation School Bell UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Kathy O'Leary Title: Grant Chairman Signature:_ �� ==4 Date: April 13, 2016 APPLICATION FOR FISCAL YEAR 2016-2017 i CITY OF ENCINITAS AND MIZEL FAMILY ' FOUNDATION COMMUNITY GRANT PROGRAM .ATEGORY: Grant requests are classified into two categories:Civic or Arts proqram. Choose only one option. Civic ❑Arts Grant Request Amount: $5000 Free of Charge: no Yes ❑ No (Not to exceed$5,000) Program Title: Operation School Bell ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0556542 2 IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Assistance League of Rancho San Dieguito (Must match name filed under the Tax/Employer Identification Number) Street Address: 1542 Encinitas Blvd. Encinitas 92024 Mailing Address: 270 F North El Camino Real, Box 368, Encinitas 92024 Doing Business as (dba) Name: Fabulous Finds, An Assistance League Thrift Shop Please list the names and titles of the organization's Board of Directors: Lois Green, President Roberta Waterman,VP Resource Development Judy White, Recording Secretary Pat Talmon, VP Philanthropic Programs Brenda Seitz, Treasurer Stella Ramos, VP Membership + Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the projectlprogram must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program(Limit to the space provided): Operation School Bell is the premier program of National Assistance League. Our program began in 1998 to meet local needs. It has continued to serve low income families since then. Each year we host shopping events for these children at a local retail store in Encinitas. Each qualified child is given $70 tax-free to spend on school clothes and shoes. Assistance League members participate by helping at the registration table, in the boys and girls' departments and at the checkout. The families and the children know we care. Research indicates that children who wear clothes that fit and are new no longer seem different from their more affluent peers. We seek to diminish the outward signs of poverty so that children can focus confidently on learning. Another facet of Operation School Bell, in addition to Clothing Children, is Science Camp Scholarships. In 2010 we learned of an unmet need in Encinitas. Schools were challenged to maintain the 6th grade science camp. In 2015 we provided partial camp scholarships to 30 Encinitas students. organizational History: We became a guild of the national organization in 1993 and a chapter in 1997. We are 100% volunteer. Our philanthropic programs are dedicated to making a positive difference ' in the lives of children and adults affected by trauma,violence, and poverty. Application Form, Page One of Two EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015-16 Date OC4-6bei-o21 , 4, j 1� Organization: Assistance League of Rancho San Dieguito Address: E) i n o I�Prt1 B nX 3&8 City: al G!k7),-/-as State CA Zip Phone: x-60 3-o)% Fax Email: C{ I rsd Gz'}1P State the goals and objectives of your project and whether they have been met. How were the goals and objectives of your project measured? Who participated in the evaluation process? How was the City's funding for this project utilized? r, FYI 5-16 CGP REIMBURSEMENT &EVALUATION FORMS APPLICATION FOR FISCAL YEAR 2016-2017 -- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts program: Choose only one option. ❑Civic M Arts Grant Request Amount: $5,000 Free of Charge: ❑ Yes 0 No (Not to exceed$5,000) Program Title: Ballet Folklorico de San Dieguito ELIGIBILITYY, DETERMINATION:.Only non-profit and/or tax-exempt or.aniiations may apply: Identify the legal status of your.organization: ■ Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-1652902 X IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Bayside Community Center (Must match name Filed under the Tax/Employer Identification Number) Street Address: 2202 Comstock Street,San Diego, CA 92111 Mailing Address: Doing Business as(dba)Name: Please list the names and titles of the organization's Board of Directors: Kevin Brown, President Christian Henry, Secretary Noel Musicha, Vice President Viviana Alexandrowicz, Board Member Vanessa Franco,Treasurer Sierra J. Spitzer, Board Member 'W Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. RROGRAM SUMMARY AND ORGAIZATIDNAL HISTORY: Summary of Program (Limit to the space provided): Bayside Comm.Ctr.is proposing to continue its successful dance education program for kids and youth at the Encinitas Community Center, begun in 2014. Classes will be held on Saturdays from 1-4pm, with two groups of 18-25 students each, grades 2-6, and grades 7-12,from July 1, 2016 through June 30, 2017. The program will continue to showcase and highlight the rich cultural traditions of Mexican dance, enabling the younger generation to forge deep emotional connections with their parents,grandparents, and country of origin. Participants will learn the discipline of dance, increase self-esteem and confidence, as well as receive the physical benefits of exercise. Bayside Community Center will be the fiscal agent. The program is fee-based at$10/class per student for 90 minutes of instruction per week.This grant will provide 30 scholarships($5 discount per class, and shoes and skirts for 10 students)to cover the costs for low income families.The following organizations have agreed to collaborate on this project to help with space, outreach and in-kind assistance: SDCOE Migrant Education, Los Angelitos, Mano a Mano, EUSD, La Colonia, Encinitas Family Enrichment Program, Encinitas Friends of the Arts, and the City of Encinitas Arts Division. Organizational History: Bayside Community Center was established in 1932 and has along history of working with multicultural,low income populations.The Ballet Folklorico program has been in existence since 2000,and at Bayside since 2008. It is led by Nadia Arambula, a professionally trained dancer and educator who has toured nationally and abroad. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 . CITY OF ENCINITAS AND MIZEL FAMILY WS Y FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION.: _. Location: Encinitas Community Center, 1140 Oakcrest Park Drive, Encinitas, CA 92024 Total Est. Cost: $17,050 Time Frame: July 2016 -June 2017 Number of Encinitas Residents Served: 30+ Fundraising Activity: 8 No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Cristina P. Gutierrez,Accountant Mailing Address: 2202 Comstock Street, San Diego, CA 92111 Telephone Number: 858-278-0771 x3006 Email Address: cgutierrez @baysidecc.org ❑■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Cristina P. Gutierrez Title: Accountant (Please print) Signature: � ,t� Date: 4/14/2016 THIS SECTION FOR OFFICIAL USI .;ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form(signed &dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: I Yes ❑ No Reasons: Application Forni, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Bayside Community Center PROJECT TITLE: Ballet Folklorico de San Dieguito PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5;000 Fee for service Family contribution(10 non-scholarships Q S10 per student)or apply for more scholarships. Pending S2,250 Grant for shoes/skirts County of San Diego Neighborhood Reinvestment Program Pending $2,200 Outreach(in-kind) Mano a Mano Foundation and County of San Diego Migrant Education Committed S1,000 Space(in-kind) Encinitas Community Center Committed $5,700 Teacher donation(in-kind) S5 fee reduction a month for scholarship students Committed S900 INCOME TOTAL*: $17,050 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified'as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Salary Payment to Nadia Arambula $5,850 Shoes and practice skirts Attire/equipment required for dance class S3,300 In-kind Outreach $1,000 In-kind Space donation $5,700 In-kind Donation by teacher($5 fee reduction per scholarship student per month) $900 Operating costs For fiscal agent(Bayside Community Center) $300 EXPENSE TOTAL*: $17,060 Budget Form *Your Total Income and Total Expenses should be equal. i Internal Revenue Service Department of the Treasury P.®. Box 2508 Cincinnati, OH 45201 Date: May 7, 2002 Person to Contact: Kathy Masters ID#31-04016 Cu`s nor—•. rvice Representative Totf Fla Ta[epl�one:Ntorarber�•: • .. •,:: - Bayside Community Center s a wR ast P.O. Box 712625 ' 877-829,5500 San Diego, CA 92171-2525 Fax(dumber: 513.283-3758 Federal Identification Number. 95-1652902 Dear Sir or Madam: This letter Is in response to the amendment to your omanizatiores•AirBde of Incorporation filed with th -onto on March 1,2001. we have updated our records to reflect thd ndme change a$kWkx bedG above. Our record's Indicate that a determination letter issued In September 1977 granted your organization exemption from federal Income tax under section 5010)(3)of the Internal Revenue Code. That letter is still in effect. 9ased on information subsequently submMbd,we classified your organization as one that Is not a private .oundedan witfttn the meaning of section 509(8)of the Code bemuse.It is an organization described In sections 509(8)(1)and 170(b)(1)(A)(vq. This classification was based on then assumption that your organizatioWa operations would continue as stated in the appncation. If your organization's sources of support,or its character,method of operations,or purposes have changed, please let us know so we can consider the effect of the change on the exempt status and foundation status oT your organization. Your organization Is required to file Form 990, Return of Organization Exempt from Income Tax,only If its Vot s receipts each year are normally more than$25,000. if a return Is required,it must be filed by the 15th the fifth n nth after the and ofthe organbMon's annual'acnounting period. The law imposes a penalty of$20 a day,up to a maximum of$10,000,when a return is filed late,unless there is reasonable cause for the delay. All exempt organizations(unless specifically excluded)are liable for taxes under the Federal,insurance Contributions Act(social security taxes)on remuneration of$100 or more paid to each employee during a calendar year. Your organization is not liable for the tax imposed under the Federal Unemployment Tax Act (FUTA). Organizations that are not private foundations are not subject to the excise taxes under Chapter 42 of the Code. However, these organizations are not automatically exempt from other federal excise taxes. Donors may deduct contributions to your organization as provided In section 170 of the Code. Bequests, legacies,devises,transfers, or gifts to your organization or for Its use are deductible for federal estate and gift tax purposes if they meet the applicable provisions of sections 2055,2106, and 2522 of the Code. f Y RESOLUTION OF THE BOARD OF DIRECTORS OF: BAYSIDE COMMUNITY CENTER WHEREAS, Bayside Community Center is a legally constituted non-profit organization and fiscal agent for Ballet Folklorico de San Dieguito under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED that the Board of Directors of Bayside Community Center hereby approves the filing of an application for Ballet Folklorico de San Dieguito with the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 14th day of April, 2016 r - Kevin Brown, CPA President, Board of Directors Bayside Community Center BAYS I D E Community Center ` ATTACHMENT C AMIN APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Bayside Community Center TITLE OF GRANT PROGRAM: Ballet Folklorico de San Dieguito UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS 13) MIZEL FAMILY FOUNDATION as the "Certificate Holder' and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and. will comply with insurance requirements 1 through 4 of the Community Grant Program and that l am authorized by the organization named below to make such representations in this application. Contact Person: Cristina Gutierrez Title: Accountant 0/, ) Signature: l Date: 4/14/2016 BAYSI-4 OP ID: M5 CERTIFICATE OF LIABILITY INSURANCE DATE 04/14/2016Y) 04/14/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES -LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED :PRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Snapp&Associates PHONE FAX Insurance Services,Inc. LAIC No EXa:619-908-3100 (A/C,No): 619-908-3110 438 Camino del Rio So.#112 E-MAIL San Diego,CA 92108 ADDRESS: Nick Cranmer INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Philadelphia Indemnity Ins,Co INSURED Bayside Community Center INSURER B:Security National Insurance 2202 Comstock St. San Diego,CA 92111 INSURER C: INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR TYPE OF INSURANCE POLICY NUMBER MM DDlYYY MM DD EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY X PHPK1372880 09/15/2015 09/15/2016 PREMISES "'Ea occurrence $ 100,00 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 X POLICY JEC 11 LOC Emp Ben. $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ A ANY AUTO PHPK1372880 09/15/2015109/15/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY ID DAMAGE $ AUTOS PER ACCENT X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS LIAB CLAIMS-MADE PHUBS09579 09/15/2015 09/15/2016 AGGREGATE $ 1,000,00 DED I X I RETENTION$ 10000 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY � TORY LIMITS ER ,/N B ANY PROPRIETOR/PARTNER/EXECUTIVE SWC1076595 07/01/2015 07101/2016 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? � NIA — (Mandatory in NH) E.I. DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 1,000,000 A Sexual Abuse PHPK1372880 09/15/2015 09/15/2016 Sex Abuse 1,000,000 A Professional Liab PHPK1372880 09/15/2015 09/15/2016 PROF: 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Re: Operations of the named insured subject to the terms and conditions of the policy. City of Encinitas & Mizel Family Foundation are named as additional insured per policy form. 30* days notice of cancellation, 10* days notice of cancellation in the event of nonpayment of premium. CERTIFICATE HOLDER CANCELLATION CITYENC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Encinitas ACCORDANCE WITH THE POLICY PROVISIONS. Mizel Family Foundation Attn: Community Grant Program AUTHORIZED REPRESENTATIVE 505 S.Vlucan Way Encinitas, CA 92024 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PEPK1372880 COMMERCIAL GENERAL LIABILITY CG 20 05 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - CONTROLLING INTEREST This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Person(s) Or Organization(s): City of Encinitas Mizel Family Foundation Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II— Who Is An I nsured is amended to C. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to their liability arising out of: If coverage provided to the additional insured is 1. Their financial control of you; or required by a contract or agreement, the most we 2. Premises they own, maintain or control while will pay on behalf of the additional insured is the you lease or occupy these premises. amount of insurance: However: 1. Required by the contract or agreement; or 1. The insurance afforded to such additional 2. Available under the applicable Limits of insured only applies to the extent permitted by Insurance shown in the Declarations; law; and whichever is less. 2. If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the applicable Limits of Insurance shown in the insurance afforded to such additional insured Declarations. will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. CG 20 05 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1 EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date I�! 2� ZO S Organization: Bayside Community Center Address: Z Z O 2 Cc,rns t?,Ck St• City: .3CtYI Di LG o State G Zip q2 Phone: G Fax 858 - 22-6— (QIG3 Email: n IC- h^,�r Cc ,orc State the goals and objectives of your project and whether they have been met. —PIectsc- sco- cA-,(-VA . How were the goals and objectives of your project measured? I ) Who participated in the evaluation process? How was the City's funding for this project utilized? 11 T:\CGP\OICGPTemplates+Forms\Agreement Return Letter with forms.doc evaluations, and measurements of success:Jim Gilliam,Arts Administrator for the City of Encinitas' City Manager's Office; Naimeh Tanha, Art Commissioner, Friends of the Arts; support staff at Bayside Community Center; and parents of dance students. How was the City's funding for this project utilized? Funding for Ballet Folklorico de San Dieguito was used to purchase new dresses and attire for the program's dancers. How many Encinitas residents did you expect to serve through this project? Ballet Folklorico de San Dieguito expected to serve 30 students, 60 parents, and roughly 1,000 community members through 4-6 performances throughout the year. How many Encinitas residents did you actually serve through this project? Ballet Folklorico de San Dieguito actually served 35 students, 70 parents, and roughly 2,500 community members at 16 performances throughout the year. Based on the outcome of this year's project,what changes/improvements will you make next year? Ballet Folklorico de San Dieguito exceeded its initial expectations set at the beginning of FY14-15.Yet there were many lessons learned and areas for improvement identified for future years' programming. More outreach and publication of the program will be done, including the distribution of fliers to promote the program before and during events, and online via the program's webpage and Facebook page. Intentional efforts to connect with the media (print, television, radio) will also be pursued, capitalizing on the initial connections and exposure made through these mediums during FY14-15.The San Dieguito director also recognized the need for continued upgrade and maintenance to the dresses and uniforms students wear, and will work to continue addressing those challenges. Lastly,the dances the students perform will continue to be more in depth and difficult, paralleling the growth in choreography with the students'growth in dance skills. Positive outcomes? Positive outcomes abounded during the FY14-15 for Ballet Folklorico de San Dieguito. In addition to the quantitative and qualitative measurements and those referenced in the previous question, the program has succeeded in retaining 22 of the 35 students (nearly two-thirds!)who participated last year into the FY15-16 programming. San Dieguito also received a great welcome in the Encinitas community, reflective in the number of venues at which the students were offered to perform.The students were also featured on the San Diego County Fair banners displayed in Encinitas on Pacific Highway 101 as proud representatives of the Encinitas community and San Diego County at large. Negative outcomes? A few challenges that arose during FY14-15 for Ballet Folklorico de San Dieguito included that several students were unable to continue or finish the program for various reasons;the continued wear and tear on students' dresses and thus the cost for cleaning, maintenance,and repair required; and the difficulties parents faced in transporting their children to performances outside of Encinitas because of a lack of vehicle or alternative modes of transportation. APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. ❑Civic it Arts Grant Request Amount: $5,000.00 Free of Charge: ❑ Yes ft No (Not to exceed$5,000) Program Title: Griset Ceramic Arts Program ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: N Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-2470435 ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Boys&Girls Clubs of San Dieguito (Must match name filed under the Tax/Employer Identification Number) Street Address: Griset Branch - 1221 Encinitas Blvd., Encinitas CA 92024 Mailing Address: 533 Lomas Sante Fe Drive, Solana Beach CA 92075 Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: Patrick Lenihan-Chairperson Doug Fisher- Board Development Chair David Thomas-Secretary At Large: Barbara Harper, Patty Maysent, Larry McDonald Doug Regnier-Treasurer/Finance Chair John Melican and Eric Nelte ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Funding for 2016/2017 supports growing the program to four days a week to fully utilize the studio.Griset Ceramics Studio has offered after school ceramic arts programs for 6 years,twice a week during the school year and arts summer camp.Aspiring artists ages 5-14 are taught free form clay design basics and thrown pieces on the potter's wheel as well as glazing and decorating techniques.Thanks to previous funding from the City of Encinitas,the Mizel Family Foundation, and and others,the ceramics studio has a new kiln(requiring an upgraded electrical panel)and six potter's wheels.60 youth a week routinely create increasingly advanced works of art.The program itself is free to Club members,however 40%of these members receive partial or full scholarships to attend,as we turn no child away.Covering costs is a key factor in maintaining and growing Boys&Girls Clubs programming Additional sessions incorporate local mosaic artist,Jennifer Kelley,to add new ceramic arts opportunities for club kids,adding a local connection to the arts.As a means to increase access to ceramic arts,transportation from our other six clubs needs to be offered to fully include low income families.A grant of$5,000.00 will help ensure that the after school ceramics program continues and expands for the 2016/2017 school year and is available to all. Organizational History: For 49 years,the Boys&Girls Clubs of San Dieguito has been at the forefront of youth development, Working with disadvantaged youth from all backgrounds. We are dedicated to ensuring that local youth have greater access to quality programs and services that will enhance their lives and shape their futures. Application Form, Page One of Two =- APPLICATION FOR FISCAL YEAR 2016-2017 --' CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Boys & Girls Club, Griset Branch - 1221 Encinitas Blvd. Total Est. Cost: 14000.00 Time Frame: 2016/2017 School Year Number of Encinitas Residents Served: 60-70 Fundraising Activity: 2 No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Shelly Kelly, Grants Manager Mailing Address: 533 Lomas Sante Fe, Solana Beach CA 92075 Telephone Number: 858-755-9371 Email Address: grants @becSanDieguito.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Marineke Vandervort Title: Chief Executive Director (Please print) 1 Signature: 61-a Date: April 13, 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed & dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: Yes ❑ No Reasons: I Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM )RGANIZATION NAME: Boys & Girls Clubs of San Dieguito PROJECT TITLE: Griset Ceramics Arts Program PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Grant Family Foundation via San Diego Foundation Secured $5,000 Grant Family Trust via Wells Fargo Trust Pending $4,000 INCOME TOTAL*: 1$ 14,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Clay 1 Ton of Clay required quarterly @$450/ton $1,800 Consumables Glaze,mosaic tile,limited use tools $1,700 Pottery Wheel 2 additional potters wheels @$600.00 each $1,200 Instructors Fee Compensation for 63 ceramics sessions-Jason Brady(trained by local Alex Long) $2,200 Instructors Fee Compensation for 63 mosaic sessions-Jennifer Kelley $2,200 Kiln Cost for new kiln @$1,200.00 and required electrical and installation $2,000 Transportation Cost for staff&club van to transport low income members from branches to Griset studio(63 sessions) $1,220 Overhead 12%Operating Expence $1,680 EXPENSE TOTAL*:F$14,000 Budget Form *Your Total Income and Total Expenses should be equal. ��� j � Depsirinri+n1 of[lie Treamil), ��n�V .1.�1_7lnlcrnai Rc�rnve S(•I'YIev P . O . Box 2508 In reply refer to : 0248222025 Cincinnati OH 45201 Nov . 15 , 2011 LTR 4168C EO 95-2470435 000000 00 00016448 BODC: TE THE BOYS AND GIRLS CLUBS OF SAN DIEGUITO 4 533 LOMAS SANTA FE DR ti� SOLANA BEACH CA 92075-1323 Ems, 010296 Employer Identification Number : 95-2470435 Person to Contact : R CLEMONS Toll Free Telephone Number : 1-877-829-5500 Dear TAXPAYER : This is in response to your Nov . 03, 2011 , request for information regarding your tax-exempt status . Our records indicate that you were recognized as exempt under section 501 (c) ( 3) of the Internal Revenue Code in a determination 1 letter issued in AUGUST 1967 . Our records also indicate that you are not a private foundation within the meaning of section 5O9(a) of the Code because you are described in section 509(a ) C2) . Donors may deduct contributions to you as provided in section 170 of the Code . Bequests , legacies , devises , transfers , or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055 , 2106 , and 2522 of the Code . Please refer to our website www. irs . gov/eo for information regarding filing requirements . Specifically, section 60330 ) of the Code provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the filing due date of the third return for organizations required to file . We will publish a list of organizations whose tax-exempt status was revoked under section 60330 ) of the Code on our website beginning in early 2011 . RESOLUTION OF THE BOARD OF DIRECTORS OF The Boys & Girls Clubs of San Dieguito WHEREAS, the Boys & Girls Clubs of San Dieguito is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Boys & Girls Clubs of San Dieguito hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. A d pril, 2016 Davy! Thomas Se, etary, Board of Directors Boys&Girls Clubs of San Dieguito GREAT FUTURES START � � a ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 AVA CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION _: . COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Boys & Girls Clubs of San Dieguito TITLE OF GRANT PROGRAM: Griset Ceramic Arts Program UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Marineke Vandervort Title: Chief Executive Director Signature: -- � Date: April 13, 2016 APPLICATION FOR FISCAL YEAR 2016-2017 %6__L;V f, CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. ❑Civic Arts Grant Request Amount: $5,000 Free of Charge: N Yes ❑ No (Not to exceed$5,000) Program Title: Diegueno Middle School Band Equipment and Instrument Purchases and Repair ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 1 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0277530 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: California Congress of Parents,Teachers, &Students Inc., Diegueno Middle School PTSA- Band (Must match name filed under the Tax/Employer Identification Number) Street Address: 2150 Village Park Way, Encinitas, CA 92024 Mailing Address: Doing Business as (dba) Name: Diegueno Middle School Band Boosters Please list the names and titles of the organization's Board of Directors: Patricia Jones, President Carrie Bishop, Secretary Carlos Lin, Treasurer ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The number one priority for our music program is to secure basic instructional equipment and an inventory of functional instruments,so that every interested student may have the opportunity to pursue music education.The benefits of music education,to the children and to the community,are enormous and well-documented.We are a public school,and there is currently no funding for music equipment or instruments in the school budget.At the middle school level, most students do not yet own an instrument. Many families find it difficult to purchase/rent an instrument,and turn to the use of instruments from the school inventory.Our beginning students often enter the program without having selected an instrument. The school inventory is also a resource to allow students to try a variety of instruments before selecting one.We are focusing on adding four instruments to our inventory as well as completing repairs on a number of the instruments we already own. Basic equipment required to operate a functional classroom includes musicians'chairs and music stands.Our goal is to obtain proper metal music stands to replace our current stands,which are lightweight plastic.They tip over easily,and over years of use have cracked,chipped and accumulated other damage.We also intend to obtain additional musicians'chairs,which the school district has defined as standard for music classes, but are not funded. Organizational History: The Diegueno Band Boosters are a committee of the Diegueno Middle School PTSA. Their mission is to provide financial, organizational, and volunteer support for activities of the music program at Diegueno Middle School in Encinitas, a public middle school serving over 1,000 students. _= APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Diegueno Middle School Total Est. Cost: $10,850 Time Frame: August 1, 2016 - June 30, 2017 Number of Encinitas Residents Served: E°�"'=x°°"""` Ct1e S SC�i t� L�m''vz un �L� Fundraising Activity: 0 No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Patricia Jones, President Mailing Address: c/o Diegueno Middle School PISA, 2150 Village Park Way, Encinitas, CA 92024 Telephone Number: (858)229-9661 Email Address: patty.jones9 road runner.com 0 Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Patricia Jones Title: President (Please print) Signature: � ���— / — Date, `tb O / 6 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ( I1 Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 . CITY OF ENCINITAS AND MIZEL FAMILY " FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Diegueno Middle School PTSA - Band PROJECT TITLE: Diegueno Middle School Band Equipment and Instrument Purchases and Repair PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grar3t City of Encinitas & Mizel Family Foundation Grant Program Pending $5,000 In-kind donation Guitar Center, San Marcos,store credit toward drum set Secured $500 In-kind donation Repair of bass clarinet,from Frederique Vernhes family Secured $250 Donation from Frank Jones family Secured $500 Donation from Pat Cheng family Secured $500 Matching donation SAP Software Solutions corporate matching program Pending $500 In-kind donation from Kevin Bishop family Pending $250 Donation Parent donations from 2015-2016 school year to be applied to this program Secured $2,000 Donation Parent donations,2016-2017 school year Pending $1,350 INCOME TOTAL*: $10,850 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Drum set Ludwig Accent Combo 5-piece drum set with Meini cymbals($500 store credit listed as income above) $646 Trombone Yamaha YSL-354 series student trombone $ 1,265 Trombone Yamaha YSL-354 series student trombone $1,265 Digital Stage Piano Roland RD-30ONX stage piano $1,403 Music Stands Manhassett M48 standard metal music stands(8 cartons of 6 each) $1,487 Music Stand Storage Carts Manhasset music stand storage cart, holds 25 stands(quantity 2) $722 Student Posture Chairs Wenger Student Chair, Black(quantity 12) $1,050 Chair Storage Carts Wenger Chair Move and Store Cart(quantity 4) $1,512 Projected instrument repairs Projected repairs for instruments in current student inventory for 2016-2017 school year $ 1,250 Completed instrument repairs Bass clarinet repairs, listed as secured income above $250 EXPENSE TOTAL*: $10,850 Budget Form *Your Total Income and Total Expenses should be equal. California State IPTJT everychild.onevoice. 2327 L Street,Sacramento,CA 95816 (916)440-1985.Fax(916)440-1986•info @capta.org•www.capta.org LETTER OF DETERMINATION October 5,2015 Margaret Griffitts, Unit President Diegueno Middle School PTSA[3945] Dear Margaret: In response to request of this office concerning your PTA's tax-exempt status,a copy of our group ruling letter dated November 18, 1943,from Internal Revenue,which grants federal income tax exemption to all PTAs in California, is enclosed. You will note the Internal Revenue Code section at that time as referred to in the letter was 101(6)—now, Section 501(c)(3)as indicated in all PTA bylaws in California.The group exemption number assigned to the California State PTA is GEN-0646. Also enclosed is a copy of the February 24,2010 letter from Franchise Tax Board confirming PTA's exemption from state franchise or income tax under Section 23701 d of the Revenue and Taxation Code. Both the federal and state exemption letters cover all of our divisions—local units(associations),councils and districts.The letters are issued to the California Congress of Parents and Teachers, Inc.The corporate name was changed as indicated on this letterhead by vote of the annual convention on May 5, 1978,and has been recorded and filed with the Secretary of State with certificate endorsed on August 14, 1978. Diegueno Middle School PTSA is a unit in good standing. It was organized on September 30, 1987 according to our official records,and is chartered as a member organization of the California Congress of Parents,Teachers,and Students, Inc. Diegueno Middle School PTSA located at 2150 Village Park Way, Encinitas,CA,92024 in the Ninth District PTA,is a nonprofit,tax-exempt association under our group ruling.The Employer Identification Number(EIN)assigned to Diegueno Middle School PTSA is 330277530 and the assigned Franchise Tax Board entity number is 8016653. Sincerely, KayDee Walbum Accounting Assistant cc: District President NOV -6 1992 Internal Revenue Service Department of the Treasury District P.O.Box 2350 Los Angeles,Calif.90053 Director Person to Contact: FELICIA C MIRAFLOR i nPTA CALIFORNIA CONGRESS OF PARENTSrelephone Number: TEACHERS & STUDENTS INC PTA—CA31 213-894-2336 930 GEORGIA ST Refer Reply to: LOS ANGELES, CA 90015-1322 EO-1102 -92 Date: Noll 13°2 RE: PTA CALIFORNIA CONGRESS OF PARENTS TEACHERS & STUDENTS INC PTA-CA31 95-1683870 Gentlemen: This is in response to your request dated October 26, 1992 regarding the above named-organization. A review of our records indicate that this organization was recognized to be exempt from Federal income tax under Internal Revenue Code section 501(c) (3) . Group exemption number 0646 has been assigned to the parent organization and its subordinates. The determination letter issued in November 1943 continues to be in effect. You should contact your parent organization for a copy of their determination letter. If you need any further assistance, please peel free to contact our office at the above address or telephone- number. Thank you for youf cooperation. Sincerely, Felicia C Miraflor Disclosure Assistant i TREASURY DEPARTMENT WASHINGTON 25• i OFFICE OF COMMISSIONER OF INTERNAL REVENUE t AOORRSB nCPLV TO COMMIsmWElt W INTERNAL REVr-NUr '�1(�/ AND RM91 TO A■y IT.F.aT al -�MAD California Congress of Parents and Teachers, Inc., 416 Union Building, Second and Broadway, Sari Diego 1, California. ' $Qssd�mes: Reference is Aade- to the evidence submitted for use in deter- mining the status of-your local associatiom for federal income tax purposes. In Bureau ruling-dated February 26, 1945, it was held that You are entitled to exemption from Federal income tax under the provisions. of seation 101(6) of the internal Revenue Code and oorreeponding provisions of prior revenue acts as it is shown that you• are organized and operated exclusively for educational purposes. It is the opinion of this office, based upon the evidence presented, that you and the local associations appearing in your Year Book 1843-1944, California Congress of Parents and Teachers, Ina., are entitled to exemption from-Federal income tax under-the provisions of section 101(6)- of the 7aaternal Revenue Code and oorresponding provisions of prior revenue acts, as, it is shown that you and the local associations are organized-and operated exclusively for educational purposes. Accordingly, it will not be necessary for you and such associations to file returns of income unless there is a change in your organization, purposes or methods of operation. you should furnish the Bureau annually, on the calendar year basis,- lists in quadruplicate showing only-the names and addresses of any now local assooiati.ons and the names and addresses of any local associatioloswhich for any reason have ceased to exist.- 5110h annual lists should be accompanied by a statement sworn to by one of your principal officers as to whether the information heretofore submitted by yon on which this ruling is based is applicable in all respect-a to the associations appearing on the lists and should be I forwarded so as to reach this office not later than February lb of BUY the following year. k7f.R 2 - California Congress of Parents and Teachers, Inc. since any organization which is exempt from Pederal income tax under the provisions of section 101 of the Internal Revenue Code also is exempt from the capital stock tax pursuant to the express provisions of section 1201(..)(1) of the Internal Revenue Code, you and the local associations appearing in your Year Book 1943-1844 will not be required to file capital stock tar: returns for future years so long as the exemption from income talc is effective. Furthermore, under substantially identical authority con- tained in sections 1426 and 1607 of the Code and/or corresponding provisions of the Social Security Act, the employment taxes im- posed by such statutes are not applicable to remuneration for services performed in your employ or in the employ of such asso- ciations so long as the conditions prescribed above for retention of an exempt status for income tax purposes are mete Contributions made to you and the local associations listed are deductible by the donors in arriving at their taxable net income in the manner and to the extent provided by section 23(o) and (q) of the Internal Revenue-Code and corresponding provi®ions of prior revenue acts. Bequests, legacies, devises or transfers, to or for your use or for the use of such local associations are deductible.in ar- riving at the value of the not estate' of a decedent for estate tax purposes in the manner and to the extent provided by sections 812(d) and 861(a)(3) of the rode and/or corresponding provisions of prior revenue..aets. Sifts of property to you or them are deductible in computing net gifts for gift tax purposes in the manner and to the extent provided in section 1004(a)(2)(B) and 1004(b)(2) and (3) of the Code end/or corresponding provisions of prior revenue acts. The collector of internal revenue at Los Angeles, California, is being advised of this action. By direction of the Commissioner. Respeetfally, Deputy Co' i.oner. / f. April 1, 2016 City of Encinitas/Mizel Family Foundation Community Grant Program City Manager's Office City of Encinitas 505 South Vulcan Avenue Encinitas, CA 92024-3633 To Whom It May Concern: Our board is meeting next on April 19, 2016. The Resolution authorizing our grant application to the City of Encinitas/Mizel Family Foundation Community Grant Program is on the meeting agenda for that date. We will submit the approved Resolution to your office following that meeting. Please let me know if you have any concerns or questions regarding this Resolution. Thank you for your generous support of the community through the Community Grant Program! Sincerely, Patricia Jones President, Diegueno Band Boosters Diegueno Middle School PTSA 2150 Village Park Way Encinitas, CA 92024 ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION --:_ COMMUNITY GRANT PROGRAM - ORGANIZATION NAME: Diegueno Middle School PTSA - Band TITLE OF GRANT PROGRAM: Diegueno Middle School Band Equipment and Instrument Purchases and Repair UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Patricia A. Jones Title: President Signature: ' ' ` Date: f C) APPLICATION FOR FISCAL YEAR 2016x2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories:Civic or Arts program. Choose only one option. ■ Civic ❑Arts Grant Request Amount: 5,000 Free of Charge: ■ Yes ❑ No (Not to exceed$5,000) Program Title: Cardiff Surf Classic and Green Expo Concert Series ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt orqanizations may apply. Identify the legal status of your organization: ■ Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 956134107 it IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Cardiff-by-the-Sea Chamber of Commerce (Must match name filed under the Tax/Employer Identification Number) Street Address: n/a Mailing Address: PO Box 552, Cardiff CA 92007 Doing Business as(dba)Name: Cardiff 101 Main Street Please list the names and titles of the organization's Board of Directors: Susan Hays, President Josh Litchman, Treasurer Brenda Dizon, Vice President Christina Mortlock, Betty Steele, Bill Andersen Malte Farnaes, Secretary Brett Farrow, Morgan Mallory 9 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The Cardiff Surf Classic and Green Expo is hosted by C101 in partnership with the Friends of the Cardiff State Beaches and the Rob Machado Foundation as the title eco-sponsor. The event will feature a surf contest, musical entertainment, and live demos. New this year, Cardiff 101 is seeking funds to help with the community solar powered stage and musical performances. Encinitas is home to exemplary musical talent and C101 hopes to showcase these talents at our event. This family oriented event is free to the public and hosts local businesses that exemplify innovation in green architecture, artwork, sustainable cuisine, reuse and recycling. Grant monies will be directed toward a more robust concert series, marketing materials, as well as stage rentals and equipment. Grant funds will help Cardiff 101 improve the arts and cultural programming that has been lacking due to budgetary constraints in the past. Organizational History: The Cardiff-by-the-Sea Chamber of Commerce became an official California certified Main Street program in 2015 and promotes tourism, community wellness, and economic development for the Cardiff Community as well as the City of Encinitas. Application Fomi,Page One of Two ` x APPLICATION FOR FISCAL YEAR 2016-2017 f CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Cardiff State Beach and Beach Parking Lot Total Est. Cost: 31,752 Time Frame: November 5th, 2016 Number of Encinitas Residents Served: 5,000+ Fundraising Activity: ■ No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Annika Walden, Executive Director Mailing Address: PO Box 552 Cardiff, CA 92007 Telephone Number: 760 533 -1552 Email Address: awalden @cardiff101.com X Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Annika Walden Title: Executive Director lease print) Signatur._: 3,{' - � Date: April 12, 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Fomi, Page Two of Two *~¢`4!• APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Cardiff-by-the-Sea Chamber of Commerce DBA Cardiff 101 Main Street PROJECT TITLE: Cardiff Surf Classic and Green Expo Concert Series PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services,ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT y 5 000, I Sponsorship Private Soonsorship pendina 13 500 Inkind Donations Prizes for Surf Contest endin g 2 000 Vendors Enviromental Fair Vendor Booths 350 each/ 18 r)endina 6,500 Surf Contest Grom Surf Contest 40 entry Fee some fee's waived) r)endina 4 752 INCOME TOTAL*: $31,752 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Event Services Contest Coordinator Judges, SecuritV, Beach Marshall Scaffolding 3,550.00 Permit State Parks Permit Peace Officer Life Guards 9 750.00 Security Beer Garden Securitv 1,200 Rentals Allies Party Rentals 1,845 Trans ortation shi Transportation Shuttles 2 347 Stacie Alternative Power Productions 3,600 Advertising Print Ads $1,100 Marketinq Printing/ Banners $1,004 Parkina LAZ Parking Lot Buyout $2,356 Bands Musical Entertainment $5,000 EXPENSE TOTAL*: $31,752 Budget Form *Your Total Income and Total Expenses should be equal. CARDIFF CARDIFF- . 5 = , Cardiff 101 Main Street Board of Directors: Authorizing the Mizel Family Foundation Grant Application Resolution of the Cardiff 101 Board of Directors WHEREAS, the Cardiff 101 Main Street is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Cardiff 101 Main Street hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 12th day of April, 2016 f i dd Malte arnaes Secretary, Board of Directors, Cardiff 101 Main Street F7 IRSDaparta�zntoFthefreaaury _ .Il Inleraai Rerenna Servico In reply refer to: 0441861293 OG6%N UT 84201-0038 Apr. 14, 2009 LTR 41680 ED 95-6134107 000000 00 000 00028484 BODC: TE CARDIFF-BY-THE-SEA CHAMBER OF COMMERCE INC ,,, PO BOX 552 Li CARDIFF CA 92007-0552 toga Employer Identification !lumber: 95-6134107 Person to Contact: Erin Johnson Tall Fees Telephone Number: 1-877-829-5500 Dear Taxpayert This is in response to your request of Apr. 03, 2009, regarding your tax-exempt status. Our records indicate that a determination letter was issued in August 1966. that recognized you as exempt from Federal income tax, and discloses that you are currently exempt under section 501(c)(6) of the Internal Revenue Cade. Because you are not an organization described in section 170(c) of the Code, donors may not deduct contributions made to you. You should advise your contributors to that effect. If you have any questions, please call us at the telephone number shown in the heading of this letter. sincerely yours, Kb,O- $ds, Rita A. L.eete Accounts Management II U APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Cardiff-by-the-Sea Chamber of Commerce dba Cord, /a/ 1"41n TITLE OF GRANT PROGRAM. Mizel Family Foundation Community Grant UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipLents are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000)for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4)Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Annika Walden Title- Executive Director Contact Person _ _ Signa ire Date: April 12, 2016 t:�• e APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two cateqories:Civic or Arts program. Choose only one option. ❑Civic ]I Arts Grant Request Amount: $5,000 Free of Charge: M Yes ❑ No (Not to exceed$5,000) Program Title: "Wildcat Band"Instrumental Music Education Program ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: Iff Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0494856 O■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Cardiff Education Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: 1888 Montgomery Ave, Cardiff by the Sea, CA 92007 Mailing Address: Same Doing Business as(dba)Name: Cardiff SEA Musk Boosters Please list the names and titles of the organization's Board of Directors: Rebecca Rideout, President Mollie Casazza, Secretary Joy Sheppard, Vice President Annette Andranian, Member Alisha Adams, Treasurer Catherine Gold, Band Director Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the proj.ect/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program(Limit to the space provided): Our program provides beginning,intermediate,and advanced instrumental music instruction to all interested 4th-6th graders.Students are taught in small and large group settings twice a week by professional musicians and educators.We provide books,sheet music,as well as instruments and supplies.Our performances are free to the public, including two formal concerts,and several informal community events such as the Encinitas Holiday Parade and Taste of Cardiff.Our program fosters creative expression,discipline,teamwork,and a love for the arts!Our graduates help sustain music programs in local secondary schools,as well as contribute to a vibrant arts community in Encinitas.As a public school program,participation is free and provides many students their only opportunity for a music education.Our band enrollment has increased by 46%in the last three years,and we currently have 110 students participating!As our numbers grow,we continue to require more instruments,supplies,and instructional hours.District and parent donations cover 65%of program costs,while our remaining budget is covered by fundraising and community contributions. Organizational History: As a part of the Cardiff School District for over 25 years, the Wildcat Band, its students, and alumni,provide a cornerstone of musical literacy in Encinitas. It is one of the few elementary school band programs in North County. The all-volunteer Cardiff SEA provides high-impact education programs like the Wildcat Band that does not receive state funding. Application Form,Page One of Two - APPLICATION FOR FISCAL YEAR 2016-2017 = -.. CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Cardiff, CA Total Est. Cost: $37,300 Time Frame: September 2016- May 2017 Number of Encinitas Residents Served: 110 Fundraising Activity: It No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Rebecca Rideout Mailing Address: 2274 Carol View Drive D208, Cardiff, CA 92007 Telephone Number: (760)390-7728 Email Address: adamusicboosters @gmail.com 0 Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C, I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Rebecca Rideout Title: President (Please print) Signature: Date: 4-13-2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form(signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Cardiff Education Foundation PROJECT TITLE: "Wildcat Band" Instrumental Music Education Program PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas&Mizel Family Foundation Grant Program Pending $5,000 MATCHING FUNDS Cardiff School District-Band Director Stipend Secured $7,000 Direct Donations Band Families Donations Pending $19,400 Fund-Raising Bake Sales-4 Bake Sales at District Events Pending $1,000 Fund-Raising Disco Bingo Pending $1,500 Fund-Raising Talent Show Pending $1,000 Fund-Raising Change Wars Pending $400 Direct Donations Coastal Community Concert Band Donation Pending $2,000 INCOME TOTAL*: 1$37,300 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Director/Coaching 17 man hours/week x32 weeks 0$40 $21,760 10 performances x3 man hours each Q$40 $1,200 Instruments Purchase/replace 10 instruments 9$400 $4,000 Repairs 20 repairs @$80 $1,600 Books/Supplies Music books,arrangements,supplies,reeds $1,500 Music Stands Replace/add 6 music stands @$40 $240 Director Stipend Covers non instructional band director duties $7,000 EXPENSE TOTAL*: $37,300 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. BOX 2508 CINCINNATI, OH 45201 Date: �r r, yfi Employer Identification Number: 33-0494856 DLN: 17053330738000 CARDIFF EDUCATIONAL FOUNDATION INC Contact Person: 1888 MONTGOMERY AVE FRANCIS E BERNHARDT ID# 31258 CARDIFF-BY-THE-SEA, CA 92007 Contact Telephone Number: (877) 829-5500 Our Letter Dated: JUNE 1992 Addendum Applies: NO Dear Applicant: This modifies our letter of the above date in which we stated that you would be treated as an organization that is not a private foundation until the expiration of your advance ruling period. Your exempt status under section 501(a) of the Internal Revenue Code as an organization described in section 501 (c) (3) is still in effect. Based on the information you submitted, we have determined that you are not a private foundation within the meaning of section 509(a) of the Code because you are an organization of the type described in section 509(a) (1) and 170 (b) (1) (A) (vi) Grantors and contributors may rely on this determination unless the Internal Revenue Service publishes notice to the contrary. However, if you lose your section 509(a) (1) status, a grantor or contributor may not rely on this determination if he or she was in part responsible for, or was aware of, the act or failure to act, or the substantial or material change on the part of the organization that resulted in your loss of such status, or if he or she acquired knowledge that the Internal Revenue Service had given notice that you would no longer be classified as a section 509(a) (1) organization. You are required to make your annual information return, Form 990 or Form 990-EZ, available for public inspection for three years after the later of the due date of the return or the date the return is filed. You are also required to make available for public inspection your exemption application, any supporting documents, and your exemption letter. Copies of these documents are also required to be provided to any individual upon written or in person request without charge other than reasonable fees for copying and postage. You may fulfill this requirement by placing these documents on the Internet. Penalties may be imposed for failure to comply with these requirements. Additional information is available in Publication 557, Tax-Exempt Status for Your Organization, or you may call our toll free number shown above. If we have indicated in the heading of this letter that an addendum applies, the addendum enclosed is an integral part of this letter. Letter 1050 (DO/CG) .CARDIFF EDUCATIONAL FOUNDATION INC Because this letter could help resolve any questions about your private foundation status, please keep it in your permanent records. If you have any questions, please contact the person whose name and telephone number are shown above. Sincerely yours, Steven T. Miller Director, Exempt Organizations Letter 1050 (DO/CG) C) RECORDERICOUNTY CLERK 2009-024(01 PLEASE PRINT/TYPE INFORMATION COUNTY OF SAN DIEGO 11111 111111111 11111 11111 11111 11111 1111 1111 AND RETURN ENTIRE FORM 1600 PACIFIC HIGHWAY,STE.260 P.O.BOX 121750 SAN DIEGO,CA 92112-1750 (619)237-0502 A G-25-2009 $30.00 - FOR FIRST BUSINESS NAME ON FILED SELECTED COPIES: STATEMENT DANTD L.BUTLER $5.00 - FOR EACH ADDITIONAL BUSINESS NAME SAN DIEGO COUNTY CLERK NEWSPAPER • Yes No FILED ON SAME STATEMENT AND DOING FEES: 34.00 CUSTOMER • Yes No BUSINESS AT THE SAME LOCATION EXPIRES: ALIC-25-2014 S5.00 - FOR EACH ADDITIONAL OWNER IN EXCESS DEPUTY: DLE`VIS3 OF ONE OWNER FICTITIOUS BUSINESS NAME STATEMENT (1)FICTITIOUS BUSINESS NAME(S): a Cardiff SEA b. (2)LOCATED AT: 1888 Montgomery Avenue, Cardiff, CA, San Diego, 92007 Street Address(P.O.Box not acceptable) City State County Zip Mailing Address P.O. BOX 1004, Cardiff, CA 92007 (opt-11) (3)THIS BUSINESS IS CONDUCTED BY: ❑ A. An Individual ❑ E.Joint Venture ❑ I.A Limited Liability Company ❑ B.Husband and Wife El F.A Corporation ❑ J.Limited Liability Partnership ❑ C.A General Partnership ❑ G.A Trust ❑ K.An Unincorporated Association-Other than a Partnership ❑ D.A Limited Partnership ❑ H.Co-Partners ❑ L. State or Local Registered Domestic Partners (4)THE FIRST DAY OF BUSINESS WAS: 11/13/1991 OR IF NOT YET STARTED,CHECK HERE ❑ (5)THIS BUSINESS IS HEREBY REGISTERED BY THE FOLLOWING: #1 Cardiff Education Foundation Owner's,Partner's.Trustee's Name or Corporation/LLC Name 1888 Montgomery Avenue Residence/CorporationfLLC Street Address Cardiff, CA 92007 city State Zip California Corporation or LLC-Print State of IncorporationfOrganizatior R Owner's,Partners,Trustee's Name or Corporation/LLC Name Residence/Corporation/LLC Street Address City State Zip Corporation or LLC-Print State of Incorporation/Organfzabon I declare that all information in this statement is true and correct.(A registrant who declares as true information which he or she knows to be false is guilty of a crime.) (6) (Signature of R..aatngf) (Print name) (Corp.ILLC pruR Tare) THIS STATEMENT WAS FILED MTH'-�£RECORDERICOUNTY CLERK OF SAN DIEGO COUNTY AS INDICATED BY FILE STAMP ABOVE NOTICE–THIS FICTITIOUS NAME STATEMENT 1vPIRPS FIVE YEARS FROM THE DATE IT WAS FILED IN THE OFFICE OF THE COUNTY CLERIC A NEW FICTITIOUS BUSINESS NAME STATEMENT MUST BE FILED BEFORI!THAT TIME.THE FILING OF THIS STATEMENT DOES NOT OF ITSELF AUTHORIZE THE USE IN THIS STATE OF A FICTITIOUS BUSINESS NAME IN VIOLATION OF THE RIGHTS OF ANOTHER UNDER FEDERAL,STATE,OR COMMON LAW(SEE SECTION 14411 ET SEQ.,BUSINESS AND PROFESSIONS CC'' IT IS THE RESPONSIBILITY OF THE REGISTRANT TO DETERMINE THAT THE FICTITIOUS BUSINESS NAME SELECTED WILL NOT VIOLATE AN OTHER'S RIGHTS E ISHED UNDER LAW. FORM 231 Ca.CLK(REV 01101x2009) RECORDERICOUNTY CLERK Ada Harris Music Boosters Meeting Agenda March 2, 2016 8:30 am Participants: Cat Gold, Becky Rideout, Mollie Casazza, Joy Sheppard,Annette Andranian 1. Agenda Review 2. February Minutes approved-Approved 3. Music director's report- New percussion instruments have arrived. Kids are very excited. Coastal Community Concert Band TBA, still trying to solidify date. 4. Treasurer's report-Alisha absent. Money is coming in for Disco Bingo. 5. Old Business- a. Disco Bingo-30 Families attending so far, more to come in. Went over with DJ Cat the set up. One of the Boosters needs to take tickets. Put everything in envelop, meal tickets, cards. Need someone to run Photo Booth. Dessert Table Cash only, no tickets, $2.00 Cupcakes$1.00 rice crispy and pretzel rods. Good on Prizes. Two$15 from East Coast. $25 from Zambazon. Basket from Starbucks. Souplantation 2 Free Meals. Native Foods $40 and cookbooks. In and Out two $15. Baker and Olive- Olive Oil and Balsamic. Movie Gift Card one$25. What needs to be purchased-Water, Hot Dogs, Hot Dog Buns, Soda Root Beer, Sprite, Diet Coke, Ketchup, Mustard, Chips, Plates, Napkin, Serving Tongs, Trays, Bags of Ice, Food Handling Gloves. 6. New Business-Joy, Pizza for Pizza Day this afternoon. Change Wars?April 16th SDA Arts Event, in the afternoon. a. Talent Show-This is not a competition, it is for fun!!Try-outs week of March 21st. b. Cardiff Concert- Do we take both bands? 4th Graders really enjoy going back to Cardiff. Parent Drivers Needed to take students and instruments. Band Photo and Advanced Band Photo seperately. c. Ice Cream Social- May 7th d. Spring Concert- May 18th e. Mizel Grant Application due April 14th.Application available today, March 2. Becky and Cat to fill out application, Becky will turn in by April 14th. Adjournment- 9:45 ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Cardiff SEA Music Boosters TITLE OF GRANT PROGRAM: "Wildcat Band" Instrumental Music Education Program UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn-. City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Rebecca Rideout Title: President f Signature: Date: 4-13-2016 J'I Tv r, - NIT, I certify that the costs outlined in this request have been incurred in accordance with t aporovFNI,Yo.vktrqNgram proposal is set forth in the grant agreement document and that the information is accurate and complete. THIS FORM CANNOT BE EMAILED OR FAXED,WE NEED AN ORIGINAL SIGNATUR .5 IN Name: ebecca Rideout Signature: EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY -' GRANT PROGRAM FY2014/15 Date Organization: Cardiff Education Foundation,Inc. (Dba: Cardiff SEA Music Boosters) Address: 1508 Windsor Rd City: Cardiff State CA Zip 92007 Phone: 760-390-7288 Fax 760-635-3950 Email: adamusicboosters(�email.com State the goals and objectives of your project and whether they have been met. I'he primary goal of the band program is to provide a high quality instrumental music education program for all interested 4th-6th graders in the Cardiff School District. A high-quality program will teach the students proficiency on their instrument and in music reading,mastery of ensemble playing, and will be open to all interested students regardless of their ability to contribute financially.Further, the program should provide both small and large, formal and informal, performance opportunities. Other goals include maintaining or increasing participation, providing high quality, enjoyable performances, and making music learning fun. These goals have been met. How were the goals and objectives of your project measured? The band enrolled a record 101 students in the Fall, 93 of whom finished the year to perform in the Spring Concert.This is a 25%increase over last year.The band included 39 families who did not make any financial contributions to offset the cost of providing instruction and instruments, and 15 students whose families made partial contributions.No student was turned away. Instrument proficiency was observed by the difficulty of the pieces and the performance level at the Spring Concert.Many who attended the concert commented on how entertaining and skilled the band members were. The band learned and performed diverse musical styles including classical,jazz,world, show tunes,patriotic, pop, and rock.Approximately 250 people attended the Spring Concert.Further,the band performed in the Encinitas Holiday Parade, Cardiff Ice Cream Social, and the Taste of Cardiff. Finally, an anonymous survey of band parents was conducted at the end of the term.Forty-nine parents responded ?nd were polled on their level of satisfaction in several areas of the program.The survey showed high satisfaction across the board, including in areas of progress on the student's instrument, performance experience, and overall enjoyment of the program.Approximately 96%of respondents were somewhat satified or better,with two-thirds of respondents being very satisfied. How many Encinitas residents did you expect to serve through the project? 84+Audiences How many Encinitas residents did you actually serve through the project? 100+Audiences Based on the outcome of this year's project, what changes/improvements will you make next year? Clear and accessible communication with our Spanish speaking parents needs to be improved. We plan to have all written material as well as electronic emails translated into Spanish by our Bilingual Coordinator and provided in hard copy form. We also plan to start a"band buddies" system that will pair more experienced band members with students who are new to our program.This will help foster a sense of community across our growing band program and help our newest members feel welcomed. Positive outcomes? The positive outcomes from teaching a child both proficiency and ensemble performance technique cannot be overstated.Through participation in the arts, children learn life skills such as teamwork, discipline, and accountability. Overwhelming research shows that instrumental music students enjoy significant improvements in self-esteem, academic skills, and overall life acheivement.The Wildcat Band positively represents the school district in the community, and is a source of community pride.Also,the band provides training to students from low-income families who have no other option for learning instrumental music. Almost three-quarters of our survey respondents reported that they were very satisfied with their child's enjoyment of the program, with 96%of survey repondents at least somewhat satisfied. Here are some comments: "We love everything about your program.Thanks for all of your hard work and effort". "Very smooth, well run, excellent, high quality program." "Excellent program -we consider ourselves very fortunate!" "Cat Gold has been amazing! I love that she supports the dedicated band member who practices all the time and takes extra lessons as well as the one who is just comes to their sectional and band practice. Some might have chased my daughter away because of her dedication level, but Cat just continued to encourage and support." Another positive outcome is that alumni from our program go on to become valuable participants in music programs at our local secondary schools. With their three years of training in the Wildcat Band,they often become mentors for newer musicians and serve to elevate the playing level of their programs.The Band Director at Oak Crest Middle School,Mrs.Julie Yaeger,told us"I rely on the Ada Harris Band program to provide experienced musicians who lead my ensembles, and afford us the opportunity to offer band at the middle level."Mr.Jeremy Weurtz,Music Director at San Dieguito academy,wrote, "Several of the finest tudents I have had in the SDAMusic Program played in the band at Ada Harris." FOR FIS PAL YEAR 2016@2V 7 CITY OF ENCINITAS AND MIZEL FAMILY FOIJNDATi0N COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classy ibli' irtc,two categories. Civic or Arts program. Choose only one option. ❑Civic ■ Arts Grant Request Amount: $5,000 Free of Charge: ` Yes ® No (Not to exceed$5,000) Program Title: Twelfth Annual Encinitas Pops Concert:A Salute to Young Musicians ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: ■ Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 91-2157402 a IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Coastal ommunl ieS Concert Band oun a Ion Must match name filed under the Tax/Employer Identification Number) Street Address: 1392 Peachwood Drive, Encinitas, GSA 92024 Mailing address: Same Coastal Doing Business as (dba) Name: Communities Concert and Please list the names and titles of the organization's Board of Directors: Kate Takahashi, President Chris Banker, Member at large Judy Thum, Secretary and Community Liaison Eleanor Tibbals-Pennington, Memb. at large Kathy Marshall-Lund, Treasurer • Board Approval, A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): ore even years now, the Coastal Communities once Band (CCCB) has performed this popular concert for the residents of Encinitas and beyond, thanks to the generous grant from the City of Encinitas and Mizel Family Foundation. At this concert we invite up to 32 student musicians from the four local high schools, recommended by their band directors, to join us for the second half of the program, during which we present up to five scholar- ships to the students who have chosen to audition for them. The top winner is invited to perform as a soloist with the band at this concert the following year. This year, Max Opferkuch, clarinetist from San Dieguito Academy, will perform at our May 1, 2016 Encinitas Concert. This concert encourages youths' participation in music, and it appeals to all ages! The CCCBand was formed in 1983 to provide a way for adults to share the joy, beauty, and org anizational History: excitement of playing a musical instrument with other musicians. Today it is a 75-piece symphonic band, under the auspices of an Dieguito Adult School. It has performed our Imes In Europe and has earned the coveted u er bilver 6croll Award. Application Form,Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: San Dieguito Academy Gymnasium Total Est. Cost: '75 Time Frame: Sunday, April 17, - 4: M Number of Encinitas Residents Served: +-50 Fundraising Activity: * No 0 Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Judy Thum, CCCBand Secretary and School/Community Liaison Mailing Address: 1392 Peachwood Drive, Encinitas, CA 92024 Telephone Number: 760-436-0783 Email Address: ludythum@hotmail.com ® Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Judy Thum Title: Secretary& Community Liaison (Please print) April 12, 2016 Signature: p,v,,i Date: THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment (IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Coastal Communities Concert Band Foundation PROJECT TITLE: Annual Encinitas "Pops" Concert: A Salute to Young Musicians PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and a;! other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT G;'ant City of Encinitas& Mizei Family Foundation Grant Program Pending Matching Fun—ds-7-1 inTdonation of time by 75 musicians each Secured 15, Matching Funds In-kind director pay by San Dieguito Adult School Secured Donation Tickets to concert, est. audience: each en ing INCOME TOTAL*: 1$22,750 EXPENSE: Lis-.l all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST In Kind Donation ot time by 15 musicians n Kind Director's pay : by u t coo ; by Salary PA sound System Salary Sound Recording Cartage Pulling of trailer full of music stands, percussion, etc. to venue 1 Donation To SDUHSD SDA Band Boosters for helping with set-up Postage Concert Mai ers ostage ranting of rograms 6 Supplies New music 650 Marketing Photography/Displays/Flowers for soloist/ Miscellaneous 425 c o ars ips Awards of each to student musicians in 2nd, 3rd, 4th, 5tF–pTa—ce Custodial Fee Custodian's fee paid to SDUHSD 5 EXPENSE TOTAL*: $22,750 sudze*. (cur Total lncorne and Tota'Expenses snuuld be equal. 2, C . BJX 2_=.. STALE'"Z MR } - Basel are .J':EtIiQ`. '1:..., •. e-a; "; _,2L 5a. 7� 'ha"° f, "� . i '.d�^S1i72� -.L �a-:F a,lizxg of sa::t�c 3 a, -= -- - _ ry,_��3:ypr�r'!"$, = +o�- a � � +— e- - �' � ice$.rot + - .2.a° __• ...-`�-4 _ �zaug•_ a� fo lr :a, a,:a -3 a—_ '[ie;'z tc y-D`'x y Y.=3 3 =iL ,. 5 a:: Coastal Communities Concert Band Foundation Board of Directors Meeting March 28, 2016 LN ATTENDANCE: Board members: Chris Banker,Kathy Marshall Lund, Kate Taka- hashi,Eleanor Tibbals-Pennington, and Judy Thum.Also in attendance were member Lucy Zizka and conductor Tom Cole. Gary Adcock arrived later. CALL TO ORDER:The meeting came to order at 5:30 PM. Newly elected board members, Chris Banker and Eleanor Tibbals-Pennington were wel- comed. Officers were appointed by unanimous votes to include: President: Kate Takahashi Secretary: Judy Thum Treasurer: Kathy Marshall-Lund Members at large: Chris Banker and Eleanor Tibbals-Pennington It was decided to keep the meetings of this board at the same time: Fourth Mondays of the month at 5:30 pm, in Room L-1 at Oak Crest Middle School. APPROVAL OF MINUTES: The minutes were approved as corrected. TREASURER'S REPORT: See attached. CONDUCTOR'S REPORT: None OLD AND NEW BUSINESS: A. Chris Banker reported that he has created Googlegroups, so that all board members can be included in communications about CCCB business. Chris can set up oth- er groups to include section leaders, section members, section coaches, etc Kate handed out instructions for use of our WWW.CCCBAND.COM-Members Only website, to re- set our user names and passwords. (See attached.) Our website will contain recordings for members to use as practice guides. B.Anniversary Party: Judy and Karen Garst-Russo selected Garcia's restaurant to cater Mexican cuisine for the 33rd Anniversary party to be held at Judy's home on Sun- day,April 17 from 2:00 until 5:00 pm. Chris will design an e-vite to be sent to the mem- bers, and Judy will make announcements at rehearsals. C.Travel: Gary Adcock reported that 56 members of the Arizona Winds from Tempe will participate in a joint concert with us on June 12. Half of those members are interested in getting together with our members the night before. Gary is still investigat- ing venues. San Dieguito park is being considered. D.The board gave instructions to Judy to apply for the Community Grant from the City of Encinitas and Mizel Family Foundation to put on our Encinitas Concert in 2017. E. Update on Salute to Young Musicians Concert:Tom will introduce the students tonight.Auditions will be held starting at 4:00 pm on Monday,April 18.Judy has re- APPLICATION FOR FISCAL YEAR 2016-2017 Cln' OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Coastal Communities Concert Band Foundation TITLE OF GRANT PROGRAM: City of Encinitas and Mizel Family Foundation C. G. Prog UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipLents are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Judy Thum Secretary & Community Liaisc Contact Person: Title- - April 12, 2016 Signature: ✓ � � Date: e EVALUATION FORM -L r CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014115 Date J�t,ne Its ►5 Organization. Coastal Communities Concert Band Address 13q 2 '1e&chwood Dr. City: r-nci n;VA.S _ State CA Zip q n o a Phone `140- 4314- 0 793 Fax Email: State the goals and objectives of your project and whether they have been met. To provide an afternoon of musical entertainment for our audience, and to involve local high school student musicians and inspire them to continue their music education. The above goals were met. We had an audience of over 350. Twenty seven students from 3 local high schools participated, and we awarded three $750 scholarships and one $1500 scholarship to the four students having the highest scores at the auditions. Last year's winner of the Caneva Scholarship, Catherine Marshall, impressed the band and audience with her flute performance of Cecile Chaminade's Concertino. How were the goals and objectives of your project measured? 1. The musicians were pleased with their efforts. The CD of this concert turned out very well. The student musicians also felt good about their performance. 2. Our new conductor, Tom Cole, did an outstanding job of integrating the students with our regular members, and thought the performance was terrific. 3. The survey of student musicians (see attached) shows how much they enjoyed being part of this honor band. Last year they suggested wanting harder music, and this year we met their standard. 4. The audience was very appreciative of both the program and the quality of music. Who participated in the evaluation process'? Those participating in the evaluation process were the following: 1. The band members 2. The conductor 3. The high school student musicians and their parents 4. The audience 5. The principal of the San Dieguito Adult School, who presented 3 of the scholarships How was the City funding for this project utilized? Funding from the City was used to pay for publicity, programs, recording, custodial and haulage fees, partial pay for the conductor, music for the concert, flowers for the soloist, and for three of the four scholarships. (Please see reimbursement budget figures.) T: CGP 0 1 CGPTemplates, Forms Agreement Return Letter with fonns.doc APPLICATION FOR FISCAL YEAR 2015-2017 CITE! OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories, Civic or Arts program, Chuose only one option. ■Civic ❑Arts Grant Request Amount: $5,000 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Holiday Baskets ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: R Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-3497926 © IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Community Resource Center (Must match name filed under the Tax/Employer Identification Number) Street Address: 650 Second Street Encinitas,CA 92024 Mailing Address: 650 Second Street Encinitas, CA 92024 Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: Paul Redfern- Chairman; Morgan Day-Vice Chairman Katrina Dodson; Mary Murphy; Lee Morrison; Craig Shugert-Secretary; JoAnne Berg-Treasurer Shawn Pynes; Lewis Shender; Jason Tajima Duanne Nelles- Past Chairman; Sandra Conners Diane"DJ"Weed; Carl Wright ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Community Resource Center's(CRC)34th Annual Holiday Baskets program will provide poultry,produce,non-perishable foods,outerwear,blankets,household essentials,infant and toddler products, age-appropriate toys,and refurbished bicycles(as available)to approximately 1,700 low-income households in North San Diego County.This program benefits over 1,200 Encinitas residents, increasing their short-term food security and freeing up limited income for other critical expenses. Information is provided to all participants regarding CRC's self-sufficiency programs as well as for other supportive services available through our partner agencies including San Diego County Health and Human Services,the Migrant Education Program, and local Head Start programs.San Diego Gas and Electric is also present to enroll clients in the CARE program,which provides monthly discounts on energy bills for low-income customers. Holiday Baskets utilizes over 2,000 volunteers who collect items for distribution and provide set-up and support for the three-day event. This opportunity not only benefits the volunteers, it also promotes unity and philanthropy within the community. Organizational History: Established in 1979, CRC's mission is to provide families in need and victims of domestic violence with safety, stability, and a path to self-sufficiency.As the primary provider of social services and DV programs in coastal North San Diego County,CRC serves over 2,300 households(8,000 individuals)every year. Application Form,Page One of Two ` APPI-1CATION FOR F!SCAL YEAR 2016-2097 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Distribution: Del Mar Fairgrounds; Registration: CRC and partnering agencies Total Est. Cost: $145,000 Time Frame: 11/1/2016-12/31/2016 Number of Encinitas Residents Served: 1200 Fundraising Activity: 9 No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Robert Kent;Acting Executive Director and Director of Finance and Operations Mailing Address: 650 Second Street Encinitas, CA 92024 Telephone Number: (760)230-6526 Email Address: rkent @crcncc.org a Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. 1 hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Robert S. Kent Title: Acting Executive Director (Please print) Signature: Date: IP THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements:en Yes I� No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Community Resource Center PROJECT TITLE: 2016 Holiday Baskets PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending Grant City of Del Mar Pending $2,500 Grant City of Solana Beach Confirmed $5,000 Grant County of San Diego Neighborhood Reinvestment Program Pending 1$15,000 Grant Farrell Family Foundation Pending $10,000 Grant Stater Brothers Charities Pending $3,000 Grant Wells Fargo Pending $5,000 Donation Public Support/Donations Pending $104,500 INCOME TOTAL*: 1$145,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Personnel salaries/wages/fringe benefits $45,000 Bike Supplies supplies for bicycles and helmets $5,000 Non-Food Items for Clients diapers,toys,and other items not received via donation $12,000 Food turkeys,chickens,and food not received via donation $50,000 Supplies food boxes,signs,program supplies $6,700 Durable Equipment racks and containers $8,300 Rental storage for donated goods and refrigeration rental $15,000 Transportation use of CRC truck for pick-up and delivery of items $2,000 Postage and Misc. postage and delivery;telephone;outreach;volunteer coordination $1,000 EXPENSE TOTAL*: $145,000 Budget Form *Your Total Income and Total Expenses should be equal. 0 0:� . community reso Center Proving lives can change RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF Community Resource Center WHEREAS, the Community Resource Center is a legally constituted corporation or public/governmental entity, under the laws of the State of Califronia, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED,that the Board of Directors of the Community Resource Center hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted q this 13th Day of April, 2016 r Craig Shugert Secretary, Board of Directors Community Resource Center 650 2nd Street I Encinitas. a �_. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION _ ' COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Community Resource Center TITLE OF GRANT PROGRAM: 2016 Holiday Baskets UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Robert S. Kent Title: Acting Executive Director 1\- � �I �' r3 Signature: ' Date' t EVALUATION FORM TAN CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATk ' I ` Q ' CLE�'J'. COMMUNITY GRANT PROGRAM FY2015-16 2Q'" 3 5 Date 2/23/2016 Organization: Community Resource Center Address: 650 Second Street City: Encinitas State CA Zip 92024 Phone: (760)753-1156 Fax (760)753-0252 Email: Iwilliams @crcncc.org State the goals and objectives of your project and whether they have been met. The goal of the 2015 Holiday Baskets was to provide low-income households from North County with resources that help to facilitate food security,personal and financial stability,and a path to self-sufficiency during a particularly stressful time of year.Our objective was to increase the short-term food security for approximately 1,700 low-income households,allowing for a percentage of their income to go towards expenses outside of food during the holiday season. Outcome:1,710 households were served(equating to over 7,200 individuals)--including 941 Encinitas residents--by the 2015 Holiday Baskets Program. Through the Holiday Baskets distribution,families are able to experienced increased short-term food security,as each household is provided with either a chicken or turkey and enough food to feed a family of four for approximately one week.CRC reached out to local churches,schools,affordable housing complexes,and other social service agencies to enroll low-income families in the program.Instrumental in this enrollment process was a partnership with Migrant Education,whose staff performed outreach beyond CRC's local capacity.In addition to food,participants were able to select one piece of outerwear for each family member,blankets and linens,pet food donated by the Rancho Coastal Human Society,age-appropriate gifts,and bicycles as available.Participants were also connected to other service providers and supportive services thorughout thecommunity including representatives from Covered California and San Diego Gas&Electric,who provided information about their programs for low-income families. How were the goals and objectives of your project measured? CRC measures outcomes using indicators such as number of households and individuals served,demographic information,household size,income,place of residence,and attendance through Efforts to Outcomes(ETD),CRC's web-based database. Who participated in the evaluation process? The Monitoring and Evaluations Manager tracked client information and monitored the number of households and individuals served through the Holiday Baskets Program.The Director of Programs,Social Services Program Manager,and Monitoring and Evaluations Manager worked with volunteer captains to evaluate overall program execution.Evaluation results are included in reports submitted to program funders,as well as in CRC eNewsletters and other collateral. How was the City's funding for this project utilized? The City's funds were used to purchase crucial food items for distribution to low-income households that helped to ensure that each family received enough food to cook a holiday meal and provide for their household's food needs for an average of one week. FYI 5-16 CGP REIMBURSEMENT& EVALUATION FORMS How many Encinitas residents did you expect to serve through the project? 900 How many Encinitas residents did you actually serve through the project? 941 Based on the outcome of this year's project, what changes/improvements will you make next year? To improve next year's Holiday Baskets,CRC plans to: Increase the number of tickets distributed overall to maximize the number of Encinitas households served Streamline the check-in process at the event for clients in order to more efficiently serve participants and capture better data *Streamline the data entry process to make it less work-intensive and to capture more meaningful data *Expand the registration process to cover more external organizations Positive outcomes? CRC was able to serve over 1,700 households(over 7,200 individuals and inclusive of 3,800 children)and provide all participants with food,blankets and linens,jackets,and gifts,and in some cases,based upon elegibility,a bicycle.CRC was also able to improve the registration process from the previous year by increasing flexibility and scheduling so that clients could select the best date and time that would work for them.Additionally,every year Holiday Baskets engages approximately 2,000 volunteers and participants from community groups who make this program possible. Negative outcomes? The negative outcomes for this year's Holiday Baskets took place behind the scenes.Data entry and learning to use and build out a new database for Holiday Baskets purposes proved to be more time consuming than originally expected.However,CRC staff received feed back from clients that the event was one of the best distributions they had experienced yet. V Please attach copies of all printed materials, articles and press clippings. ® Please attach a copy of newspaper articles or media coverage on the project. al- 4, l 3 Signature Dat t Name (print or type) Title Upon completion of the project please submit this form and attachments to: City Manager's Office City of Encinitas 505 S. Vulcan Avenue Encinitas, CA 92024 NOTE: This form must be submitted no later than June 30, 2016. Applicants who fail to submit their evaluation form may be ineligible for grant funding in FY2016-17. Tel 760/633-2600 FAX 760/633-2818,505 South Vulcan Avenue,Encinitas,CA 92024 TDD 760/633-2700 APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two cateqories: Civic or Arts proqram. Choose only one option. 19 Civic ❑Arts Grant Request Amount: $5000 Free of Charge: ■ Yes ❑ No (Not to exceed$5,000) Program Title: Alley Activation Plan ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: FL Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-3843066 ❑■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Downtown Encinitas MainStreet Association (Must match name filed under the Tax/Employer Identification Number) Street Address: 818 S Coast HWY 101 Encinitas CA 92024 Mailing Address: Same Doing Business as (dba) Name: Encinitas 101 MainStreet Association (E101) Please list the names and titles of the organization's Board of Directors: Dave Peck, President/Shawn Shamlou, VP John Dewald/Jarrod Harms/Doug Long/ Carolyn Cope, Secretary/Shelly Sougias, Treasurer Bev Goodman/Bart Smith/Lorraine Telnak/ Board Members: Haven Dunn/Emily Hart/Tom Cozens C■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program(Limit to the space provided): Phase II of the Alley Activation Project will provide more enhancements in the alley to the west of HWY 101, between D to E Streets.The addition of murals,landscaping and lighting here continues to repel the presence of the negative element that was seen here for years.By creating an inviting,artistic alleyway for the public to stroll through, nefarious activities continue to be minimized in the face of public scrutiny.The project's scope includes employing local artists to paint murals on several store backs, planting succulent walls as well as street-level planter boxes,creating dumpster enclosures and installing ambient lighting for night viewing and safety. We will recommend businesses open their back doors to invite guests in through the alley.The increased foot traffic will enliven the area.For years,this alley has drawn drugs&drinking, negatively impacting our youth, residence and merchants in our otherwise family-oriented community. Discussions with the business owners located here indicate that all involved already notice a difference and believe this project will continue to have a positive, lasting impact.A$10,000 grant from the county in 2015 further increases the effectiveness of this project. Organizational History: E101 has served, and worked with,downtown businesses, residents,visitors&the City for over 27 years by providing events, promotions, programs and advocacy. Our mission is to preserve, improve and promote culture, character and commerce of Downtown Encinitas. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: The alley between Coast HWY 101 and 2nd, from D to E Street Total Est. Cost: $31,000 Time Frame: July 1, 2016-June 30, 2017 Number of Encinitas Residents Served: All Fundraising Activity: N No C Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Thora Guthrie, Executive Director Mailing Address: 818 S Coast HWY 101 Encinitas, CA 92024 Telephone Number: 760-943-1950 Email Address: tguthrie @encinitas101.com ❑■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Angie Gallo Title: Operations Coordinator (Please print) c F Signature: 1 �` l�1 1\� . April 13, 2016 g Date. THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: Yes E] No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 -_ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Downtown Encinitas MainStreet Association PROJECT TITLE: Alley Activation Program PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services,ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Grant County of San Diego Community Enhancement Grant 2016/2017 Pending $15,000 Business Donations Target Businesses Pending $5,000 Business Sponsors Business Sponsors Pending $2,500 Event Fundraising Event Pending $2,000 Business Sponsor EDCO Waste Management Pending $1,000 In-Kind Food Donation for Special Event Pending $500 INCOME TOTAL*: $31,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Rendering Conceptual Renderings to Help Donors Visualize Project $250 Wall Prep Preparation of Mural Walls Prior to Actual Painting $1,000 Artwork Artists'Time&Labor $17,000 Wal Prep Preparation of Garden Walls Prior to Planting $1,000 Plants Plant Purchase $3,000 Electrician Lighting Installation $2,000 Printing In-Kind Printing of Materials $250 Food In-Kind Food Donation for Fund Raising Event $500 Planter Boxes Succulent Wall Plantings $3,000 Labor Laser Lighting Installation $3,000 EXPENSE TOTAL*: $31,000 Budget Form *Your Total Income and Total Expenses should be equal. [aIRS cpa�lmont of the Treasury ]Dtern.l Revenue Servlce P.0, BOX 2500, Room 4010 In reply refer to: 4077552510 Cincinnati GH 45201 Jan. 20 , 2010 LTR 41680 0 95-3843066 000000 00 00022266 BdDC: TE DOWNTOWN ENCINITAS MAIMSTREET ASSN 818 S COAST HIGHWAY 101 ENCINITAS CA 92024-4401 001938 Employer Identification Number: 95-3843066 Person to Contact: Michelle Jones Toll Free Telephone Number ; 1-677-829-5500 Dear Taxpayer ; This is in response to your Dec. 23, 2009, request for information regarding your tax-exempt status. Our records indicate that Your organization was recognized as exempt under section 501(c) (6) of the Internal Revenue Code in a determination letter issued in August 1983, ►� Because you are not an organization described in section 170(c) of the Code, donors may not deduct contributions made to you . You should advise your contributors to that effect. If you have any questions, Please call us at the telephone number shown in the heading of this letter. Sincerely yours, Cindy Thomas Manager, FO Determinations f;Gf� Encinitas 101 MainStreet Association J 1�1r 818 S. Coast Hwy 101 Encinitas, CA 92024 ENCINITAS �c 260.943.1950 D0WNi0WH1..u:: B EACH - RESOLUTION FROM THE BOARD OF DIERECTORS OF ENCINITAS 101 MAINSTREET ASSOCIATION AUTHORIZING THE GRANT APPLICATION FOR THE CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM WHEREAS, the Encinitas 101 MainStreet Association is a legally constituted corporation under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE BE IT RESOLVED that the Board of Directors of the Encinitas 101 MainStreet Association hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 20156-2017 Fiscal Year. Adopted on this 13th day of April, 2016 r Carolyn Chi Secretary of the Board of Directors Encinitas 101 MainStreet ATTAC'MMENT S ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Downtown Encinitas MainStreet Association TITLE OF GRANT PROGRAM: Alley Activation Project UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City M ra ger, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Angie Gallo Title: Operations Coordinator Signature: �y y' ' I D April 13, 2016 Si Date- 5 EVALUATION FORM = CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION 'T COMMUNITY GRANT PROGRAM FY2014115 Date Organization: Downtown Encinitas Main Street Association Address: Q t City: r, .. a S State !_P- Zip r / Phone: ,�/, �" ljy 3 Fax Email: r [ V State the goals and objectives of your project and whether they have been met. f C sz �4 \ �c-- A 6CL-..I� i� G, <4C trr4f� l r 1 How were the goals and objectives of your project Lmeasured? c - `�l IQ Who participated in the evaluation process_?r e �H jo'w was the City's funding for this project utilized? 6/.- -e_ T:\CGP\O1 CGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classed into two categories:Civic or Arts program. Choose only one option. ❑Civic ■ Arts Grant Request Amount: $3,150.00 Free of Charge: ® Yes No (Not to exceed$5,000) Program Title: 5th and 6th Grade Guitar Explorers ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: ❑Non-profit ■ Tax-exempt Tax/Employer Identification Number(TIN/EIN): EIN 330912776 Lid IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: amino C;Fgek Elementary nClnl aS niOn SE5661 Mtrictj Must match name filed under the Tax/Employer Identification Number) Street Address.. 7885 �aseo Aliso, Carlsbad, CA 92009 Mailing Address: Same Doing Business as(dba) Name: Same Please list the names and titles of the organization's Board of Directors: Cynthia Stanford-President Christine Bloom-Secretary Monica Attilli-Treasurer iiii! Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): and 6th grade s u ens at ammo Greek elementary school have a strong interest in learning to play guitar.Already, the ECC Fund generously provides a consultant to give weekly music instruction to all ECC students. The lessons include: reading music; singing, wind, percussion instruction; and music theory and appreciation. This new program will give 5th/6th graders the chance to learn guitar in the school classroom. Each year, the program will conclude in an all-school musical.in which the 5th and 6th graders play guitar and the K-4th students will act, sing, dance, and accompany. To permanently expand the curriculum to include guitar instruction, the ECC community has been working together to assemble the needed resources. We have teacher, a loan of 10 student guitars, and a location. ECC and the ECC Fund will continue to support the program annually, so all that remains is to purchase 15 more guitars for a total of 25 which would provide an ideal 1:1 student to guitar ratio for optimal learning. Organizational History: Weekly music instruction has been steadily supported by the ECC Fund for 16 years. ECC students and parents all thrive as a F.es6lt of the program and regu ar pe ormances. e Fund is committed to the noted b ene its of musip ins ruction an m`a es it a lundralsing priority. Application Form,Page One of Two - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: El Camino Creek Elementary School-Encinitas Union School District Total Est. Cost: 40,052.60 Time Frame: September-June every year Number of Encinitas Residents Served: 192 Fundraising Activity: O No ® Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS. Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Shannon Hartley, Music Consultant at El Camino Creek Elementary School Mailing Address: PO Box 231204 Encinitas, CA 92023-1204 Telephone Number: 442-232-5799 Email Address: Shannon.Hartley @eusd.net El Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Shannon Hartley Title: Music Consultant at ECC Elementary Please rint) Signature: Date: 04/12/16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: Yes 1:1 No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: El Camino Creek Elementary PTA PROJECT TITLE: 5th and 6th Grade Guitar Explorers PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income,confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services,ticket revenue, membership feesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas&Mizel Family Foundation Grant Program Pending $3,150.00 Loan San Diego Music Foundation (10 Taylor Stdt. Guitar kg) secured $4,890.00 Grant ECC Foundation-Music consultant/teacher-563.32 hours from September to June 25./hour secured Donation 10 after school ours re earsaFaonated by music consultant 25./hour secured $250.00 Donation ractice Room at 30/hour tor 56132 hours of instruction secured $16,899.60 Donation Auditorium for Perf ormance 6 hours 80 our secured Donation lyers and Brochur—e—s—fo—r-F5erformances secured INCOME TOTAL*: 1$40,052.60 EXPENSE: List all projected expenditures.'lf you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST nstruments 15 student-sized guitar tuner case package at $200/package an 1 sets o additional strings o rep ace normal use rea age se ; Instrument Loan San Diego Music Foundation (10 75y1or Student.G uitar Packag es 4, Instruction Fees EGG Foundation-Music consultant/teacher-563.32 hours from September to June 25./hour $14,083.00 Show ReheiTrsal 10 after school hours rehearsal donated by music consultant 25. our 250.00 Facility Practice Room at 30/hour for 563.32 hours of instruction 16,899.60 Facility Auditorium for Performance-6 hours 80 hour 480.00 Publicity Flyers and Brochures for Performances $300.00 EXPENSE TOTAL*: $40,052.60 Budget Form *Your Total Income an 'Totai 6xpenses.s�?oul , '-e equal. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM ORGANIZATION NAME:_& I Camino Creek ELe,inen-[Ary 'PTA TITLE OF GRANT PROGRAM: 5th and 6th Grade Guitar Explorers UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Title: Shannon Hartley Music Consultant at ECC Eler 04/12/16 Signature Date: Resolution from the Executive Board Authorizing Grant Application Resolution of the El Camino Creek Parent Teacher Association Executive Board WHEREAS,the El Camino Creek Elementary PTA is a legally constituted corporation or public/governmental entity, under the law of the State of California,and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED,that the Executive Board of the El Camino Creek Elementary PTA hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this day of April 11,2016 � Sy 10 aIV%,� Christine Bloom Secretary,Executive Board El Camino Creek Elementary PTA California State PTIT euerychilcL one voice 2327 L Street,Sacramento,CA 95816 (816)440-1985•Fox(916)440-1986•info @capta,org•www.capta.org August 31,2009 Christy Whalen,Unit President El Camino Creek Elementary PTA[5498] 2841 Avenida Helecho Carlsbad,CA 92009 Dear Christy: In response to request of this office concerning your PTA's tax-exempt status,a copy of our group ruling letter dated November 18,1943,from Internal Revenue,which grants federal income tax exemption to all PTAs in California, is enclosed. You will note the Internal Revenue Code section at that time as referred to in the letter was 1 01(6)—now Section 501(c)(3)as indicated in all PTA bylaws In California.The group exemption number assigned to the California State PTA is GEN-0646. Also enclosed is a copy of the February 24, 197$letter from Franchise Tax Board confirming PTA's exemption from state franchise or Income tax under Section 23701d of the Revenue and Taxation Code. Both the federal and state exemption letters cover all of our divisions—local units(associations),councils and districts.The letters are issued to the California Congress of Parents and Teachers,Inc.The corporate name was changed as indicated on this letterhead by vote of the annual convention on May 5,1978,and has been recorded and filed with the Secretary of State with certificate endorsed on August 14, 1978. El Camino Creek Elementary PTA is a unit in good standing.It was organized on June 7,2600 according to our official records,and is chartered as a member organization of the California Congress of Parents,Teachers,and Students,Inc. El Camino Creek Elementary PTA located at 7885 Paseo Aliso,Carisdad,CA,92009 in the Ninth District PTA, is a nonprofit,tax-exempt association under our group ruling.The Employer identification Number(FIN)29919ned to EI Camino Creek Elementary PTA is 33-0912776, Sincerely, Elvira Knox Accounts Receivable/Sales Clerk cc; Carolyn Johnson, Ninth District PTAPresident TREASURY PEPARTMENT WAS14ING?TON 25• ' OFF=OF - COMMLeStONER OF INTERML REVENUE AODR.c Mer1A To eouul.axx+cM of n +®xie MW 18 ua n EVmER'M'no ITsAsTs1 r . .t MAp t california. Congress of Parents and Teaohers, Inc., 416 Union. Building, Secoxid and Broadway, San Diego 1, California. t , - b6essc3entee: Res€erenos is ;ss AOd to the evi,deu qe :submitted for use in fleeter mining the status or.;YO u' local a>saoolations for Federal income tax purposes. In Bnreeu ruling date li, pebra ry 26, 1843, it was held that you are entitled to elxa 1pti-WA from Federal inoom tax'under the provisions.of section 101(6) of the Internal Revenue; Code and corresponding provisions of prior revenue e:ota as it is ehowm that you, are uraani.eesd and operated exclusively for educational purpasss. ' it is the opinion of this offices based upon the evidence presented, that you and the local assoaiati.ons appearing in your Year Boole 1943-1944, Celifornie. Congress of Regents and Teavhers, Ino., are entitled to emwaption from Federal income tax underethes provisions of section 131(6). of the lutOmitl Rffsaui Code and corresponding provisions of prior revenue act", as it is shown that you and the local assoo atioao ate orgomise.d.and ogoraterl exclusively for educational purposes, &ocordingly, it will not be neoeasary for you and: such ae80e3at ons to file returns of income unless there is a et=ge in your organisation, purposes or methods of operation. you should rurnish the J3urvau dually, on the calendar year basis, lists in quadrupliaete abowing only.the asAes and address +�' of eay new local associationa and the names and &dd.rOX8as of &my looa2 a6soaisti.orewhich for any reason have *eased to exist., Such a=ual lists should be accompanied by a statement o"rn to by one of your prinoipol officears as to whether the information herotofore y'c submitted by you on which this ruling is based is applicable Jsh all respects to the asso`sie t-ions apPseribf on the ]lets and should be, W'[M forwarded no as to re fiAh this Office not later then Pibru"y 15 of . sVjy the following yeas. tics so— MM California Congress of Parents and Teachers, Inc. Since any organisation which is exempt from Pederal income tax under the provisions of section 101 Of the Internal Revenue Code also is exempt from the capital stock teat pursuant to the express provisions of section 1201(x)(1) of the Internal Revenue Code, you and the local associations appearing in your Year Book 1945-192x4 will not be required to file capital stock tax returns for future years so long as the exemption from income tax is effective. Furthermore, under au?stentjally identical authority cart- twined in sections 142$ and 1607 of the Code and/'or corresponding provisions of the Social Seour ty ,sat, the employment taxes im- posed by such statutes are not applicable to remuneratfou for servicea performed In your employ or in the expl.oy of such asso- ciations so long as the conditions prescribed above for retention of an exempt status for income tax purposes are met. Contributions made to you and the local associations listed are deductible by the donors in arriving at their taxable net income in the manner and to. the extent provided by section 23(0) and (g) of the Internal Revenue-Code and corresponding provisions of prior revenue acts. Bequests, legacies, devises or transfers, to or for your use or for the use of such local associatious are doduatible.in ar- riving at the value of the net estate-of a decedent for i stkte '{`.etx purposes in the manner and to the extent provided 1ay sections 812(d) and 861(a)(3) of the Cade and/or corresponding provisions of prior reventie,'acts. Gifts of property to you or them are deductible in computing net gifts for gift tax'rurposes in the maimer and to the extent provided in section 1004(a)(2)(B) and 1604(b)(2) and (3) of the Code and/or corresponding provisions or prior revenue acts. The collector of` internal revenue at Ln,g Aggeles, California, is being advised of this action. By direction of the Commissianer. Respectfully, f /Deputy C Q, ioner. fi N 0 61992 internal Revenue Service Department of the Treasury District P.O,.Box 2350 Los Angeles,Calif.90053 Director Person to Contact: FELICIA C MIRAFLOR --PTA CALIFORNIA CONGRESS OF PXTSj�elePhone Number: TEACHERS & STUDENTS INC PTA—CA31 213-594-2336 930 GEORGIA ST E3eferR�piyto. LOS ANGELES, CA 90015-1322 EO-1102--92 Date: NGy G 5 t�32 RE., PTA CALIFORNIA CONGRESS OF PARENTS TEACHERS & STUDENTS INC PTA—CA31 95-1683870 Gentlemen: This is in response to your request dated October 26, 1992 regarding the above named-organization. A review of our records indicate that this organization was recognized to be exempt from Federal income tax under internal Revenue Code section 501(c)(3). Group exemption number 0646 has been assigned to the parent organiz&ti,oin and its subordinates. The determination letter issued in November 2943 continues to be in effect. You should contact your parent organization for a copy of. their determination letter. if you nest any further assistance, please feel free to contact our office at the above address or telephone number. Thank you for gout cooperation. Sincerely, Felicia C Miraflor Disclosure Assistant STATE Of CALIFORNIA - FRANCHISE TAX BOARD SACRAMENTO,CALIFORNIA 95867 �E ��!! February� ' �{�?� Telephone (916) 355-0392 J �1/ 7 In reply refer to 344:RM:vb:g California Congress of Parents and Teachers, Inc. 930 Georgia Street Los Angeles, Ca. 90075 Purpose:. Charitable & Educational Form of Organization Corporation Accounting Period Ending: May 31 Organization dumber: 103$440 Based on the information submitted and provided your present operations continue unchanged or conform to those proposed in your application, you are exempt from state franchise or income tax under section 2370id, Revenue and Taxation Code. Any change in operation, character or purpose of the organization must be reported immdiately to this office so that we may determine the effect czs your exempt status. Any change of name or address also must be reported;. You are required to file Form 1" (Exempt Organization Annual Information Return) or Form 1998 (Eaelmpt Organization Annual Information Statement) on or before the 15th day of the 5th month (4-1/2 months) after the close of your accounting period. See aatival instructions with forms for requirements. You are not required to file state franchise.or income tax returns =less you have income subject to the unrelated business income tax under Section 23731 of the Code• in this event, you are required to file Form 109 (Exempt Organization Business Income Tax Return) by the 15th day of the 3rd month ( 2- 1/2 months) after the close of your annual accounting period, Contributions made to you are deductible by donors as Provided by Sections .17214 through 1721.6.2 and 24357 through 24359.of the Code, unless your purpose is test- ing for Public Safety. If the organization is incorporating, this approval will expire unless incorporation is completed with the. Secretary of State within 30 days. Exemption from federal income or other taxes and other state taxes requires separate applications. f "This letter confirms previous exempt statue. Giroud Supervisor Exempt Organizations Fl cc: Secretary of State (Corp.) cc: Registrar of Charitable. Trusts FTB 4206 (11-75) Mate Bylaws 8.1 Bylaws of the Callft>rnia Cuatgrcss of **�k ARTICLE tit--Basic PaucsES ` Parents,Teachers,and Students,I.M THE Foi4)wing are basic polities of the California l (As AmendiA May 2002) State M in common with those of the National t PTA. ARTICLEt—NAME ' a.The organization shall be noncommerdal, i TLu name of this corporation is the California p9nsectaIjan,and nonpartisan; Congress of Parents,Teachers,and Students;Inc., h.The organization shall work with the schools a branch of the National Congress of Parents and Teachers.It is also known and will be referred to and commune ovfdc education in these bylaws as the California State PTA. for and youth and shall seek to par- in in the decision-malting process estab- Hereinafter in these bylaws&turn'k=1 PTA°` lisping school policy,recognizing that the legal wherever used to designate a kod unit shalt also des- responsibility to snake decisions has been dele- ignate"PTW where such may exist gated bry the people to boards of education, state education authorities,and local education authorities.; ARTICLE 11—PusrasES c.The organization shall.work to promote the health and wdfare of children and youth.and Section I.The purposes of the CaUf mda State shall seek to promote collaboration between PTA,in common with those of thlo National PTA., parents,schools and the community at large; are d.No part of the net earnings of the organization a To promote the welfare of children and youth .shall inure to the,benefit of,or be.dislri'butable in home,school,community,and place of wor- to its members,directors,tr tstses,officers,ox . other private persons except that the organiza- Ship- tion shall he authorized and empowered to pay b.1b raise the standards of home life, reasonable compensation for services rendered c.To secure adequate lan for the care and 1w' and to noake�apments and�listiibutinns is tection of children and youth. furtherance bf the purposes set forth iu Amide 11 herec4 J d.To.bring into closer relation the home and the me school,that parents and teachers may cooper- e.Notwithstanding-any other provision of these . ate intelligently in the education of children articles,the organixauon.shd not carry on any and youth,and other activities not permitted to be ceiried on Pederal i (i)by an organization exempt from e To develop between educators and the general nt income tax under Section 501(c)(3)of the public such united&Drts as will secure for all Internal Revenue Code,or(ii)by an organza- children and youth the highest advantages in tion,.coutnbutions to which are deductible ' physical,mental,social,and spiritual education. under Section 170(c)(2)of the Interml Section 2 The purposes of the National PTA and Revenue Code; the California state PTA are promoted through £"upon the lissohrdon of this organization;after an advocacy and educational program directed paying or adequately Providing for the debts toward parents and teachers and the general pub- and obligations o E the organization;the lic;developed through conferences,committees, temabling assets shah be:disrributed to one or Projects and programs;and governed and quali- more nonprofit hinds,foundations;or organi i fled by the basic policies set forth in Ar"11L zations t APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classed into two categories:Civic or Arts program. Choose only one option. ❑Civic ■ Arts Grant Request Amount: $1,200 Free of Charge: 0 Yes O No (Not to exceed$5,000) Program Title: Pacific View ReConnect Project ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: ■ Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 47-4786753 It IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: ncin aS Arts Culture and Ecology Alliance (Must match name filed under the TaxlEmplo er Identification Number) Street Address: 629 S. Vul-mn Ave., Encinitas, CA 92024 Mailing Address: 629 S. Vulcan Ave., Encinitas, CA 92024 Doing Business as(dba) Name: Please list the names and titles of the organization's Board of Directors: Caroyn Cope Jon Humphrey Danny Salzhandler Kay Colvin John DeWald Garth Murphy ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program(Limit to the space provided): Encinitas Arts Culture and Ecology Alliance is making repairs to Psoific View School in order to to revitalize its campus into a thriving arts center. Reconnecting Pacific View's campus in downtown Encinitas (closed to the public since 2003) to the community is immediately benefitting EACEA's partner, the Encinitas Historical Society, and its museum programs based at the 1883 Schoolhouse located on the campus. EACEA's repairs are allowing for the museum's public entrance to be moved from an alley to Pacific View's main entry on a popular street, which will increase the museum's visability and aid EHS in its fundraising and goals to launch new community programs. EACEA respectfully requests funding toward the cost of replacing Pacific View's aged gate entrance with a new metal gate to provide enhanced security. The gate's custom deign will welcome visitors of all ages and alert passerbys to the renewed artistic energy progressing on the campus. Organizational History: Founded in 2014, Encinitas Arts Culture and Ecology Alliance's mission is to create and arts and ecology learning experience at ace is View campus and benefit commune members of all ages an educational, a s and cultural u . Annliention Form PAPe One.of Two _- APPLICATION FOR FISCAL YEAR 2016-2017 -ja CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Southwest corner of Third and E Streets, Encinitas, California, 92024 Total Est. Cost: $4,200 Time Frame: One month or fabrication and installation. Number of Encinitas Residents Served: 60,0 Fundraising Activity: No ® Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Garth Murphy Mailing Address: 629 S. Vulcan Ave., Encinitas, CA 92024 Telephone Number: 760-402-$360 Email Address: garthmy @gmail.com a Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. 1 hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Garth Murphy Title: President/EACEA (Please print) ���� � April 14, 2016 Signature: - k I / Date: THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment (IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM JRGANIZATION NAME: Encinitas Arts Culture and Ecology Alliance PROJECT TITLE: Pacific View ReConnect Project PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services,ticket revenue, membership feesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas&Mizel Family Foundation Grant Program Pending Grant oun ty Neighborhood Re nvestment rogram Pending $3,000 INCOME TOTAL`: 1$4,200 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Materials e a sWck and assorted ings used in gate assembly. $1,7uo an a unng Planning, preperation,tabrication and installation of new gate. $2,500 EXPENSE TOTAL*: $4,200 Budget Form *Your Total Income and Total Expenses should be equal. __&� Alf 4,C,1wt*kT IRS DEPI TM�LTTI'' OAF UE SERVICE Y CINCINNATI OH 45999-0023 Date of this notice: 08-13-2015 Employer Identification Number: 47-4786753 Form: SS-4 Number of this notice: CP 575 E ENCINITAS ARTS CULTURE AND ECOLOGY ALLIANCE 649 S VULCAN AVE For assistance you may call us at: ENCINITAS, CA 92024 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you EIN 47-4786753. This BIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it's very important that you use your BIN along with your complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information shown above isn't correct, please send us the correction using the attached tear-off stub. Annual filing requirements Most organizations with an EIN have an annual filing requirement, even if they engage in minimal or no activity. A. If you are tax exempt, you may be required to file one of the following returns or notices: Form 990, Return of Organization Exempt From Income Tax Form 990-EZ, Short Form Return of Organization Exempt From Income Tax Form 990-PF, Return of Private Foundation Form 990-N, e-Postcard (available online only) Additionally, you may be required to file your annual return electronically. If an organization required to file a Form 990, Form 990-PF, Form 990-EZ, or Form 990-N does not do so for three consecutive years, its tax-exempt status is automatically revoked as of the due date of the third return or notice. Please refer to www.irs.gov/990filing for the most current information on your filing requirements. B. If you are not tax-exempt, you may be required to file one of the following returns: Form 1120, U.S. Corporation Income Tax Return Form 1041, U.S. Income Tax Return for Estates and Trusts Form 1065, U.S. Return of Partnership Income Please refer to Publication 1635, Understanding Your EIN, for more information about which forms you may be required to file. 0 0 ENCINITAS ARTS CULTURE AND ECOLOGY ALLIANCE April 14,2016 Encinitas Arts Culture and Ecology Alliance City of Encinitas and Mizel Family Foundation Community Grant Program: Attachment B Encinitas Arts Culture and Ecology Alliance's next Board of Directors meeting is scheduled for April 19,2016. The Resolution from Encinitas Arts Culture and Ecology Alliance's Board of Directors authorizing this Grant Application is on the agenda and an original signed copy will be submitted to the City Manager's office. Signed EACEA Secretary BlEoulualnJ3000aill )a H A:(,- APPLICATION FOR FISCAL YEAR 2016-2017 == CITY OF ENCINITAS AND MiZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAMES TITLE OF GRANT PROGRAM: ACl�lC I/Lrzt� UNDERSTANDING OF INSU ANCE REDLIREMENTS-ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars($1,000,000)for each occurrence. 2) The granlee's insurance company must provide a 'Certificate of Insurance' naming both: A)CITY OF ENCINITAS B)MV-EL FAMILY FOUNDATION as the `Certlflcate Holder" and as an `Additlonal insured' by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, Win: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call(760)633-2610. 3)The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4)Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: C�'� f 6P�i Title: u�u�iiUxwm rrrrrr[rrrnmm Signature Date.wun run t FOUn n tmrrr firma 10 r 1 APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. ❑Civic A Arts Grant Request Amount: $4,862 Free of Charge: A Yes ❑ No (Not to exceed$5,000) Program Title: American Classics"Eight by Benny Goodman" and Scholarship to local Extraordinary students. ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt orqanizations may apply. Identify the legal status of your organization: Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 30-0734546 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Encinitas Ballet Academy and Arts Center (Must match name filed under the TaYJFmployer Identification Number) Street Address: 264-D. North El Camino Real.Encinitas, CA 92024 Mailing Address: 264-D. North El Camino Real , Enciitas, CA 92024 Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: Sayat Asatryan, President, Secretary Sergey Simavoryan, Vice President Olga Tchekachova, Chief Financial Offer N Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Program 1 : Bringing back American Classics to North County. " Eight by Benny" Choreography by Heinth Poll. ( please see attached ) Program 2. Providing Scholarships training for the worlds larges global network of dance. Youth America Grand Prix. ( please see attached) for two students. Organizational History: Established in 2008 , EBAAC is the classical ballet school in the North County. (please see attached) Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 r- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas, CA Total Est. Cost: $4, 862 Time Frame: June 2016- February 2017 Number of Encinitas Residents Served: 400 Fundraising Activity: N No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Sayat Asatryan, Mailing Address: 264-D. North El Camino Real Telephone Number: 760. 632.4947 Email Address: Welcome @encinitasballet.com ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Sayat Asatryan Title: President, Secretary (Please print) Signature: Date: April 1, 2016 l l/ THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 = ; CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM uRGANIZATION NAME: Encinitas Ballet Academy and Arts Center PROJECT TITLE: American Classics " Eight by Benny Goodman" and Scholarships PROGRAM BUDGET Before you begin. r~lease refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending Matching Crowdfunding Pending $500 Matching Logic Systems Pending $200 Matching Helmstetter Family Foundation Granted $300 Matching Raffle tickets during the Spring performance Pending $250 Matching Stunning-Photography, sponsor Pending $1,000 Matching Tickets sales from Swan Lake performance May 7,2016 Encinitas Ballet Pending $2,500 INCOME TOTAL*: 1$4,750 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Program 1 Bringing back American Classics to North County"Eight by Benny" Choreography fee and rights (see attached copy of email) $2,000 Rent outdoor Amphitheatre SDA for 5 hours($75 per hour) $375 and 5 hours Custodian$42($210) $585 Program 2 Youth America Grand Prix International Ballet Competition 2017.Scholarships Scholarship 1 Competition fee for 1 variations $100 each,two variations $200 Classes at Encinitas Ballet $170 per month(5 month)starting from Sep.2016 $850 Scholarship 2 Classes at Encinitas Ballet$170 per month (5 monthe)starting from Sep 2016 $850 Competition fee for two variations $200 2,500 cards for Free Publick performance"Eight by Benny" $ 177 will be printed by Next Day Flyers/marketing EXPENSE TOTAL*: $4,862 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE P. O. BOX 2508 DEPARTMENT OF THE TREASURY CINCINNATI, OH 45201 Date: NOV 24 2014 Employer Identification Number: 30-0734546 DLN: ENCINITAS BALLET ACADEMY AND ARTS Contaact ct P Pe170e 16044 rson: CENTER C/O SAYAT ASATRYAN THOMAS E GERITY ID# 31664 264 N EL CAMINO REAL STE D Contact Telephone Number: ENCINITAS, CA 92024 (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 509(a) (2) Form 990 Required: Yes Effective Date of Exemption: March 6, 2012 Contribution Deductibility: r Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter 114221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Sincerely, Director, Exempt Organizations Letter 947 RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF Encinitas Ballet Academy and Arts Center WHEREAS, the EBAAC is a legally constituted corporation or public/governmental entity, under the laws of the state of California, and is complete control of its affairs through its own officers and members, NOW THEREFOR, BE IT RESOLVED that the board of Directors of the EBAAC hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the city's 2016- 2017 Fiscal Year. Adopted on this 1St day of April, 2016 7 Sayat Asatryan, President, Secretary Encirq't ,s -.all cademy and Arts Center Sergey�Simavoryan , Vice President / EBAAC l kj Olga Tchekachova, Chief Financial Officer/ EBAAC ATTACHMENT C ft APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION ' COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Encinitas Ballet Academy and Arts Center TITLE OF GRANT PROGRAM: American Classics UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000)for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Sayat Asatryan Title: President, Secretary Signature: Date: April 1, 2016 Grant requests ar3 ;lac-lfiied ir`o i c catertoneS Civic JI A 4 Grogram Ci oose om ore Cp•Mor n CI✓rc G-art-Equest P^ou^r � $3:3d5 es r - (Not to e-ceed X5,000) Program Title: Encinitas CERT Disaster Preparedness and Training Program E!�IaIE:Y'T`f C=TERM..A.-Ji X': _nly nor-profit ardor tac-exer;rt urganizatlors rna,, av M. Identifi,the legal status of your organization: i1 Non-profit i Tax-e::empt Tax/Employer Identification Number;TIN/EIN) 32-0224058 ❑� IRS Letter A copy of your arganization s letter from the IRS showing status must be enclosed as A tachment A. ORGAN Z.',TICN IN1=OR.-YVTiCV- Organization Narne: Encinitas CERT, Inc. (Must match name filed under the Tax/Employer Identification Number) Street Address, 540 Balour Drive, Encinitas,CA 92024 Mailing Address: 1470 Encinitas Blvd 4142, Encinitas, CA 92024 Doing Business as (dba Name n/a please:list the names and titles of the organization's Board of Directors. Doan Hishmeyer President Lisa Bentson, Treasurer Dave Tostenson, Vice President Loyd Wright, Director i Lori Didley Secretary I 3,.as l_ :"r a ra'. A cop" of�our organization's Resolutic;r or Meetirc Minu±?s reflecting 9c°-y appre-ra, )f thF � project/program must be enclosed as Attachment B. Summar o! rcgram i Lima to the space provided`- CERTS primary mission is to provide emergency preparedness educatror any training to all citizens c17 Encinitas. CERT has aimady established itself as the city's go-to;esourca Ter volunteer amer3encv services ar our:re,.rbersrin:(.rltirues to gro(v.iith fully trained disaster,:or%ers tc support the fire department and 3ther,irst r°^panders�r timcs crisis '"rhil vt ire gro—rng,we^erne into contact nitt,many citizers .hat aren't ahle to or don't ha ve ''he time to commit to`he_r31nirg I ' required to become: ully tmined.CERT (isaster responder Howe-ter,they are deeply ingested in learning ovhat they car do ir.heir o, n.lime VIII to prepare ther-tsal.es 3nould a disaster si.rike and chat resour,es ileyond CEPT a.a available to there. Ta addr-s_this, DEFT I .or?res.r�tinn a 3r.paigr eu distribr.te printed ernerpency brDchures ec all of Encinitas' iu OOC -esidents so .hev`Ma, -. ;;(e bdihr t�ouild a ,r,L 3r3rir L.is oundation a er i they gram able to be acb,,e in CEPT In other words,we .vant'.0 orovide them .pith the . -)I to Le p; 30 d arf sr_3rairable,.aliart and nave 3 lc- vei imFa ,t or disaster recover services it tt-e e,art at e. t'r-;3 IC; T _T•'.l' rE', °. .rr: ?((.' urll it 1J o e,,ie ignirg )L! S( r -i inciude.l r _:Its F-e 2r -P 'it', i l-tJ. ".tn:,` ct�'_ �._'•t. - } ",4 ,Ja„rZdelur1dl.1rSt;r_ Tine crGritas f=irs-uapai,rient starter],_a CERT p.oyrarn'f 21,U- L_r,_ raids' i 311 clunte3r R 1.. L: -ion-profit.Some 3Cu+have taken CERT training and ECERT has approximatery uG acirre members that .,e rnL„di. by the fire department in response tc disasters that overNhelm the limited resources of the Cit;-'s firefighters. Apps*cat:c,n Fc—rr, Page line ol-Tvvu a3�, Y111�`r�f..I1,�TIJN �r- ±or 'a;+ous :ucaticns throughout Encirit3s. including Fir: 3taJor.s, ti a ccrnnIL41,'cl,.cl ai-d :ie. Ha;i Taal Eat. Cos,- Time Frame: Ongoing-this budget is for 2013 Number of Encinitas Residents Served: AJi-60,000 F,-ndraisinc3 Activity: A No u des If yes, please explain: C.'JATACT WFORt,ATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the e::penditure of any communit,;grant funds allocated by the City of Encinitas to the organization) Name and Title: Doan Hohmeyer, President Mailing Address: ILIrl 0 Ens jnih-a \6 I? ram -ti 7,7 _Nsc r:.'tTA_3 4ZO`4 293., Telephone Number7k''10to--610 CO Email Address: +70Ar+.�'lOh Nt 2c,1 P'' encGe r arc 'Jndsstanding of Insurance Requiraments. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. i heraty affirm that the inifornation contained in this application is true and correct,to the best of my knowledge, a!-,d tha:I a.:�aathorizad!�-y the organization named h arein to mace such reprEsentaticns and statements it tr:s application. Contac Person Doan Honme j er Title Presiders (Please print) Signaturi.�)��1C., � `"' Date: Cats°ycei•+ac'- App';catior °cckat Comoiet� .:dy�ral ',c,sigi,t-.,,pies, "ppncavc r F..r-- -s1711ed &c, rograrn Budget A tachrnert.` '13!_attar i e5 ' vn Regscns ,pp)teaf-i.Fcr-,:'age Tw?of Tvvo f; �97.' 2^ y!TAS AND MIZEL ,AWL t ^ J JND,l1I'D1 i'D 1i1jM V � Tf .� �� Mi" 7A 7 E nriri+as CERT, Ire. CEP,7 Dsaster Preparedness ar i T, fining P:.gTa.-n BUD3JET y.- z -;_ �F�-'"• t..l°9S�.'3.-�,'f�' `.�F: r S'T::;'C^ .�':'QQt�^!CS."."'t,:�Ef'✓ '_'�C3��3 7^. "" '3.`J� :? -�-��_� �A 1 43 ¢-, s �z',t .�-.,e r-�.,t7-.--�f' - ,..e.�47 r -S X7.1 t- I j_43 0r►*3 '.9TIS C'`g.^OrjS and S2,rfi:eS- t C C?t "3`ie .,3. t T`-'PE SJUR STATUS AMOJNT $3.325 Grant SDGE/Sempra Pending $2,500 Donaticn Firehouse Subs-Donation for Life Saving Equipment $3,100 Donation Anonymous $5.000 I li:CME TZ)3 A *: $14-525 �i-a a;' -)r)iectee exnend'V--as. li v�rj cla-mea Ir-'c'�I 'lc Dne `.1at iter* sOoul l z�s: �_a _',.3 L- s ;=7 g ` r , , c . y , 4,. Z%7 Public Education Print and distribute tr-fold brochures to deli-,er'reach out to even, household it Encinitas y 1 5CC I insurance GL and Directors Liability Insurance 51825 Attachment A Oa- . 13 C14 LT'2 4,68C l 32 022:_G5g 1;0003J 00 03 2 1� BOr--. TE LM,1 41T,',:, CERI INC 1'_9 N EL C 4 1 W RL A' tiTF F-1 4:7 ENCINITAS CA 92024 _; Employer Identification Number : 32-0224058 Person to Contar.t : Ms . P. Skiles loll Frec lelephor.e Number : 1-811-829-n500 Dear Taxpayer - Tfis is in response to you- Feb. 27, 2014 , req�.,est for information regardi:ig vOur to < exempt status . Ou• records irdicate that you were recognized as exempt u.-4zr secticr 501 ( c) (3) of the Internal Revenue Code in a determinati ,) lette- isaued in January 2009. Our records also indicate that yap are not a private foundatioi wi �hio the meaning of section 509(a) of the Code because you are described in sectionis, 509ka) ( 1j a )d 170tb) ( 1) (A) (vi) . Du -,rs ma , deduct co-itrlbutio -s to you as Frovidej it section 17' �_ f th_ CaL.e . Bej..ests , legacies , d -- visas , trans :e.-s , a- gifts to „ s.. f- - y3t - use are deduc+ibl3 for Federal estate and gift ta" R!Ar"^ 'es i f t . � m_at tha aooii.3ble P-o jisio- , of sattions ?05C • 21106 er j 'h . Ccjz . Fla-d,e efer cj ou ahsite e3 fo: i- formaticn rega-di -_� filirj requireme^ts . Spe-ificall), . sectio., 03317 ) of the Ceda yV that fallU -e tC f31n an inf:)rn%atinn return f ,. t.- --a cor.3ecati�ra :;ears resylts in revocatior of tax-exempt status as -fe -iii ,y d.:e date of tra thiru retu.-n fo,. organizations reajir 4e will F .,blisf- a list cf o*gaaizatiors whrase tax-exert. *_ status ras rey3kad under se :tior. h733(J ) s,f the Code or• o ...• webs' '-e -eji. i -g in earl . 2311 . a .0 10 _•s L"rr 163- C �2-q ?58 3 ?OJCC ou 119 _- C.' -%E,` _ STE E-142 CO2� 1f yo , have any a'..estions, piaase call us at tya telep:ti ►2 nvn.ber in tha '-eading of this lette- . Sincerely yours ; Susan M . O'Neill, Pe-)artment My ,. Accounts Maragemant Operations L ernpt Cr-,3ntzatxns St-.1ect Check http-- Organizations Ebgit%e to Receive T--x-Deductible Charitable CorytributicnR(Pub 78 data)-Search Results The Pck,iing'ist includes 4m:-examp*arganizatir-is chat are:::igibia to,ecelve tax-deductiL49 chadtab:a contributions.0116 on the DeductiL;Iity Status CL'umr for an a.planation of limitadr,rns on'te cleductib'lity of contributions made to different fypes of tax-exempt organizations Results care sorted by EIN.To sort resorts by another category.click an the con next to the a'umn heading for that category.Clic:dng on that icon a second Jrrre Mll Tevema the port :)rder Clic' -a column heading for an explanation of information in that column- 1-1 of I results Results Per Page 25 OK C prey 1-1!Next - (DOMg MI&Minw-;S AS) 32-0224058 Encinitas Gert Inc, Encinitas CA United States a Prev 11-11 Next RLtunn to Search 1 oft 10,2010 12:241 Attachment B RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF ENCINITAS CERT, INC. WHEREAS, Encinitas CERT, Inc. is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members. NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of Encinitas CERT, Inc. hereby approves the filing of an applicatior for the City of Encinitas and Mizel Family Foundatic�, Ccmm,.jnit,/ Grant Program funding for the City's 2016-2G17 Fiscal Year. Adopted on this 12th day of April: 2015 CERT, Lic. Attachment C : Ty ✓= =ENC!0?TAS Al"D C 0MM1JX7`v' GRANT PP0GRA%1 0RGA1y'Z4kTK)1rj !QAFAE: Encinitas CERT Inc., —7, E "c GIRA,."T PR'--4RA!x. Encinitas CE.RT Disaster Preparedness anci Training Program l,WQ!=,RJ'9JANr-)1NQ QF IN,' R 9111RANC!E RE-QUI E.MFNTS - ATTACHMFNT Q 1; Ahi g,aiit recipients are required 1:3 obtain and, during the taar, of the grant G-y:;Ie, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California. in an insurable amount of not less than one million dollars ($1,000,000)for each occurrence 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as ttie "Certificate Holder" and as ar "Additional Insured" by endorsement on these policies and further have the endorsement sent to the City of Encinitas, aftn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610 1) The aforementioned insurance policies snail not be canceled, terminated, or allowea to expire witno it thirty dais prior writ-ten notice to the CITY. 4) Any person who drives an automoDile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle hereby .,nde.-stand and will comply with insurance requirements 1 through 4 of the Gra -ai a.,d that I aam authorized by the orga iization named netic:•,�f to nt Rog, i 111a le 1;) ,h rA,--�ser:;;4ons in This -aDDii0atior Title: Prasident EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date 6/18/2015 Organization: Encinitas CERT, Inc. Address: 308 Firtree Court City: Encinitas State CA Zip 92024 Phone: 76OA06-3106 Fax Email: dhohmeyer@ericcertorg State the goals and objectives of your project and whether they have been met. The objectives of CERT are to spread emergency self reliance,grow its membership,and support the fire department in the event of a disaster. To meet these goals,over the last year CERT has conducted two Training Academies,setup hands-only CPR stations at many community events including Oktoberfest,Street Fairs,and Fire Station open houses. This has generated new members active in the organization in addition to spreading emergency preparedness and awareness. To support the fire department,CERT has made great strides in acquiring the equipment and skills needed to support the fire department in supporting them in an emergency situation How were the goals and objectives of your project measured? For promoting emergency awareness,CERT remained active in participating in local events,where sign up sheets are available for people to be included in fitire CERT meetings and events. This has been mstrumerr ak in driving new CERT membership and participation throughout the community For membership growth,the goals are measured in terms of the number of people who graduated each CERT Training Academy. The Fall 2014 class had 15 Encinitas graduates,while the Spring 2015 class had 9. Academies are open to other municipalities,and Encinitas has always accounted for the majority of graduates—in the Spring 2015 Academy only 1 graduate was from out-of-city. In total,Encinitas CERT has roughly 180 graduate members. Who participated in the evaluation process? The members of the CERT Board of Directors and Arnie Lewin,CERT's FEMA point of contact How was the City's funding for this project utilized? The City's funding was used to cover some operating costs of the organization,but also to update the CERT Emergency Response Vehicle(ERV). The ERV is a great visual tool to generate membership and interest in the organization at street fairs and other events,but also needs to be functional in the event of an emergency. The City's funding enabled CERT to give the ERV a much needed facelift,as well as outfit it with an emergency power generator and a large trauma kit. Additionally,the funding was used to supply each CERT division with their own trauma kits, following a model spearheaded by the Solana Beach CERT. - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM G/kTEGORY:GranfreQuests-are.classified-into-tweeategodes GivieorArtsprogram. Ghoose-only-one option, 0 Civic ❑Arts Grant Request Amount: $5,000.00 Free of Charge: A Yes ❑ No (Not to exceed$5,000) Program Title: Junior Achievement Biz Town for 5th Grade Students of Encinitas Union School District ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: Ki Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0178719 ❑ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Encinitas Educational Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: 101 S. Rancho Sante Fe Road, Encinitas CA 92024-4349 Mailing Address: Same Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: Shelly Kelly, President Shad Butte, Secretary Lisa Rimbach, Vice President James Baxter, Rick Johnson, Greg Poteizinani, Jason Bell,Treasure Laura Calderone, Jill Thomas, Glenn Warren ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): JA BizTown combines in-class learning with a day long visit to a fully interactive,simulated mid city.The program gives real-world professional work experience in a mock town setting. Prior to visiting the site,students engage in a comprehensive curriculum that teaches students how an economy works,citizen responsibilities&rights,how to get a job,how to operate a successful business&how to manage a personal bank account.Tasks include completing a job application,inter- viewing and may even be part of an election for Mayor!The curriculum,which aligns with common core,emphasizes the importance of ethical business practices,teamwork and making sound business decisions.At BizTown 5th grade students become"citizens"where they work in one of the 21 real world businesses,make personal&business financial decisions,hold business meetings,pay taxes,and donate to charity.This simulated work day has the student go to work,participate in business&town meetings,get paid twice,manage a checking account,purchas retail items to take home,get a health checkup and much more.The goal of the program is to teach students personal responsibility and the importance of becoming a successful professional in our community.Year after year,over 600 EUSD students bring this experience to our community.While this has been self supported via EUSD funds,our community support is vital to assuring the continuation of this program. Organizational History: Founded in 1984, EEF has continually provided funds to enrich the educational experience of 5,000 K-6 students within EUSD.The Goal of the foundation is to raise awareness and find support for the many programs offered to students in Encinitas and South Carlsbad public schools with our primary focus on creating World Ready citizens. Application Form, Page One of Two 7T APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PRO.G>3AM INFORMATION: Location: EUSD Classrooms and field trip to Jr.Achievement mock town in San Diego Total Est. Cost: $29,694.00 Time Frame: Spring 2017 Number of Encinitas Residents Served: 437 Fundraising Activity: W No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Shelly Kelly Mailing Address: 7903 Calle Madrid, Carlsbad CA 92009 Telephone Number: 760-331-3118 Email Address: shelly.kelly @eefonline.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that 1 am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Shelly Kellly Title: President (Please print) Signature: I Date: April 14,2016 THIS SECTION FOR OFFICIAL USE ONLY,.' Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: T= APPLICATION FOR FISCAL YEAR 2016-2017 to CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Encinitas Educational Foundation PROJECT TITLE: Junior Achievement Biz Town for 5th Grade Students of EUSD PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is re.luired. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Grant Carlsbad Chamber of Commerce Pending $10,000 General Fund Encinitas Union School District Secured $14,694 INCOME TOTAL*: 1.t 29,694 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Program Fee Jr.Achievement BizTown classroom and site education package($21.00 x 754 students) $15,834 Transportation Bus Transportation for General Ed students to JA BizTown in Mission Valley,San Diego $9,900 Staff Special Education Aid to facilitate special needs students(9 x$120.00 per day) $1,080 Transportation Van Transportation for Special Ed Students to JA BizTown(9 x$320.00) 1$2,880 EXPENSE TOTAL*: $29,694 Budget Form *Your Total Income and Total Expenses should be equal. -IR'S'nalw ro N Ve lu Treasury A+VmchvnewV A Inirruai I2,e�'rtmr Service P. O. Box 2508, Room 4010 In reply refer to: 4077556534 Cincinnati OH 45201 Jan. 02, 2015 LTR 4168C 0 33-0178719 000000 00 00057287 BODC: TE ENCINITAS EDUCATIONAL FOUNDATION Y. ENCINITAS UNION SCHOOL DISTRICT 101 S R-ANCHO SANTA FE RD ENCINITAS CA 92024-4349 38601 Employer Identification Number : 33-0178719 Person to Contact : S LENARD Tall. Fre_e. Telephone Number : 1-877-829-5500 - Dear Taxpayer: This is in response to your Oct . 24, 2014, request for information regarding your tax-exempt status . Our records indicate that you were recognized as exempt under section 501 (c) (03) of the Internal Revenue Code in a determination letter issued in December 1986 . Our records also indicate that you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section(s) 509(a) (1) and 170(b) (1) (A) (vi) . Donors may deduct contributions to you as provided in section 170 of the Code . Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. Please refer to our website www.irs.gov/eo for information regarding filing requirements. Specifically, section 6033(j) of the Code Provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the , iiing due date of the third return for organizatiors required ed to file. We will publish a list of organizations whose tax-exempt status was revoked under section 6033(j ) of the Code on our website beginning in early 2011 .. 4077556534 Jan. 02, 2015 LTR 41680 0 33-0178719 000000 00 00057288 ENCINITAS EDUCATIONAL FOUNDATION % ENCINITAS UNION SCHOOL DISTRICT 101 S RANCHO SANTA FE RD ENCINITAS CA 92024-4349 If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely yours, Tamera Ripperda Directory, Exempt Organizations 2 � I ` �f i• n�f�nsuutae�� 1'.'J.'1 l.f".?.iJ.F f.' F t RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF Encinitas Educational Foundation WHEREAS, the Encinitas Educational Foundation is a legally constituted non-profit organization under the laws of the State of California,and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED,that the Board of Directors of the Encinitas Educational Foundation hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 12th day of April Shad Butte ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 - —_- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Encinitas Educational Foundation TITLE OF GRANT PROGRAM: JA BizTown for 5th Grade students of EUSD UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Shelly Kelly Title: President Signature: Date:f•'.4, `� .. � 2 - I Ap ril 14, 2016 ""- APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are cfassified into two Categories:Civic or Arts program. Choose only one option,. On Civic Arts UK yes Request Amount: 5,000 Free of Charge: LJ Yes ❑ No (Not to exceed$5,000) Program Title: EcoFest Encinitas 2017 _ ELIGIBILITY DETERMINATION: Only non-profit ari&or tax=exempt organizations may " Identify the legal status of your organization: 101 Non-profit 01-Tax-exempt Tax/Employer Identification Number(TIN/EIN): 36-4795885 IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Encinitas Environment Day Inc. (Must match name filed under the Tax/Employer Identification Number) Street Address: 1859 Autumn Place, %Kasia Epstein, Encinitas, CA 92024 Mailing Address: 1859 Autumn Place, %Kasia Epstein, Encinitas, CA 92024 Doing Business as (dba) Name: EcoFest Encibntas _ Please list the names and titles of the organization's Board of Directors: David Ahlgren, President Sonja Marikovics, Marketing Director Sandy Atkinson, Vice President Kasia Epstein, Secretary I Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The EcoFest is a day-long grassroots, celebration/event designed to help_ Lnclnitas become a model for communities that practice sustainable living and enjoy the resulting prosperity. It showcases 140 eco focused exhibitors, food, live entertainment and 30 interactive family activities that inspire the citizens of Encinitas to live healthier, more sustainable and prosperous lives each and every day. Much of EcoFest's success is due to the use of the Pavilion format(ie by subject matter) including: Climate, Earth, Water/Ocean, Health/Wellness, Schools, Kids Planet, Green Cuisine. Eco Art and the Sustainability Plaza. The The Pavilion format attracts volunteers, generates community spirit and drives attendance. EcoFest creates a transformational experience for many. Each year EcoFest has increased it's effectiveness as evidenced by the growing attendance and number of volunteers and exhibitors involved. The EcoFest funding has grown along with the reach of the event. The goal is to increase revenue from fees and services now at—60% and to rely less on sponsors and grants and at the same time to keep EcoFest a free event for the community Organizational History EcoFest Encinitas is held on the 3rd Sunday of May and has been operation since 2006_ as a free service to the entire community. It was formally known as and is hosted by Encinitas Environment Day Inc. . a 501 c3 tax exempt non-profit organization. _ Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 _ r _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION:' Location: Coastal Root Farm/Liechtag Foundation Total Est. Cost: $49,500 Time Frame: Day of Event-May 14, 2017. 5Community outreach is active for 9 months Number of Encinitas Residents Served: 5000 Fundraising Activity: V No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: David Ahlgren, President Mailing Address: 1859 Autumn Place, %Kasia Epstein, Encinitas, CA 92024 Telephone Number: 760 846 0357 Email Address: dave @ncecoalliance.org _ J Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: David Ahlgren Title: (Please print) THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed & dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: I! Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY C'_ Y FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Encinitas Environment Day Inc. PROJECT TITLE: EcoFest Encinitas PROGRAM BUDGET F34lare you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $5,000 Grant Leichtag Foundation pending $5,000 Grant EDCO pending $3,000 Grant SDGE Pending $3,000 Grant Metropolitan Water Pending $2,000 Fees Exhbitor Fees Pending $31,425 INCOME TOTAL*: $49,425 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Administration General Overhead,Event planning,Accouting,IT,hosting $9,000 Marketing Marketing,Artwork,Web content,Day of Survey,Local orgs&events $4,750 Advertising-Media Print&Digital, print flyers,posters,biz cards $5,000 Community Outreach Meeting,attend events $500 Equipment Equipment&Office supplies $1,300 Event Logistics Exhibitor Management, booth rentals,permits $16,550 Security Parking,Security&Transportation $5,000 Event Program Program and supplies $5,350 Other equipment Signage,barriers,etc. $1,975 EXPENSE TOTAL*: $49,425 Budget Farm *Your Total Income and Total Expenses should be equal. DEPARTMENT OF THE TREASURY ' INTERNAL REVENUE SERVICE �, p. O. BOX 2508 % CINCINNATI, OH 45201 Employer Identification Number: Date: NOV 1 4 2014 36-4795885 DLN: 26053714001564 ENCINITAS ENVIRONMENT DAY INC Contact Person: ID## 31954 2317 SUMMERHILL DR CUSTOMER SERVICE ENCINITAS, CA 92024-5446 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: June 30 Public Charity Status: 509(a) (2) Form 990/990-EZ/990-N Required: Yes Effective Date of Exemption: October 6, 2014 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: we're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c) (3) . Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests, devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your exempt status. Please keep it for your records. Organizations exempt under IRC Section 501(c) (3) are further classified as either public charities or private foundations. we determined you're a public charity under the IRC Section listed at the top of this letter. if we indicated at the top of this letter that you're required to file Form 990/990-Ez/990-N, our records show you're required to file an annual information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard) . If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked. If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter 114221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c) (3) public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 5436 ATTACHMENT C Lib APPLICATION FOR FISCAL YEAR 2016-2017 t. CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION = COMMUNITY GRANT PROGRAM ORGANIZATION NAME: TITLE OF GRANT PROGRAM: UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: :,a,�� �-��°�` t �li Title: ;0L�S (• !��`" . . .. Date: — r� Encinitas Environment Day, Inc BOARD OF DIRECTORS RESOLUTION AUTHORIZING MIZEL GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS WHEREAS, WHEREAS, Encinitas Environment Day, Inc is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of Encinitas Environment Day Inc. hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year Adopted on this 10th day of April, 2016 Kasia Epstein Secretary, Board of Directors Encinitas Environment Day, Inc APPLICATION FOR FISCAL YEAR 2016-2017 -Y` CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories: Civic or Arts proqram. Choose only one option. ❑Civic 49'Arts Grant Request Amount: $5,000 Free of Charge: K Yes ❑ No (Not to exceed$5,000) Program Title: 3rd Annual Encinitas Dia de los Muertos Celebration ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: K Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 38-3956405 !K IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Encinitas Friends of the Arts (Must match name fled under the Tax/Employer Identification Number) Street Address: 1155 Melba Road, Encinitas, CA 92024 Mailing Address: Same Doing Business as (dba)Name: Please list the names and titles of the organization's Board of Directors: Naimeh Tanha Woodward, President Collette Murphy Stefanko, Teresa Barth Joann Johnson, Treasurer Deanne Sabeck, Patricia Frischer Laura Diede, Secretary N. Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The Encinitas Dia de los Muertos Celebration once again was welcomed by the community at large as a significant event fostering an appreciation and awareness of Latino culture. This free arts and culture celebration provided programming to participants from throughout the greater North County area, appealing to both residents of Latino heritage while also uniting people of all backgrounds and traditions. Participation in the event doubled in its second year, with roughly 4,000 recorded in attendance. Participants experienced four art-making workshops, three artist demonstrations, a robust student art exhibit and performances by seven different groups from throughout San Diego County at the Encinitas Community Center. Visitors also had the opportunity to enjoy food truck vendors from throughout the area while experiencing an exhibit of classic cars that displayed individual Ofrendas(altars) in their trunks. In addition,two primary Ofrenda displays were available for hands-on participation at both the Community Center as well as the Encinitas Library.The event involves over 15 community organizations and receives significant media support locally, regionally and to multiple markets. Organizational History: The Encinitas Friends of the Arts partners with the City of Encinitas by fundraising and advocating for the cultural arts in Encinitas and to support a city-owned Arts Center.A volunteer board of local residents,the Friends raise funds that 100%directly supports programming for a vibrant and burgeoning arts community in Encinitas that serves the greater North County area. Application Form, Page One of Two _ APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Community Center Total Est. Cost: 29,500 Time Frame: November 1, 2016 Number of Encinitas Residents Served: 6,000+ Fundraising Activity: EN] No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Naimeh Tanha Woodward Mailing Address: 1155 Melba Rd., Encinitas, CA 92024 Telephone Number: 619-414-8929 Email Address: friendsofthearts1 @gmail.com Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Naimeh Tanha Woodward Title: President (Please print) Signature: : , _� x Date: 04/13/16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed&dated) Program Budget Attachment (IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two dOWN APPLICATION FOR FISCAL YEAR 2016-2017 khoil CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Encinitas Friends of the Arts PROJECT TITLE: 3rd Annual Encinitas Dia de los Muertos Celebration PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Grant San Diego County Community Enhancement Grant Program Pending $10,500 Program Funds Encinitas Friends of the Arts Secured $2,500 In-Kind Donation City of Encinitas $2,500 In-Kind Donation Beatriz Villareal $2,000 In-Kind Donation Paul Ecke Elementary School(volunteer support:art exhibition) $1,000 In-Kind Donation Volunteer Support($10/hour,6 hours per person, 100 volunteers) $6,000 INCOME TOTAL*: $29,500 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Event Coordinator Oversees event,manages permits&volunteers,installs exhibition and manages workshops $1,500 Workshops&Exhibition 4 hands-on workshops(face painting,sugar skulls,mask making&tissue Flowers)&student exhibit materials $3,500 Performance Fees 8 regional,high-quality music and dance ensembles($600 per ensemble) $4,800 Artist Demos 6 regional,high-caliber visual art demonstration artists($300 per artist) $1,800 Marketing Volunteer shirts,print advertising(3 newspaper ads),graphic design work $3,750 Technical Sound fees&equipment rental(2 sound technicians) $3,250 Ofrenda Displays Two displays(library and community center) $1,200 Volunteer Support Water,Snacks&Drinks,Name Tags $700 In-Kind Volunteer hours($10/hour,6 hours per person, 100 volunteers) $6,000 In-Kind Media(PR on Spanish TV network&newspaper) $1,500 In-Kind Master of Ceremonies(Beatriz Villarreal) $500 In-Kind Parks&Recreation:staff support for mask making workshop $1,000 EXPENSE TOTAL*:1$29,500 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. BOX 2508 CINCINNATI, OH 45201 Date: NOV Z 2��� Employer Identification Number: 38-3956405 DLN: 17053294307025 ENCINITAS FRIENDS OF THE ARTS Contact Person: 1155 MELBA ROAD JASON T SAMMONS ID# 31616 ENCINITAS, CA 92024 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 509(a)(2) Form 990/990-EZ/990-N Required: Yes Effective Date of Exemption: July 21, 2015 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c)(3) . Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests. devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your exempt status. Please keep it for your records. Organizations exempt under IRC Section 501(c)(3) are further classified as either public charities or private foundations. We determined you're a public charity under the IRC Section listed at the top of this letter. If we indicated at the top of this letter that you're required to file Form 990/990-EZ/990-N, our records show you're required to file an annual information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard). If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked. If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter "4221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c)(3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 947 ENCINITAS FRIENDS OF THE" ARTS Sincer y, Jeffrey I. Cooper Director, Exempt Organizations Rulings and Agreements Letter 947 RESOLUTION FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF ENCINITAS FRIENDS OF THE ARTS WHEREAS, the Encinitas Friends of the Arts is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Encinitas Friends of the Arts hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 13th day of April,2016 Laura Diede Secretary, Board of Directors Encinitas Friends of the Arts ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Encinitas Friends of the Arts TITLE OF GRANT PROGRAM: 3rd Annual Encinitas Dia de los Muertos Celebration UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Naimeh Tanha Woodward Title: President 04/13/16 Signature:Signature: �� - Date: EVALUATION FORM to. *4% CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015-16 Date 4/19/16 Organization: Encinitas Friends of the Arts Address: 1155 Melba Road City: Encinitas State CA Zip 92024 Phone: 619414-8929 Fax Email: Friendsof&eait,,1.@MilLI.com State the goals and objectives of your project and whether they have been met. The Encinitas Dia de los Muertos Celebration is distinguished from other Day of the Dead events by 1)its focus on creating a quality family experience,2)fostering active participation in arts education activities and 3)presenting a 100%free event that is welcoming to families from throughout San Diego County regardless of socio-economic factors providing opportunities where parents can engage with their children in artistic endeavors in the visual and performing arts while having a fun experience. Attracting people from throughout San Diego county,this event attracted over 4,000 participants—both residents of Latino heritage as well as people of all backgrounds. Due to overwhelming demand,the event was held at the Encinitas Community Center,creating the opportunithy to expand programming by offering two community altars-"Ofiundas" (one hosted at the Encinitas Library),four art-making workshops,three artist demonstrations and performances by seven different San Diego County area groups. Visitors also had access to food truck vendors as well as a unique exhibit of classic cars that displayed personal Ofrendas in their trucks. Over 15 community organizations were involved in realizing the success of this event. How were the goals and objectives of your project measured? Goals and objectives were measured in participation numbers and the attraction of additional community partner groups. The support of the Community Grant Program enabled Dia de los Muertos to more than double attendance from it's first year Funds provided enabled us to offer increased artist demonstrations and live performances—expanding the reach of both participation and audience.Visitors came not only from Encinitas and the greater North County area but also as far as Chula Vista and Tijuana Support from key partners enabled marketing to encompass local,regional and broader,Latino advertising opportunities which attracted visitors to our city that might not have normally participated in an Encinitas event. Encinitas Friends of the Arts(EFA)has subsequently developed a robust list of groups,organizations and performers that are interested in participating in the future based on its reception by the San Diego County community. Who participated in the evaluation process? EFA board members,city staff,participating community members and volunteers all actively participated in program evaluation.A vital part of our event, Program Director of Mano a Mano and event emcee Beatriz Villareal provided a tremendous amount of support in advertising and marketing the event.Her efforts alone provided some of the invaluable feedback we received:"You do not even know how many thank you notes I have in my Facebook!!I received 231 notes!!! We had families coming from Encinitas(of course),San Ysidro,Escondido,Vista,Oceanside,Carlsbad,San Marcos,Chula Vista,Valley Center,San Marcos,even from Tijuanal."This event resonated across the county through audience participation, performers attracted and volunteers/community member participation,providing a broad base of feedback for evaluation. How was the City's funding for this project utilized? Funding from the Community Grant Program was focused on Performance fees (allowing the event to increase performance offerings by 40%), increased volunteer support(event shirts,hospitality) and technical sound expenses for performances. FY15-16 CGP REIMBURSEMENT&EVALUATION FORMS APPLICATION FOR FISCAL YEAR 201692017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two cateqories: Civic or Arts proqram. Choose only one option. Civic ❑Arts Grant Request Amount: $5,000 Free of Charge: ® Yes } No Not to exceed$5,000) Program Title: EXPOSURE:A Women's Benefit Event ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt orqanizations may apply. Identify the legal status of your organization: 6 Non-profit ■Tax-exempt Tax/Employer Identification Number(TIN/EIN): 46-4935624 © IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: a e Must match name filed under the Tax/Employer Identification Number) Street Address: 1030 hillips St. Vista, CA 92083 Mailing Address: 1030 Phillips St. Vista, CA 92083 Doing Business as(dba) Name: Please list the names and titles of the organization's Board of Directors: Amelia Brodka, President Lesli Cohen, VP &Treasurer Beatrex Quntanna, Secretary K Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Women's Berietit Event is the biggest women's skateboarding event in the world. The mission of the event is to empower women through skateboarding by creating a showcase of the progression of females within action sports. Beyond providing inspiration and opportunity, the event supports women by donating proceeds to Carol's House, a shelter for survivors of domestic violence.The event is free to the public and features learn- to-skate clinics taught by X-Games medalists which offers free equipment, yoga clinics, autographs by action sports celebrities, raffles, auctions, music and a vendor village featuring many local brands. Over 100 girls from Australia, Japan, Holland, Brazil,Argentina and the US come out to compete in our event each year. Representatives from Carol's House attend the event in order to educate the crowd about the severity of omestic violence. We add Tony Hawk's vert ramp In the center of the park so that we can represent vert, street& bowl disciplines. We expect over 5,000 attendees. Organizational History: The first annual EXPOSURE event took place in 2012 and has grown each year. By 2014 , we expanded o become a nonprofit In order to better fulfill our mission of using skateboarding as a vehicle to teach sell-conticlence, perseverance and wellness to women and girls. Application Form,Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Community Park Total Est.Cost: $90,000 Time Frame: November 5th 9am -6pm Number of Encinitas Residents Served:5,000 Fundraising Activity: ' � No ® Yes If yes,please explain: Proceeds are donated to CRC's Carol's House for DV Survivors CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Amelia Brodka, President Mailing Address: 1030 Phillips St. Vista, CA 92083 Telephone Number: 908 463 0485 Email Address: amelia.brodkaCaexposureskate.org © Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Amelia Brodka President Contact Person: Title: (Please print) Signature: _ Z `- Date: 3-29-16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: I❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: EXPOSURE SKATE PROJECT TITLE: EXPOSURE:A Women's Benefit Event PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income,confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending Grant San Diego Community Enhancement Fund pen ing Grant AAUW Community Action Grant pen Fng $1,000 Grant an Diego Heinvestment Fund pen ing In-Kind ony Hawk Industries Ramp Donation, Consulation, Staff secured $1 bb00 In-Kind o unteers secure ponsors Fps Purchases of various event sponsorship packages pending , Donations Donations from our supporters secure INCOME TOTAL*: 1$136,500 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Event Staffing Emcees, DJs, Judges, core eeper, ven anagers & Prod ucers , -E–qu—ipment Hental Bleachers, Portable es rooms, op- p I en s Awards Prize money tor top temale skaters Fn the world, Donation Donation to Community Hesource Center's aro s House $20,000 Permit Expenses Securing Insurance, Security Off-Site Parking, Shuttle Service, etc. Promotional Banner, Poster,Apparel, Sign &Advertisement rinting MISC upp Fes Clipboards, Duct Tape, Marking Chalk, ens, Markers Vert Ramp enta Rental of ony Hawk Industries 13ft tall Vertical a pipe $10,000 to ing taff Provided by Tony Hawk Foundation for event management Labor et-up an take-down o Tony Hawk Industries amp 4, Volunteer to Volunteers for set-up, event day ana tear- own PR onsu tant FrFng a mar etmg specialist to promote event during months prior $10,000 Event onsu tant Event Consultation Sessions provided y Tony Hawk Foundation $1,000 Volunteer Suppor Food and waters for volunteers and staff throughout t e wee en , After party Celebration for volunteers, staff and participating skateboarders EXPENSE TOTAL*: $136,500 Budget Form *Your Total Income and Total Expenses should be equal. Attachment C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION _ COMMUNITY GRANT PROGRAM ORGANIZATION NAME;EXPOSURE Skate TITLE OF GRANT PROGRAM: EXPOSURE:A Women's Skateboarding Event UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipLents are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Amelia Brodka Title: President 3-29-16 Signature: Date: e INTERNAL REVENUE SERVICE AttechmentA. DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: AUG 18 2014 46-4935624 DLN: EXPOSURE SKATE 17053192339004 C/O REBECCCA L GROVE Contact Person: 39400 WOODWARD AVE STE 101 CUSTOMER SERVICE ID# 31954 BLOOMFIELD HILLS, MI 48304 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170(b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: February 25, 2014 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter 114221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 947 Attachment A. EXPOSURE SKATE We have sent a copy of this letter to your representative as indicated in your power of attorney. Sincerely, Director, Exempt Organizations :,etter 947 RESOLUTION FROM ABOARD OF DIRECTORS AUTHORIZING GRAN'APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF EXPOSURE SKATE WHEREAS, EXPOSURE Skate is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED,that the Board of Directors of EXPOSURE Skate hereby approves the filing of an applicatior+for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 29th day of March 2016 i Anima Btodka President, Board of Directors EXPOSURE Skate Pesli Cohen Vice President&Treasurer, Board of Directors EXPOSURE Skate ---- Beatrex Quntan a Secretary, Board of Directors EXPOSURE Skate -- APPLICATION FOR FISCAL YEAR 2015-2017 R. CITY OF ENCINITAS AND MIZEL FAMILY ' FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classed into two categories:Civic or Arts program. Choose only one option. W Civic ❑Arts Grant Request Amount: $4,790 Free of Charge: 9 Yes ❑ No (Not to exceed$5,000) Program Title. Dash ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 80-0868817 ❑■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A, ORGANIZATION INFORMATION: Organization Name: H2O Trash Patrol (Must match name filed under the Tax/Employer Identification Number) Street Address: 130 Countrywood Lane, Encinitas, CA 92024 Mailing Address: PO Box 231792, Encinitas, CA 92023 Doing Business as (dba) Name: H2O Trash Patrol Please list the names and titles of the organization's Board of Directors: President, Stephanie Stock, CEO, Cedros Soles& His Board Member, Betty Steele, CEO, Steele Realty Vice President,Kathy Hacker,Environmental Programs Consultant Board Member,Season Kepler,General Manager&consultant,SK consulting Secretary, Beth Pryor,Account Manager Patti Diaz,Co-Founder,Executive Director,Aquatic Biologist and Outdoor Education Instructor ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): With the introduction of the Trash Dash, H2O Trash Patrol seeks to bring marine debris education and action to a new audience in it's own backyard. Encinitas residents Lorenzo and Patti Diaz founded H2O Trash Patrol in 2011.With the Trash Dash,H2O seeks to engage the athletes of Encinitas and the surrounding area in helping to keep Encinitas city beaches beautiful and safe.The six free evening runs/cleanups will be held once a month during the peak outdoor season(July,Aug, Sept 2016 and April, May,and June 2017)along city beaches.Fifty to 100 participants are expected at each event which will integrate running and debris collection along the beach.As with all of H20's cleanups,RSVP's and liability waivers are required for all participants to ensure a safe and successful event.The runs will begin and end at local businesses,which also promotes shopping local.Several businesses have already expressed interest in co-promoting,providing raffle prizes,and participating.The H2O crew will provide marine debris safety,prevention and awareness education before the runs to ensure appropriate handling and disposal of debris.After the event, all debris will be collected,weighed,sorted,and recorded.The crew will then properly dispose of materials,including recycling whenever possible.The Trash Dashes will cultivate environmental stewardship among our citizens as well as beautifying our beaches during peak season. Organizational History: Since 2011, H2O Trash Patrol has been cleaning North County San Diego beaches and waterways, and providing marine awareness and education to the students and citizens of Southern California. To date, H2O Trash Patrol has removed more than 13 tons of marine debris and engaged more than 6,000 volunteers through it's programs. Application Form,Page One of Two =- APPLICATION FOR FISCAL YEAR 2016-2017 _ - 4 CITY OF ENCINITAS AND MIZEL FAMILY ' FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas City Beaches Total Est. Cost: $7,890 Time Frame: July-Sept 2016 and April-June 2017 Number of Encinitas Residents Served: 400 Fundraising Activity: W. No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Patti Diaz, Executive Director Mailing Address: PO Box 231792, Encinitas, CA 92023 Telephone Number: 760-230-5830 Email Address: pickitup @h2otrashpatrol.org K Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the Information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Patti Diaz Title: Executive Director (Please print) i Signature: ° ` ° _ Date: April 12, 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: 1:1 Yes E] No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY Nft�T_ FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: H2O Trash Patrol PROJECT TITLE: Trash Dash PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership feesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $4,790 In Kind Market ng(Adverti sing support from partners Pending $800 In Kind Raffle prizes Pending $2,100 Ticket Revenue Optional tickets for raffle prizes Pending $200 INCOME TOTAL*: 1$7,890 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Transportation Costs Collection gloves,collection buckets,educational materials,office supplies,first aid supplies $600 Insurance General Liability&Auto Insurance $570 Contract Labor Skilled,trained contract labor for event education,setup,management,and cleanup $1,200 Transportation Costs Fuel&vehicle expenses for event set-up and debris disposal $1,020 Marketing Event promotion including flyers,printing,and advertising $900 Raffle Prizes Prizes for optional raffle $2,100 Permit Fees City of Encinitas Special Event Permits for 6 runs $900 Overhead Supply storage and administrative costs $600 EXPENSE TOTAL*: $7,890 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 Date: NOV �r�� 80-0868817 yIdentification Number: DLN: 17053265309022 H2O TRASH PATROL Contact Person: PO BOX 231792 REGINA M PARKER ID# 31274 ENCINITAS, CA 92023-1792 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170(b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: November 17, 2011 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Sincerely, Director, Exempt Organizations Enclosure: Publication 4221-PC Letter 947 (DO/CG) Trash Patrol Stand Up for Cleaner, Hea(tkier Waterways - -� 501(1)3 Nan-DmFa On an:za5ca RESOLUTION FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF H2O TRASH PATROL WHEREAS, H2O Trash Patrol is a legally constituted public benefit corporation, under the laws of the State of California, and is in complete control of its affairs through its own officers and staff. NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of H2O Trash Patrol hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year Adopted on this 22nd day of March, 2016 Elizabeth Pryor Secretary, Board of Directors H2O Trash Patrol PO Box 231792.Encinitas,CA 92023.(760)230-5830.pickltUp@H20TrashPatrol.org.www.H2OTrashPatrol.org ❑ ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION E• �_ COMMUNITY GRANT PROGRAM ° ORGANIZATION NAME: H2O Trash Patrol TITLE OF GRANT PROGRAM: Trash Dash UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Ll Contact Person: Patti Diaz Title: Executive Director Signature: l' "-' Date: April 12, 2016 N_. APPLICATION FOR FISCAL YEAR 2016-2017 N&i 4 It CITY OF ENCINITAS AND MIZEL FAMILY - FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts program. Choose only one option. N Civic ❑Arts Grant Request Amount: $4,790 Free of Charge: A Yes ❑ No (Not to exceed$5,000) Program Title: Trash Dash ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 80-0868817 X IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: H2O Trash Patrol (Must match name filed under the TaWEmployer Identification Number) Street Address: 130 Countrywood Lane, Encinitas, CA 92024 Mailing Address: PO Box 231792, Encinitas, CA 92023 Doing Business as (dba) Name: H2O Trash Patrol Please list the names and titles of the organization's Board of Directors: President, Stephanie Stock, CEO, Cedros Soles& His Board Member, Betty Steele, CEO, Steele Realty Vice President,Kathy Hacker,Environmental Programs Consultant Board Member,Season Kepfer,General Manager&Consultant,SK Consulting Secretary, Beth Pryor,Account Manager Patti Diaz,Co-FOUMer,Executive Director,Aquatic Biologist and Outdoor Education Instructor ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): With the introduction of the Trash Dash, H2O Trash Patrol seeks to bring marine debris education and action to a new audience in it's own backyard. Encinitas residents Lorenzo and Patti Diaz founded H2O Trash Patrol in 2011.With the Trash Dash,H2O seeks to engage the athletes of Encinitas and the surrounding area in helping to keep Encinitas city beaches beautiful and safe.The six free evening runs/cleanups will be held once a month during the peak outdoor season(July,Aug, Sept 2016 and April, May,and June 2017)along city beaches. Fifty to 100 participants are expected at each event which will integrate running and debris collection along the beach.As with all of H20's cleanups,RSVP's and liability waivers are required for all participants to ensure a safe and successful event.The runs will begin and end at local businesses,which also promotes shopping local.Several businesses have already expressed interest in co-promoting,providing raffle prizes,and participating.The H2O crew will provide marine debris safety,prevention and awareness education before the runs to ensure appropriate handling and disposal of debris.After the event, all debris will be collected,weighed,sorted,and recorded.The crew will then properly dispose of materials,including recycling whenever possible.The Trash Dashes will cultivate environmental stewardship among our citizens as well as beautifying our beaches during peak season. Organizational History: Since 2011, H2O Trash Patrol has been cleaning North County San Diego beaches and waterways, and providing marine awareness and education to the students and citizens of Southern California. To date, H2O Trash Patrol has removed more than 13 tons of marine debris and engaged more than 6,000 volunteers through its programs. Application Form,Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts program. Choose only one option. ■ Civic ❑Arts Grant Request Amount: $5,000 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Signs of Community Health ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: ■ Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 45-4290015 ❑ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Healthy Day Partners (Must match name filed under the Tax/Employer Identification Number) Street Address: N/A Mailing Address: PO Box 235456 Encinitas, CA 92024 Doing Business as(dba)Name: N/A Please list the names and titles of the organization's Board of Directors: Joy Singleton - President Kathy Rippy- Secretary Teresa Barth -Treasurer ❑ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program(Limit to the space provided): Farm Lab is a school site and community gathering space that offers educational opportunities to students, residents and visitors. Part of its community edu- cation is in a public food forest on Quail Gardens Drive, offering 24/7 access to healthy food for ALL. We are requesting matching Mizel CGP funds to contract a local artist and builder to help develop educational signage to display throughout the community food forest. Signs will provide valuable information to ALL residents and visitors, demystifying food forests and addressing important public health issues such as soil and air quality, rain collecting, low water and sustainable growing methods, biodiversity, composting, healthy food access and nutrition. All visitors to this Encinitas neighborhood will witness an urban farm model that grows fresh food to support the local school lunch program and those in need, while working in collaboration with our E3 Cluster neighbors to utilize agricultural expe- riences that inspire citizens to take responsibility for their health, at home and in their community. Organizational History: Healthy Day Partners has been helping to improve community through environ- mental and wellness education since 2012. We educate and empower youth and local residents while beautifying our neighborhoods and supporting our vulnerable neighbors. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: 441 Quail Gardens Drive (EUSD Farm Lab) Total Est. Cost: $10,000 Time Frame: July 1, 2016 - January 15, 2017 Number of Encinitas Residents Served: Open Fundraising Activity: N No ❑ Yes If yes,please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Mim Michelove Co-President Healthy Day Partners Mailing Address: PO Box 235456 Encinitas, CA 92024 Telephone Number: 714-329-1349 Email Address: mim @healthydaypartners.org X Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Mim Michelove Title: Co-President (Please print) Signature: i X` — Date: / ' 7 '6 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment (IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two _ APPLICATION FOR FISCAL YEAR 2016-2017 ' CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Healthy Day Partners PROJECT TITLE: Signs of Community Health PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services,ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 In-Kind Graphic Artist- matching dollar-amount discount Secured 800 Matchinci Funds Farm Lab Secured $4,200 INCOME TOTAL*: $10,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Graphic Artist Professional graphic design and content development 800 Educational Sin Professional city-approved metal educational sign fabrication 10 $2,200 Frames/structures SturdV structures for displaying each sin 10 $1,500 Installation Professional installation of sign structures and attachment of si ns 500 Graphic Artist In-kind/matching donation of 50% of cost 800 Educational Sin Matchina funds from Farm Lab $2,200 Frames/structures Matching funds from Farm Lab $1,500 Installation Matching funds from Farm Lab 500 EXPENSE TOTAL*: $1 o,000 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: 1j U N 14 261t 45-4290015 DLN: 17053109316012 HEALTHY DAY PARTNERS Contact Person: C/O CAMILLE SOWINSKI JEFFERY A CULLEN ID# 31215 3115 VERDE AVE Contact Telephone Number: CARLSBAD, CA 92009 (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170 (b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: January 6, 2012 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are, also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Sincerely, C4- 0 e Lois G. Lerner Director, Exempt Organizations Enclosure: Publication 4221-PC Letter 947 (DO/CG) RESOLUTION of the Board of Directors of Healthy Day Partners The Board of Directors of Healthy Day Partners, a legally constituted corporation under the laws of the State of California, proposed and approved the following resolution. Resolved: WHEREAS Healthy Day Partners is a recognized 501(c)(3) organization that serves the Encinitas community. Be it Resolved, that the Board of Directors of Healthy Day Partners hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Si ned1�` � ��� Date Name and title ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Healthy Day Partners TITLE OF GRANT PROGRAM: Signs of Community Health UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person. Mim Michelove Title. Co-President Signature: Date: �' 2616 EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date 615115 Organization: Healthy Day Partners Address: PO Box 235456 City: Encinitas State CA Zip 92024 Phone: 714-329-1349 Fax Email: mix*,,healthydaypartners.org State the goals and objectives of your project and whether they have been met. The original goals and objectives of conducting a series of 8 CGP Healthy Habits Workshops was to promote and educate our Spanish speaking neighbors in the growing of fresh foods and begin to show how to incorporation these healthier foods into the diet, to show that food can be grown anywhere, even if you do not own land and to help show how healthy food can be affordable to all. Another critical aspect of the bilingual workshops was inclusion. Until now, it has been extremely challenging to find Hispanic neighborhood champions who could rally their friends to participate in the school garden movement. The non-inclusion of Hispanic families in school gardens is a regional issue. Even though we only received a portion of the funding requested, we were able to work very efficiently to address many issues in 2 workshops.After many attempts to find key stakeholders, we were able to have great success in inviting and working with nearly 50 participants per workshop! How were the goals and objectives of your project measured? For our purposes, as this was the first time out, we could really only evaluate by the numbers of participants. Once we realized that we could only offer 2 workshops with the City funds, we set a goal for ourselves of serving a total of 75 neighbors. We were extremely pleased with our turn out. As a non- traditional evaluation measurement, we also noted that the enthusiasm was high and the connection to the project became lasting. Who participated in the evaluation process? The evaluation was so simple that we did not need a team to participate in the process. How was the City's funding for this project utilized? Healthy Day Partners was happy to be able to supply the majority of the resources used in these workshops, including many of our hours as well as the plants, pots and soil for take away items. City funding was needed to cover the cost of development, oversight and instruction hours. T:\CGP\O1 CGPTemplates+Forms\Agreement Return Letter with forms.doc -- APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts program. Choose only one option. ❑Civic N Arts Grant Request Amount: $4,000 Free of Charge: # Yes ❑ No (Not to exceed$5,000) Program Title: Community Concert Series at the Encinitas Public Library ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0975672 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: The Hutchins Consort (Must match name filed under the Tax/Employer Identification Number) Street Address: 701 Third Street, Encinitas, CA 92024 Mailing Address: 701 Third Street, Encinitas, CA 92024 Doing Business as(dba) Name: Please list the names and titles of the organization's Board of Directors: Howard Jelinek, Chairman Paul Lloyd Warner, Secretary Barbara Woods, President Robert and Ruth Ann Burns, Treasurers Susan Beechner, Vice President Sharon McNalley ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The Hutchins Consort presents the Community Concert Series at the Encinitas Library between 5-7 times annually. The monthly concerts engage audiences of all ages with interesting, unique, and varied repertoire, performed by professional musicians of the highest calibre. Each themed performance includes audience interaction, such as dancing or singing. The admission-free program attracts an audience of approximately 750 attendees each year and is one of the library's most popular programs. Attendees range from young children to senior citizens, engaging Encinitas'vibrant community with world-class admission-free performances. Performers include the 8 members of the Hutchins Consort, along with special guests artists from around the nation who specialize in the type of music to be performed that day. Each program is created by Artistic Director Joe McNalley, and is selected to ensure a diversity of music, encouraging audiences of all cultures and interests to engage with the series. Organizational History: Formed in 1999 in Encinitas by Director Joe McNalley,the Hutchins Consort plays on the eight scaled violins created by luthier Carleen Hutchins.The one-of-a-kind instruments sound like no other instruments in the world. For the past 8 years, the Consort has presented the Community Concert Series at the Encinitas Library. Application Form, Page One of Two -- APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Public Library Total Est. Cost: $11,000 Time Frame: September, 2016-May, 2017 Number of Encinitas Residents Served: 750 Fundraising Activity: R No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Joe McNalley, Artistic Director Mailing Address: 701 Third Street, Encinitas, CA 92024 Telephone Number: 760-632-0554 Email Address: info hutchinsconsort.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Joe McNalley Title: Artistic Director (Please print) x' - Y-� '� Signature: _ � Date: March 14, 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) .Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: The Hutchins Consort PROJECT TITLE: Community Concert Series at the Encinitas Public Library PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $4,000 Grant County of San Diego Community Enhancement Program Pending $3,000 Donation On-site donations(post-concert donations from audience) Pending $1,000 Donation Board donations to support admission-free programming Secured $3,084 Donation Individual donations to support admission-free programming Pending $1,000 INCOME TOTAL*: $12,084 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Hutchins Consort Artist fees Payment to Hutchins Consort artists $163 per artist(8)per concert(6 concerts) $7,824 Guest Artist fees Payment to 2 guest artists(average)per concert(6 concerts) @ $200 per artist $2,400 Composer fees Payment of$200 per concert for music arranging and new compositions $1,200 Grantwriting Preparing the City of Encinitas grant $90 Event staffing Setting up chairs,greeting guests,cleaning up-$15/hour for 3 hours per show(6 concerts) $270 Artist hospitality $20 per show for water,coffee,light snacks $ 120 Marketing Administrative time for marketing-1 hour per show @$30 per hour $180 EXPENSE TOTAL*: $12,084 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45202 Employer Identification Number: Date: W U 7 -a 33-0975672 DLN: 17053035719076 HUTCHINS CONSORT Contact Person: 701 THIRD ST SUSAN Y MALONEY ID# 31210 ENCINITAS, CA 92024 Contact Telephone Number: (877) 829-5500 Public Charity Status: 170(b) (1) (A) (vi) Dear Applicant: Our letter dated February, 2002, stated you would be exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code, and you would be treated as a public charity, rather than as a private foundation, during an advance ruling period. Based on the information you submitted, you are classified as a public charity under the Code section listed in the heading of this letter. Since your exempt status was not under consideration, you continue to be classified as an organization exempt from Federal income tax under section 501(c) (3) of the Code. Publication 557, Tax-Exempt Status for Your Organization, provides detailed information about your rights and responsibilities as an exempt organization. You may request a copy by calling the toll-free number for forms, (800) 829-3676. Information is alsv cr_ our Internet Web Site at www.irs.gov. If you have general questions about exeftipr organizations, please call our toll-free number shown in the heading. Please keep this letter in your permanent records. Sincerely yours, C'4� ■ &A'tow� Lois G. Let = Director, Exempt Organizations Rulings and Agreements Letter 1050 (DO/CG) THE HUTCH I NS CONSORT RESOLUTION OF THE BOARD OF DIRECTORS WHEREAS,the Hutchins Consort is a legally constituted corporation, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE,BE IT RESOLVED, that the Board of Directors of the Hutchins Consort hereby approves the filing of an application for the City of Encinitas and Mizel Famiiy Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 8th day of March,2016 r 13arbara Woods,President of the Board of Directors ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:The Hutchins Consort TITLE OF GRANT PROGRAM: Community Concert Series at the Encinitas Public Library UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Joe MCNalley Title: Artistic Director Signature: Date: March 14, 2016 EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION � r COMMUNITY GRANT PROGRAM FY2O14/15 Date 25 Organization: J `^ Address: �- City: State C zip 2- Phone: - G 0 2 ass Fax n(/ A- Email: State the goals and objectives of your project and whether they have been met. C-0 rc- G How were the goals and objectives of your project measured? Who participated in the evaluation process? How was the City's funding for this project utilized? C T:\CGP\O1 CGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 _-' CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts program. Choose only one option. ❑Civic f Arts Grant Request Amount: $5,000 Free of Charge: ❑ Yes N No (Not to exceed$5,000) Program Title: Staged Reading Series at the Encinitas Library ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: A Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 27-16753766 A IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Intrepid Shakespeare Company (Must match name filed under the Tax/Employer Identification Number) Street Address: 540 Cornish Drive, Encinitas CA 92024 Mailing Address: PO Box 235852, Encinitas CA 92056 Doing Business as(dba)Name: Intrepid Theatre Company Please list the names and titles of the organization's Board of Directors: Stuart Schaffer Robert Goldstein Michael Bernstein CoCo Smith Linda Sorkin Lee Vincent 0 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Intrepid strives to create inspirational theatre that provokes conversation expands perspectives,and challenges thinking within our city,our schools,and the greater artistic community.Intrepid is seeking funding to support its monthly Staged Reading series at the Encinitas Library.lntrepid has produced over 50 professional staged readings in the community room at the Encinitas Library since 2010.This program has directly served over 4,500 local residents to date,has become a social and theatrical mainstay for local residents and a way for the citizens of Encinitas to come together monthly to socialize,engage in spirited discussions with artists and playwrights,and experience outstanding professional theatre in an intimate environment.This program is reflective of the desires of the Encinitas residents we serve.In the most recent Encinitas Arts Master Plan,the poll results strongly show the preference that residents have for theatre as their primary form of entertainment(polled as the number one preferred art medium at 72%) Residents also strongly indicated their need for arts programs that bring the community together(74.1%),that arts should be included in public building and facilities(69.5%)and most importantly that art enhances the quality of life(79.9%).We serve many senior residents that are unable to travel to experience theatre and are grateful that we offer professional performing arts that is accessible to them. Organizational History: Award-winning professional theatre company that produces productions,staged readings,youth summer camps and a Shakespeare School Tour.Intrepid has produced in Encinitas since 2010 and is proud to call Encinitas our artistic home.In that time Intrepid has directly served over 110,000 San Diegans and was awarded Outstanding Small Theatre Company in 2015 by the Critics Circle Application Form,Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Library Total Est.Cost: 12,620 Time Frame: July 2016-June 2017 Number of Encinitas Residents Served: 1,200 Fundraising Activity: 14 No ❑ Yes If yes,please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Christy Yael, Producing Artistic Director Mailing Address: PO Box 235852, Encinitas CA 92023 Telephone Number: 760-295-7541 Email Address: christy @intrepidtheatre.org X Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Christy Yael Title: Producing Artistic Director (Please print) Signature: Date: April 14, 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: \pplication Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Intrepid Shakespeare Company (dba Intrepid Theatre Company) PROJECT TITLE: Staged Reading Series at the Encinitas Library PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Ticket Revenue Estimated ticket revenue from this program Pending $6,000 In-kind Service donated by two volunteer ushers(36 hours/$15 per hr) Secured $1,080 In-kind Service donated by one volunteer bartender(36 hours/$15 per hr) Secured $540 INCOME TOTAL*: 1$12,620 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Talent Actors, Directors $5,500 Food&Beverages Complimentary appetizers and drinks(including wine)served prior to every staged reading $2,400 Room rental Community Room rental fee at the Encinitas Library $1,500 Materials Scripts,props $600 Marketing Graphic Design,online advertising,direct email campaigns,flyers $1,000 Labor In-kind service donated by volunteer ushers(36 hours/$15 per hr) $1,080 Labor In-kind service donated by volunteer bartender(36 hours/$15 per hr) $540 EXPENSE TOTAL*: $12,620 Bu Iget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: LA)3 2011 27-1653766 U11W Q DLN: INTREPID SHAKESPEARE COMPANY 17053013311011 C/O BEAMER LAUTH STEINLEY & BOND LLP Contact Person: JAMES E LAUTH RICHARD COMBS ID# 31024 401 B ST 1530 Contact Telephone Number: SAN DIEGO, CA 92101 (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170(b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: February 4, 2010 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Letter 947 (DO/CG) INTREPID SHAKESPEARE COMPANY We have sent a copy of this letter to your representative as indicated in your power of attorney. Sincerely, Lois G. Lerner Director, Exempt Organizations Enclosure: Publication 4221-PC Letter 947 (DO/CG) RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF INTREPID SHAKESPEARE COMPANY WHEREAS,the Intrepid Shakespeare Company(dba Intrepid Theatre Company)is a legally constituted corporation or public/governmental entity,under the laws of the State of California,and is complete control of its affairs through its own officers and members, NOW THEREFORE,BE IT RESOLVED,that the Board of Directors of the Intrepid Shakespeare Company (dba Intrepid Theatre Company)hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 1 st day of April,2016 Lee Vincent Secretary,Board of Directors Intrepid Shakespeare Company ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION _ w COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Intrepid Shakespeare Company(dba Intrepid Theatre Company) TITLE OF GRANT PROGRAM: Staged Reading Series at the Encinitas Library UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and properly damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000)for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Christy Yael Title: Producing Artistic Director Signature: Date- April 14, 2016 _ EVALUATION FORM -- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014115 Date Organization: Int/reepid Shakespeare Company Address: Citv: —1—t-=-Mc i r7 i 71 g-T State C./¢ zip Phone: 76 O- 7J--Y/Fax Email: " . .9e� State the goals and objectives of your project and whether they have been met. o XeY' S 7L� S�`,�r�ts t��ro weec. Po/'o� G -�"� -�'"f ✓%s''G� S cr.•?.y-E'r ��r���r' C���.r �/�S�"�-s+�.!'. _r ti c c cXX 711W C /v r� `✓�y+J ya '�"l� //ac-�f� �l� `r� ydoa , ,•� 9r�l-yf- ��h�yf. sC h �J.4-r��i.,•as , / � s� ���mss ,6r h j�. �-��� �fc� y`-�-use Sc h� -ra-A.ios. How were the goals and objectives of your project measured? v7/�'v�- �f Lo v� ���f� ��' /��-!�'f:G •,d,f-�-� �S.e-�, �-�f r'�rcYi Who participated in the evaluation process? How was the City's funding for this project utilized? C4 V1�� `��J fir s-� �a �- `-.� ����'T Li �C✓ Sf uG��t +� �,J' Cc/�e � �'�/aryl f r`f'c-lr�i �G ��'tr/Ge� S LA r9 T:\CGP\OICGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM .;ATEGORY: Grant requests are classified into two categories:Civic or Arts program. Choose only one option. ❑Civic Arts Grant Request Amount: $5,000 Free of Charge: ❑ Yes Off No (Not to exceed$5,000) Program Title: 2016 iPalpiti Festival in Encinitas ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: Iff Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-4618040 A IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: iPalpiti Artists international, Inc. (Must match name filed under the Tax/Employer Identification Number) Street Address: 1900 Avenue of the Stars, Suite 1880, Los Angeles, CA 90067 Mailing Address: Same Doing Business as(dba)Name: Please list the names and titles of the organization's Board of Directors: Jonathan Steinberg, Chairman Nathan Frankel Mary Levin-Cutler, Founding Chairman John Flynn, Dana Wilkey Ada Sands, Vice Chair Ludmila Gierowitz, Hermando Courtright Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): From July 7-10, six celebrated young musicians from throughout the world will present four Soloist Concerts(3 evening and 1 afternoon)led by music director Eduard Schmieder, at the Encinitas Library, as part of the 5th Annual iPalpiti Festival in Encinitas. For the 2nd year in a row,the festival will also include a performance by the 26 member iPalpiti Orchestra. The concert will take place on Saturday,July 16 at 2pm in a nearby church. Encinitas Friends of the Arts will offer an opportunity drawing to raise funds for the Pacific View arts, culture and ecology center. iPalpiti Artists, Int. is presenting the concert to thank the community and show support for the new arts center in Encinitas. Grant funding will keep ticket prices affordable for all members of the community($15 per concert).The festival is the most popular classical musical event in the city and is beloved by many. To attend an iPalpiti Festival is to glimpse the future of classical music as each musician is under 30 and the winner of major international music competitions.These musicians are some of the finest in the world. The festival will allow the public to interact with the musicians, who will be in town 7 days this July at concerts and other events. We anticipate 550 people will attend the Soloists Concerts and 600 will attend the Orchestra Concert. Organizational History: iPalpiti Artists International was established in 1997 to"advance the careers of young professional talented classical musicians and promote peace and understanding through music."They provide awards and scholarships and over 535 concerts. Each year,they host a 3 week festival and bring together more than 27 musicians from around the world. Application Form, Page One of Two - - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROORAM iNFORMATION: Location: 2016 iPalpiti Festival in Encinitas Total Est. Cost: 21,360 Time Frame: July 7-16, 2016 Number of Encinitas Residents Served: 1750 Fundraising Activity: ❑ No '1i Yes If yes, please explain: Encinitas Friends of the Arts will offer opportunity drawings at the Orchestra Concert. CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Laura Schmieder, Executive Director Mailing Address: 1900 Avenue of the Stars, Suite 1880, Los Angeles, CA 90067 Telephone Number: (310)650-2789 Email Address: info @ipalpiti.org Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. 1 hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Laura Schmieder Title: Executive Director (Please print) Signature: L7 e Date: 04/13/2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) beets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 . .:, CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM k--.GANIZATION NAME: iPalpiti Artists International, Inc. PROJECT TITLE: 2016 iPalpiti Festival in Encinitas PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 In-kind Donation iPalpiti Festival administration Secured $700 In-kind Donation Enc,Library Comm.Room(37 hrs x$30) Secured $1,100 In-kind Donation Piano tuning Secured $160 In-kind Donation Brochure,fliers,eblasts,media release Secured $600 In-kind Donation Video and Audio Recording by Hiro Ikezi Secured $800 Ticket Sales (4 concerts:x 100 attendees x$15,Orchestra concert,400 attendees x$15) Pending $12,000 Matching Income *Private donor:transportation for the soloists and orchestra Secured $500 Matching Income *Private donor:food for 26 orchestra musicians(dinner) Secured $500 INCOME TOTAL*: $21,360 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST In-kind Donation iPalpiti Festival administration $700 In-kind Donation Enc,Library Comm.Room(37 hrs x$30) $1,110 In-kind Donation Piano tuning $160 In-kind Donation Brochure,fliers,eblasts,media release $600 In-kind Donation Video and Audio Recording by Hiro Ikezi $800 Housing 5 nights,6 musicians(McNeill House) $1,500 Receptions food,beverages,supplies,paper goods(5 concert receptions for the public) $1,340 Marketing Newspaper ads(2 x$300 Coast News; 1 x$600 U-T) $1,200 Marketing Graphic design(poster,flier,banners) $850 Ticketing Fee Tix,com online ticketing service fee($2.50 x 400).Charge Card fees(5%of ticket purchase) $1,300 Housing 5 night stay. 1 music director and 1 executive director $900 Food/expense stipend Soloist Concerts:6 musicians,2 directors x 5 days $4,900 Expense stipend Orchestra Concert:25 musicians,2 directors $5,000 aI Fee Use of the church for the orchestra concert $700 Rentals Music stands,orchestra concert $300 EXPENSE TOTAL*: $21,360 Budget Form *Your Total Income and Total Expenses should be equal. 601b State of California Secretary of State { I, DEBRA BOWEN, Secretary of State of the State of California, hereby certify: That the attached transcript of�_ page(s) has been compared with the record on file in this office, of which it purports to be a copy, and that it is full, true and correct. 42..'., '.. `;i IN WITNESS WHEREOF, I execute this certificate and affix the Great Seal of the State of California this day of T I T 9. 7 M R DEBRA BOWEN Secretary of Statc ....,.«. Sev&lare Form CE•107(REV 112007) INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 NOV o� 20Q Employer Identification Number: v Date: 95-4618040 DLN: 17053279794011 YOUNG ARTISTS INTERNATIONAL INC Contact Person: 2430 APOLLO DR MICHAEL RYAN ID# 31362 LOS ANGELES, CA 90046 Contact Telephone Number: (877) 829-5500 Our Letter Dated: October, 1997 Addendum Applies: No Dear Applicant: This modifies our letter of the above date in which we stated that you would be treated as, an organization that is not a private foundation until the expiration of your advance ruling period. Your exempt status under section 501(a) of the Internal Revenue Code as an organizatio cribed in section 501(c) (3) is still in effect. Based on the informa n you submitted, we have determined that you are not a private foundation within the meaning of section 509(a) of the Code because you are an organization of the type described in section 509(a) (1) and 170 (b) (1) (A) (vi) . Grantors and contributors may rely on this determination unless the Internal Revenue Service publishes notice to the contrary. However, if you lose your section 509(a) (1) status, a grantor or contributor may not rely on this determination if he or she was in part responsible for, or was aware of, the act or failure to act, or the substantial or material change on the part of the organization that resulted in your loss of such status, or if he or she acquired knowledge that the Internal Revenue Service had given notice that you would no longer be classified as a section 509(a) (1) organization. You are required to make your annual information return, Form 990 or Form 990-EZ, available for public inspection for three years after the later of the due date of the return or the date the return is filed. You are also required to make available for public inspection your exemption application, any supporting documents, and your exemption letter. Copies of these documents are also required to be provided to any individual upon written or in person request without charge other than reasonable fees for copying and postage. You may fulfill this requirement by placing these documents on the Internet. Penalties may be imposed for failure to comply with these requirements. Additional information is available in Publication 557, Tax-Exempt Status for Your Organization, or you may call our toll free i number shown above. If we have indicated in the heading of this letter that an addendum applies, the addendum enclosed is an integral part of this letter. Letter 1050 (DO/CG) RESOLUTION FROM THE BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF IPALPITI ARTISTS INTERNATIONAL, INC. WHEREAS, iPalpiti Artists International, Inc. is a legally constituted corporation or under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of iPalpiti Artists International, Inc. hereby approves the filing of an application for the 2016-2017 City of Encinitas and Mizel Family Foundation Community Grant Program to fund Concerts in Encinitas. Adopted on this 13th day of April, 2016 Jonathan Steinberg Chairman, Board of Directors ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 -- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: iPalpiti Artists International, Inc. TITLE OF GRANT PROGRAM: 2016 iPalpiti Festival in Encinitas UNDERSTANDING OF INSURANCE REQUIREMENT -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Laura Schmieder Title: Executive Director 1 Signature: �` _� Date: 04/13/2016 EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015/16 Date August 1,2015 Organization: iPalpiti Artists, International Address: 1900 Avenue of the Stars,Suite 1880 City: Los Angeles, State CA Zip 90067 Phone: (310)650-2789 Fax Email: info @ipalpiti.org State the goals and objectives of your project and whether they have been met. On July 9,10, 11, 12 and15,2015 six celebrated young musicians from other countries presented five Soloists Concerts(4 in the evening, 1 in the afternoon)led by music director Eduard Schmieder,at the Encinitas Library,in partnership with the Encinitas Commission for the Arts.From July 12-18 the entire 25 member iPalpiti Orchestra was in residence in Encinitas. Monday-Friday,they rehearsed at the Encinitas Library,which included open rehearsals for the public to watch and enjoy the process to learn and perfect the music.Each musician is a winner of a prestigious international music competition and was invited to participate in the 18th Annual iPalpiti Festival of International Laureates(Encinitas,July 7-18; and Los Angeles July 19-25).On July 18,the orchestra presented a free concert for the community at San Dieguito Academy Gymnasium.This collaboration presented these talented young musicians in a total of 6 concerts for Encinitas audiences.A long term City arts goal is to bring world-class musicians to perform for residents,alleviating the need for them to travel to downtown San Dieqo—the iPalpito festival helps us fulfill this goal.To witness an iPalpiti Festival is to glimpse the future of classical music How were the goals and objectives of your project measured? The iPalpiti Festival is measured by the number of tickets sold,the quality of the concerts,the participation of volunteers,the satisfaction of the musicians,and the response from attendees,iPalpiti staff,and city staff and the Commission for the Arts. Comments from the community are received both verbally and via email.This festival was the largest to date with a 2 week residency in Encinitas.The overwhelming response from the public was positive.The opportunities for free events:open rehearsals,dinners with the musicians,and the free orchestra concert,made this a banner year for the festival,with resounding approval by Encinitas residents. Who participated in the evaluation process? Members of the community,concert attendees,Laura Schmieder,Executive Director of iPalpiti,Eduard Schmieder,iPalpiti Conductor,the iPalpiti Board of Directors,the iPalpiti musicians,Jim Gilliam,Encinitas Arts Administrator,Cheryl Ehlers,Arts Program Assistant,the Commission for the Arts,library staff,and volunteers. How was the City's funding for this project utilized? Grant funds were utilized for festival expenses (marketing, printing, ticketing, advertising) and musician expenses (stipends, food, housing, transportation). T:\CGP\OICGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 ° CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant reauests are ciassr&4 into trio caitegones:Civic or Arts moaram. Choose oniv one option. ❑Civic Arts Grant Request Amount: 5,000 Free of Charge: ❑ Yes No (Not to exceed$5,000) Program Title: San Diego Italian Film Festival at La Paloma ELIG11It3IF,.1T'Y DETERMINATION:Orgy non-profit and/or tax-exempt organizations may apply, Identify the legal status of your organization: 1.10 Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 26-0236264 ® IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Italian American Art and Cultural Association of San Diego (Must match name filed under the TaxlEmployer Identification Number) Street Address: 3593 Fifth Avenue Suite A,San Diego,CA 92103 Mailing Address: 3593 Fifth Avenue Suite A, San Diego, CA 92103 Doing Business as(dba)Name: San Diego Italian Film Festival Please list the names and titles of the organization's Board of Directors: Victor Laruccia, President, Sandra Silverstein,VP Clarissa Clo' Ph.D.,Janice Laruccia, Ron Sahmel, CPA,Treasurer, Michael Volkov, Secretary Ron Miriello, Don Santamaria, Jose Alonso,Anthea Beletsis Saundra Saperstein, Rosetta Sciacca-Volkov 8 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The San Diego Italian Film Festival will sponsor monthly film screenings of contemporary and popular films at the Paloma Theater starting July 1,2016 through June 30,2017.Next year's program new design will include:2 additional screenings;at least 5 featured experts on Italian film&culture relevant to films;and TWO local community events.The festival also begins a Community Partners program in Encinitas to share outreach,audiences and films. Endorsement&support by the Mizel Family Fdn/Community Grant Program has augmented funding from the County Community Enhancement Fund District 3.Adding 2 more North County residents to the board from Encinitas and Carlsbad and Communications Director from Encinitas will strengthen ties with local community groups and enhance the the festival's presence as an Encinitas"event."Attendance ranges from 250 attendees to sold-out screenings with a reach that includes Solana Beach, Carlsbad,Vista and Escondido attracting film aficionados, Italian clubs,residents and college language students who have been our most targeted group this year.The end result is a young corps of volunteers who are infusing new energy and ideas to festival program. Grant funds will be used to subsidize venue and film rentals. Organizational History: The IAACASD and its offspring,the San Diego Italian Film Festival,were founded in 2006 to celebrate Italian culture and film.The festival promotes Italian fifm through screenings,conferences&cultural events.Since it began at MoPA's Joan and Irwin Jacobs Theater in Balboa Park,the festival has gradually expanded to the historic Paloma Theater in Encinitas. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM V r�.GANIZA TION NAME: Italian American Art and Cultural Association. of San Diego PROJECT TITLE: San Diego Italian Film Festival at La Paloma PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT City of Encinitas& �lrzef Farrrify Fcundetion Grant Program Pending $5,000 City Ticket Revenue Projected ticket revenues for 13 film screenings at La Paloma Theater Pending $21,300 Grants SD County Community Enhancement(from District 3-based on last 2 year's awards) Pending $4,000 Contributions Individual contributions designated specifically for the film festival in Encinitas Secured $4,300 In-Kind DuChateau Creative-in kind Secured $2,000 C INCOME TOTAL*: $36,600 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Theater Rental La Paloma Theater-2 nights(July&Aug 2016);3 nights(Oct 2016,8 nights Jan-June 2017) $14,000 Film Rental 13 films,shipping&handling $9,800 Marketing In-kind design of postcards,website,email blast,PR $2,000 Printing Festival cards,monthly series cards,flyers $4,800 Event Coordinators Hired @$115 per event,volunteer management,card distribution $800 Insurance Insurance for events as per venue contract $600 Materials&Supplies Disks,DVD Player,Signage $400 Social media Content Ads,stories,copyright material $600 Other marketing Press Relations;and Communications Director(allocated @ 50%dedicated for Encinitas events) $1,600 Film curation Artistic Director-specifically allocated for Encinitas festival $2,000 EXPENSE TOTAL*: $36,600 �.-u , , -- - • v �rr,� rl� 7� �e ' -"' n' 6/tr a '7!r01 -:itwrr R�venu!dery c� a en. Z;istfict Director A ;tf' �'�� i ��� Employer IdentH41'rf€*i�'vr-A 4' T5 -36,C Accounting.t erl�- 7-_4011 Dec-mber 31 FoundsUarl Status ClasslRcstion: 4,V#, I)('_) Advance Ruling Peffod Endu �I imi ted Jazz D,nr a *'r-%due'i.it D- - ,nru r I 1. 1)P� 148 F Vi 11_ Al C.n to "Mon to Comm, .a Joll i, G 92n3" I Iii i 1 Confect Telephone Number. 688 +88*1 —' -)car Applicant• W%zed on inform.tior s`upplisd a.nd .ssuming 'Pe "'' ^g 4i-- 'e as 9 a9 -nur app.istion fnr recognition exnmptlln wA a ,e zI ar^.rRd �m F-deral ...,tome •a- andur sec'ti)n 5C. :+ Z Secau3�, you -rm 1 ndwly cre..tad o--gyn.zatiorl we are nt nov mar_ng a finz. %ermination cf your foundation status unde so-_ ` '. 3e W' n h3 r- dut-rmined that you car. rawonab.v '^e expo- = - 5. -raniz..t+or �n s-ction 5`° a Acoordingly you will bu tre-ted as . publinlj .au,:^,_.Ta1 -rgan _za'._ a private foundation 3uryng an advan; _':ng -f,- .s -j a -e g ' _g.zs D- tn_ d-t- _f y^u- _n.:upt;3r. an:1 P:hs -- ie as _- .w : Aithin 9C days oft_r th _nd f ynu*' adv_nc_ -I_'•n6 ^P' _ ,d you mus= subm.' _-forma'.on ne-,ded tr i^termine wheth2 • vz� have me' }:icable support tur' during .he :dv,.nce r-..Lng pert_'. f^ 2s'aC_ S` ?. iea^ a publicly s3pport;d nrgarization u a•.._ -e _acs.f_ed ;AE at _ ? -- 509 a « organization as long as y-'. _ ,r'. mee _�:e ; ie appi_cable s-ippZ-+ t-St :f you j.i no mee- - s.,- _ _ _ .Z he advsnse -U_i^g pe-ioi you w--'l: be class- _e{ a re pt, :jM ._.s- �r yo,-. are cl3sui C_�d a, a _ '3' -a" h -aa'ei .a 4 pr.`rL'.e d I and 4940 �r y''-'s ias3 3anor@ m..y "ly %r th_ dPturmin_* n i ,, lu ^' >, ."t'3 -al and -)' y - ayv r rc tn.. +.., 9� 33,,' g''i: - - T- Net • r MEETING MINUTES FROM THE BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS Italian American Art and Cultural Association of San Diego D13A SAN DIEGO ITALIAN FILM FESTIVAL WHEREAS,the Italian American Art and Cultural Association is a legally constituted corporation or public/governmental entity,under the laws of the State of California,and is complete control of its affairs through its own officers and members, NOW THEREFORE,BE IT RESOLVED,that the Board of Directors of the Italian American Art and Cultural Association of San Diego hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City S 2oi6-2017 Fiscal Year. Adopted on this the 22nd day of March,2016 C- Victor Laruccia,Ph.D. President,Board of Directors ITALIAN AMERICAN ART AND CULTURAL ASSOCIATION OF SAN DIEGO ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 --- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION •= COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Italian American Art and Cultural Association of San Diego TITLE OF GRANT PROGRAM: San Diego Italian Film Festival at La Paloma UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Victor Laruccia, President Title: Executive Director April 10 2016 Signature: V � - �� ��.� �� � t- Date , _—_ APPLICATION INSTRUCTIONS (Continued) A- SUBMITTAL Your completed Application Package must include: ONE SIGNED ORIGINAL Application Form,Budget,and Attachments A,B,and C;and EIGHT COPIES of the Application,Budget and Attachments A,B,and C. DO NOT use staples,notebook binders or folders. Please do use binder clips or paper clips to collate your original and copies. Submit your completed Application Package by U.S. Mal or hand deliver to the location fisted below. Applications must be received into the City Manager's Office by 3:00 PM,Thursday,April 14,2016. Emailed applications will not be accepted. Community Grant Program City Manager's Office City of Encinitas 505 South Vulcan Avenue Encinitas, CA 920243533 Page 5 of 7 APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classed into two categories: Civic or'Arts program. Choose only one option. a Civic ❑Arts Grant Request Amount: $1,000 Free of Charge: 0 Yes ❑ No (Not to exceed$5,000) Program Title: U Drive,Arrive Alive! ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0951993 0 IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Jonathan Tarr Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: 162 S Rancho Santa Fe Road,Suite#F-20 Encinitas,CA 92024 (Offices) Mailing Address: 1231 Evergreen Drive Encinitas, CA 92024 (Original Mailing Address) Doing Business as(dba)Name: Jonathan Tarr Foundation Please list the names and titles of the organization's Board of Directors: Sherry Yardley, President Veronica Baker,Vice-President Stacy Fuerte, Secretary Noralie Lannon,Treasurer Chrystell Brace, Board Kathryn Reyes, Board 9 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): U Drive,Arrive Alive!is a Jonathan Tarr Foundation community service program creating safer and healthier neighborhoods and communities by increasing awareness through true life stories and continually reminding teens,young adults and their families about the following messages: U Drive, U Text, U Pay * Buckle Up for Safety * Don't Drink and Drive * U Drive,Arrive Alive! JTF will target approximately 500 students and adults at Grauer School, Diegueno Middle School, Sunset HS, San Dieguito Academy,and MiraCosta College San Elijo with this grant.U Drive,Arrive Alive!is the direct result of Jonathan Tarr, a teen who died in a tragic auto accident. Distracted driving was the main cause of the fatality and Jonathan was not wearing a seat belt. He was thrown from the passenger side window and died of blunt force head injuries. Jonathan Tarr Foundation will work tirelessly repeating the four messages so that Encinitas, Leucadia, Cardiff and Olivenhain drivers, passengers and pedestrians are safer and healthier. JTF is an education based non-profit located in Encinitas. Organizational History: Jonathan Tarr Foundation provides Scholarships,Workshops and Resources to students graduating from Non-Traditional and Traditional high schools to help student recipients succeed in college or certified career programs. JTF is a permanent 501 (c)(3)Nonprofit Corporation since 2001. Application Form,Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: On site campuses at 5 Schools and 1 Community College for Students and Adults Total Est. Cost: $2,000 Time Frame: School Year 2016/2017 Number of Encinitas Residents Served: 500 Fundraising Activity: 0 No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Robin J.Tarr Mailing Address: 162 S. Rancho Santa Fe Road, Suite#F-20 Encinitas, CA 92024 Telephone Number: 760-230-2344 (Office) Email Address: robinjtarr@gmail.com ❑� Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Robin J. Tarr Title: Founder (Please print) Signature: •_ ' Date: April 14,2014 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: application Form,Page 1 wo o i"I-wo APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY -7 FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Jonathan Tarr Foundation PROJECT TITLE: U Drive, Arrive Alive! PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $1,000 In-Kind School Venues with AN,room set up,lighting,hardware for Power Point Pending $250 In-Kind 1500 color copies for handouts by USBuilding&Development Pending $200 In-Kind 2 Encinitas Residents,true story presenters,transportation and auto insurance Pending $450 In-Kind 500 Cell Phone bags and Florist Ribbon by Judith Lee Secured $100 INCOME TOTAL*: $2,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST In-Kind School Venues with AN,room set up,lighting,hardware for Power Point $250 In-Kind 1500 color copies for handouts by USBuilding&Development 1,500 sheets x.13 $200 In-Kind 2 Encinitas Residents,true story presenters,transportation,auto insurance 30 hours x$15 $450 JTF Liability Insurance 2%Pro-rated $50 JTF Offices at 162 S.Rancho Santa Fe Road #F-20 2%Pro-rated $250 JTF Graphic design specific for each school power point presentation and handouts $300 JTF/In-Kind Cell phone bag,key chain,mints,JTF story,business card,label and ribbon 500 x$1 $500 EXPENSE TOTAL*: $2,000 B Lis.get Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF T� -. T§9A'S1Yk-r P. 0. BOX 2508 CINCINNATI, OH 45201 i Date: Employer Identification Numbery 33-0951993 DLN: 17053084792066 JONATHAN TARR FOUNDATION Contact Person: 1231 EVERGREEN DR GREGORY S PAJDA ID# 31533 ENCINITAS, CA 92024 Contact Telephone Number: (877) 829-5500 Public Charity Status: 170(b) (1) (A) (vi) Dear Applicant: Our letter dated December 2001, stated you would be exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code, and you would be treated as a public charity, rather than as a private foundation, during an advance ruling period. Based on the information you submitted, you are classified as a public charity under the Code section listed in the heading of this letter. Since your exempt status was not under consideration, you continue to be classified as an organization exempt from Federal income tax under section 501(c) (3) of the Code. Publication 557, Tax-Exempt Status for Your Organization, provides detailed information about your rights and responsibilities as an exempt organization. You may request a copy by calling the toll-free number for forms, (800) 829-3676. Information is also available on our Internet Web Site at www.irs.gov. If you have general questions about exempt organizations, please call our toll-free number shown in the heading. Please keep this letter in your permanent records. Sincerely yours, s r Lois G. Lerner Director, Exempt Organizations Rulings and Agreements Letter 1050 (DO/CG) Jonathan Tarr "Recognizing Potential, Rewarding Determination" Foundation Resolution From Board of Directors Authorizing Grant Application Resolution of the Board of Directors of Jonathan Tarr Foundation WHEREAS, the Jonathan Tarr Foundation is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Jonathan Tarr Foundation hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 41 Day of April, 2016 Gd'Z Stacy Fuerte Secretary, Board of Directors Jonathan Tarr Foundation ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Jonathan Tarr Foundation TITLE OF GRANT PROGRAM: U Drive, Arrive Alive! UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Robin J. Tarr Title: Founder J- Date: April 14, 2016 g Si nature: — ��� f APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY ` FOUNDATION COMMUNITY GRANT PROGRAM A Civic ❑Arts Grant Request Amount: 5:000 Free of Charge. Yes ❑ No (Not to exceed$5,000) Program Title: 1reasure Chest Literacy Program r ELIGIBILITY Wit . t Identify the legal status of your organization: T Nor-profit ❑Tax-exempt 1 Tax/Employer Identification Number(f-IN/EIN): 57-1138284 IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANI y Organization Name: Kiwanis Club of Greater Encinitas Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: 217 Cerro Street, Encinitas CA 92024 Mailing Address: P.O. Box 230635, Encinitas, CA 92023 Doing Business as (dba) Name: Treasure Chest Literacy Proy,arn Please list the names and titles of the organization's Board of Directors: 14orris Pike , Foundation President and CEO Dave Brookes, Treasure Patti Phillips, Club President Relda Colvin, Secretary J Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRA, �I ,jy a.. h Summary of Program (Limit to the space provided): Every year,through the Treasure Chest Literacy Program,Captain Book (aka Dr. Morris Pike) and his crew, the Kiwanis Club of Greater Encinitas members, give free books to Encinitas Head Starts, K-5th grade elementary school children, Title 1 students and Encinitas elementary school teachers. The Treasure Chest Literacy Program dispenses books directly to the children through 1.) Personal visits/performances by Captain Book, 2.)a Treasure Hunt Program where the Title 1 children select two books each and 3.)The books Ahoy Program where Encinitas Elementary School Teachers select ten books for his/her classroom. Based on the premise that books are vitai to children's success in school, Gr. t-ike performs as the reading pirate to insipire cididren and them to promise to read, read, read. Organizational History: Dr. Pike conceived the idea of the program in 2000.Today he averages more then 70 visits a year to Head Starts, Libraries and Public School Classrooms. As of this writing we have given away 100,000 books to children who may not otherwise have them. Annti!'Qtlnn Pnrm AaRA APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM F'RQGF2gM:�INi=Q iY Location: City of Encinitas, New Encinitas, Leucadia, Cardiff and Olivenhaim Total Est. Cost: $5,000 Time Frame: 08/15/2016-06/25/2017 Number of Encinitas Residents Served: 3,500 Fundraising Activity: ❑ No ❑W Yes }y If yes, please explain: Kiwanis Comedy Night and Private Donations ONTAt1TIfN99A �*TJq. .Qi a l '�,, ;'�;,',s, e r E'••r Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure or any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Morris R. Pike, President & CEO Mailing Address: P.O. Sox 230635, Encinitas, CA 92023 Telephone Number: 760-942-8778 Email Address: mnpike @mac.com Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Morris Pike Title: President& CEO (Please print) � J Signature: L44 - �� Date: ��-�-r�1 j, zo lr, THIS SECTIO .. - ..- 'r`5� •'s�S.�=�"+#f �.h.' ��1 "ter Jt9F��'i���`° ' r Date Received. Application Packet Complete (original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) i,,.;ets Eligibility Requirements: Yes 0 No Reasons: Application Form, Page Two of Two Internal Revenue Service Direct,),, i•K)Rulings& Agreements Department of the Treasury P 0.Ro•.,25()5 Cincinnati.OH 45201 Ctt:pto)ei iu�tiu(icatton,Number Date:September 26,2006 57-1138284 Document Locator Number- 17053-252-741209-6 KIWANIS CLUB OF GREATER ENCI1dIT S FOUNDATION Toll Free Number: 877-829-5500 I PC' BOX 230635 ENCINITrS, CA 920,23 ekknOwledbement of Your Request We received your Form 8734,Support Schedule for Your Advance Ruling,or other information regarding your public support status, When communicating with us,please refer to the employer identification number and document locator number shown above. Your tax?xe"t t Status� i- p and r section 501(c)(3)of the Internal Revenue Code remains i.n effect. lvhnt Happens ,IvL t? � ante as been s n you suhnutted was entered into our computer system at our processing center in Covington.Kentucky, and has been sent to our Cincinnati office for initial review W'e approve some cases based on this review, If this is the case,you will receive a letter stating that you are a publicly supported organization. If tine review indicates that additional information or changes are necessary,your case will be assigned to an Exemp t � Organization Specialist in Cin n cutnu who will call or write you. 'ti•'e assign cases in the order we receive them, It the additional information indicates that you meet one of the public support tests,you will receive a letter stating that you are a publicly supported organization. if the pubic support tests are not met,we will send you a letter re-classifying you as a private foundation. That letter will alit you why we believe you do not meet the public support tests,and will include a complete explanation of your appeal rights. I 'Vile'$Can You l xpecr To Initially hear Front Ls Aboru Your Applfcrtiat:? i Normally,you may expect to hear from is within 120 days. If you do not,you may call our toll free number at 1.877-829-5500 Monday through Friday. Please have your identification numbers available so that we can identify case If you would rather write than call,please include a cups of this notice with your correspondence. Your I Notice 3369(cg)-(Rcv. 12/2000) APPLICATION FOR FISCAL YEAR 2016-2017 0.5 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ;ANIZATION NAME: Kiwanis Club of Greater Encinitas Foundation 3ROJECT TITLE: Treasure Chest Literacy Program PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on whaf is rears/rerf_ NCOME: List all types and its source of Income, confirmed or pending, to include but not limited to irants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, ind all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE _ ` STATUS AMOUNT ,rant City of Encinitas & Mizel Family Foundation Grant Prograill Pending 5,000 latching funds Kiwanis Club of Greater Fncinitas-Fundrasars Secured $2,000 onations Individuals and Other Kiwanis Clubs Serured $2,000 i Kind Service Kiwanis Members-individuals Secured $2,000 i Kind Service Captain Book Visits Secured $3,000 i Kind Service First Mate Pages Secured $3,000 INCOME TOTAL*: $17,000 :XPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be icluded as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Doks Books at an average cost of$5.00 per book, 1,500 books 1$7,500 Dok Markers Book Markers given to each child,bought in 20,000 blocks $700 )ok Moblie Book Moblie visits,gas,insurance,up keep 1$8,800 EXPENSE TOTAL*: $17,000 - ldget Form '"Y"our Totoi encome an `Tota) Expenses should be equal. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM + ORGANIZATION NAME: Kiwanis Club of Greater Encinitas Foundation TITLE OF GRANT PROGRAM: I reasure Chest Literacy Program UNDERSTANDING OF INSURANCE REQUIREMENTS ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall net be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Morris Pike Title: President & CEO Signature. Date: 3/08/2016 I Se r v i n +; t 2 C h i l d r n o f t h e N o l d www.captainbook.org Resolution from the Board of Directors Authorizing Grant of Application. Resolution of the Board of Directors of the Greater Encinitas Kiwanis Club Foundation. Whereas, the Greater Ecinitas Kiwanis Club Foundation is a legally constituted corporation under the laws of the State of California and is in complete control of its affairs through its own officers and members. Now therefore, be it resolved, that the Board of Directors of the Greater Encinitas Kiwanis Club Foundation approves the filing of an application for the City of Encinitas and the Mizel Family Foundation Community Grant Program funding the city's 2016/2617 fiscal year. Adopted on this Day, March 9, 2016 R Ida N Colvin Secretary, Board of Directors KIWANIS CLUB OF GREATER ENCINITAS FOUNDATION P.O. Box 230635 Encinitas, CA 92023 KCGE Foundation is a 501(c)(3)Corporation.Your gifts are tax deductable.EIN 57-1138284 ACt�R� CERTIFICATE OF LIABUTY INSURANCE DATFIMM/DDIIYYV _ 3!8/?016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE `' 'RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. I. JRTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,suhiect to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). RODUCER I N6ME: 11Sa_ChristeaSD_a ylant Group Inc-Indianapolis PHONE 01 Pennsylvania Parkway,#201 A/C.No Exn•317-817-5172 ac No)317 817 1 1 E MAIL dianapolis IN 46280 ADDRESS: Iw i cent cr hylant com _ INSURERS AFFORDING COVERAGE NAIC_I INSURERA:LeXincjtOnjnjLMDLeCQR1�1'n �� �. JSURED KNAJAN03 I INSURERS: iwanis International,All Clubs and Their Members — —� INSURER C 636 Woodview Trace _ Idianapolis IN 46268 :INSUR ERESURER O: ___ INSURER F: :OVERAGES CERTIFICATE Nl1M5ER:1617561983 _ RE_VISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERT INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI$ CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE 0RIBED HEREIN IS SUBJECT TO ALL THE TERM.i EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R TYPE OF INSURANCE AN R SWV R POLICY NUMBER POLICY EFY111112016 OLICY EXP T MMIDDIYYYMlDD/YYYY LIMITS GENERAL LIABILITY Y 013136005 1 11/1/2015 EACH OCCURRENCE -0 s2,00D,oDa X COMMERCIAL GENERAL LIABILITY AGE R N p— ---' PREMISES Ea occurrence) $500,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5,000 --- PERSONAL&ADV INJURY $2,000,OOD —r X Liquor Liability GENERAL AGGREGATE $2,000,000_ GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $2,000,000 r � _ POLICY PRO- JECT'_� LOC ¢ Liquor Liability $1,000,000 rOMOBILE LIABILITY 013136005 1111/2015 11/1/2016 Ea accident 1,000,000 ANY AUTO BOCIL"INJURY(Perperson) $ t ALL OWNED SCHEDULED I I _ AUTOS J AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAG AUTOS E i � � I Per accident Is I ggregate $3,000,000 UMBRELLA L.L42! J OCCUR -- — -- L�I I EACH OCCURRENCE _$ EXCESS LIAB� CLAIMS-MADE - T A -MADE ;AGGREGATE $ —, DIED RETENTION$ _ _ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN __ . -�I'.'; _ _ OFFICER/MEMBER EXCLUDED? ❑ N/A I E.L.EACH ACCIDENT _ I g (Mandatory in N I I E.L.DISEASE-EA EMPLOYEE $ It yes,describe unndd er ISE_ _F DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ Self-Insured Retention 013136005 11/1/2015 11/1/2015 All Claims $75,000 I Sr'RIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remark^Sch-duh,if more space Is required) !rtificate Holder is named as Additional Insured as respects to General Liability only regarding the following Kiwanis event(setup,take wn& rain date(s)during the policy term are included): )OKMOBILE AT ENCINITAS SCHOOLS, LIBRARIES&HEAD STARTS. PRIMARY AUTO COVERAGE IS EXCLUDED.ADDITIONAL SURED INCLUDES:MIZEL FAMILY FOUNDATION,THE CITY OF ENCINITAS, ITS ELECTED OFFICIALS, OFFICERS, EMPLOYEES ID AGENTS FOR GENERAL LIABILITY AS RESPECTS TO FRIENDS OF THE ENCINITAS LIBRARY'S USE OF GRANT MONIES. :RTIFICATE HOLDER CANCELLATION I SHOULD ANY OF THE ABUVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATE THEREOF,MIZEL FAMILY FOUNDATION&CITY OF ENCINITAS ACCORDANCE EXPIRATION HDHE POLICY PROVISIONS. WILL BE DELIVERED IN 505 S VULCAN AVE. ENCINITAS CA 92024 AUTHORIZED REPRESENTATIVE C 1888-2010 ACORD CORPORATION. All rights mscrvc,4. ;ORD 25(2010105) The ACORD name and logo are registered marks of ACORD EVALUATION FORM _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2O14/15 Date Organization: Kiwanis Club of Greater Encinitas Address: (' dAi X 2-30,6/3 c City: �/Vti A),, /J� S State Zip / a9a3 Phone: —i60 5'7 972? Fax '-ZK® Email: A-7 z;9/ State the goals and objectives of your project and whether they have been met. All elements of the Treasure chest Literacy Program are design to foster literacy among children attending encinitas elementary schools.The program supports both students and teachers.The book filled treasure chest is an attempt to get books into the hands and homes of children who are least likely to have them by targeting title one children within the district We aim to stimulate all students to identify themselves as"book pirates to enjoy reading.Dr Pike aka Captain Book opens the eyes and minds of young readers to the treasures of reading.In this age of computer games..Ahe value of books and reading sets them on the right path. How were the goals and objectives of your project measured? We served 2,321 students in the district by giving away that number of books.We also supported 50 teachers with free books to help them with their classrooms.Attached are the positve feeback we get from both students and teachers. Who participated in the evaluation process? The Teachers and students of various Encinitas elementary schools provide feedback and help evaluate Dr.Pike as he performs as the reading pirate to inspire children.Captain Book also recieves hundreds of letters from the children thanking him. How was the City's funding for this project utilized? The city's funds were used to purchase books and book markers that are given out by Captain Book as he visits the children in the classrooms, head starts of Encinitas to open the eyes and minds of our children to reading. T:\CGP\O 1 CGPTemplates+Forms\Agreement Return Letter with forms.doe APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM 4mot'a"m%.f �qt orjes Ci or Arts progtram. Cho ❑ Civic Arts Grant Request Amount: 5000 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Arts Alive Banner Unveiling arl&O:r tax-exempt organizations n;Ry:apply. Identify the legal status of your organization: N Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): ❑■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. Organization Name: Leucadia Arts and Cultural Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: NA Mailing Address. N Coast Hwy 101 Encinitas, Ca 92024 Doing Business as (dba) Name. Same Please list the names and titles of the organization's Board of Directors: Charley Marvin, Presidnet Nick Winfrey, Secretary Morgan Mallory, Vice President William Morrison, Treasurer O Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. i0"L HISTORY: Summary of Program (Limit to the space provided): The Leucadia Arts and Cultural Foundation is thrilled to partner with the 101 Artists Colony and the Cardiff 101 Main Street on the 16th Annual Arts Alive Banner Program.There are 101 banners total that are hand painted and hung along Hwy 101 to make a six mile long art exhibit. This is the largest public art exhibit in the City. The Leucadia Arts and Cultural Foundation will be responsible for 18 of the banners and the unveiling reception.The estimated budget below reflects only the costs associated with the"8 Leucadia Banners and the banner unveiling and reception.This project provides our community with an outdoor art gallery accessible to everyone making our community an arts destination in North County San Diego.The Arts Alive banner program always begins with a huge unveiling reception for the artists and the whole community We would like to make this event larger in order to give the artists greater exposure and highlight our local talent.This year we would like to incorporate a private Friday night reception for those who have purchased banners in the past. The following Saturday we will host the larger community reception open to everyone After the banners are unveiled they are immediately hung on Hwy 101 for the whole community to enjoy.The unveiling reception is the largest art show in the City and brings the whole community together around local art! Organizational History The Leucadia Arts and Culutral foundation was formed in 2015 in the interest of promoting and funding pub is art in our community We would like the arts to be easily accessible to all of Encinitas with a specific focus on creating a vibrant art experience in Leucadia. Application Porm. Page One of Two _ APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM Location: All along Hwy 101 from Leucadia to Cardiff Total Est. Cost: 8900 Time Frame: February to May 2017 Number of Encinitas Residents Served: 50,000 Fundraising Activity: i No 11' Yes If yes, please expla In: The original an banners are auctioned off at the end of the program and half is given to the artists and the other half pays for the costs of the program Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Carris Rhodes, Program Manager Mailing Address: 386 N. Coast Hwy 101 Telephone Number: (760) 688-8275 Email Address: carrisrhodes @gmail.com CI Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Carris Rhodes Title: Program Manager (Please print) rY 1 7S � O Signature: �! �� �' Date: 4/11/16 L bN-Ly- Date Received: Application Packet Complete (original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements J Yes ❑ No Reasons. Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Leucadia Arts and Cultural Foundation PROJECT TITLE: Arts Alive Banner Unveiling PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOM:List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mi2el Family Foundation Grant Program Pending $5,000 In-Kind Promotion Writing press releases and social media promotion will be done by organization volunteers Secured $500 Venue donation If we host the event at the Leichtag Foundation property in 2017 then the venue will be donated Pending $500 Banner Sales Income We auction off the banners and give half of the proceeds to the artists Pending $1,500 In-kind Service Volunteers will run the unveiling event Secured $ 150 In-kind Adertising The Coast News Provides in-kind advertising and editorial for this project Secured $1,000 Bookmark Sales Revenue from the sale of the souvenir book marks Pending $250 INCOME TOTAL*: 1$8,900 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional'information.) ITEM DESCRIPTION COST Banner Installation We need to hire a professional to install and take down the banners $950 Permitting fees We must get a permit with the City of Encinitas,ABC and a permit to hang the banners $250 Private unveiling reception We will need to hire music,purchase appetizers and have professional bar service $1,000 Public unveiling reception We will need to hire music,purchase appetizers and have professional bar service $1,500 Raw materials cost We need to buy and print the backs of the vinyl banners $800 Advertising In-kind editorial and advertising from the Coast news $1,000 Equipment rental Rentals for unveiling reception $ 1,00D Bid Book Printing We print high quality bid books to help promote the artists and promote the sale of the banners $500 Book Mark Printing We print bookmarks to hand out to the artists and sell to the public for souveniers $400 Event promotion In-kind Donation by volunteers for press releases and social media promotion $500 Venue Rental In-Kind Donation of Venue rental and all associated costs with hosting an event at the Leichtag Foundation $500 Liability Insurance We will need to secure the proper liability insurance to host this event $500 EXPENSE TOTAL*: $8,900 Budget Form *Your Total Income and Total Expenses should be equal. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 J— CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: LeuCadia Arts and Cultural Foundation TITLE OF GRANT PROGRAM. Alive Banner Unveiling UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1 ,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn-. City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Cards Rhodes Title: Program Manager Signature: l� Date: -—_ RESOLUTION OF THE BOARD OF DIRECTORS OF Leucadia Arts Cultural Foundation WHEREAS,the Leucadia Arts Cultural Foundation Is a legally constituted nonprofit corporation or public,/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BF IT RESOLVED, that the Board of Directors of the Leucadia Arts and Cultural Foundation hereby approves the filing of an application for the City of Encinitas Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on the April 13, 2016 'Vick Winfrey, Secret:,I� -d of Directors INTERNAL RFVF'�T-E SERVICE DEPARTMENT OF THE TRFA9URV P. O. BOX 2508 CINCINNATI OH 45201 64 Employer Ident-f-cation Number: Date: 47-5284327 DLN: 26053694002035 LEUCADIA ARTS AND CULTURAL Contact Person: FOUNDATION CUSTOMER SERVICE ID# 31954 386 N COAST HWY 101 Contact Telephone Number, ENCINITAS CA 92024 0000 (877) 829-5500 Accounting Period Ending: June 30 Public Charity Status: 170 'b) (11 (A' (vi) Form 990/990-EZ/990-N Required: Yes Effective Date of Exemption: October C9, 2C15 Contr_bLtson Deductibility: Yes Addendum App.' -es. No Dear Applicant: We're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC; Section 5011c) (3) . Donors can deduct contributions they make to you ander IRC Section !7C . You're also qual-f,ed to receive tax deductible bequests, devises, transfers or gifts ander Section 2055, 2106, or 2522. '"his letter could ?-.elp resolve questions on ycar exempt status. Please keep it for your records. Organizations exempt under 1RC Section 501 ;c) ,? are further classified as either public charities or private foundations. we determined you're a p, i- ic charity under the IRC Section listed at the top of this wetter. Tf we -ndica*led at the top of this letter that you're required to fire Form 990/990-EZ/990-N, our records show you're required to file an annual in'crmation return (Form 990 or Fc.rm 99r)-77; cr electronic r.otice (Ftr'r 950-N, the e-Postcard) . If you don't file a required return cr -c.t-ce fcr `tree consecutive years, your exempt status will be automatically revoked. If we indicated at the top cf this letter that an adderdam applies, the enclosed addendum is an 1ntegrai part cf this letter. For important -nformation about your respons.hil_t-es as a -ax-exemp, orgar_ization, go to wiow.irs gov/charities. Enter 114221 PC' in the search bar to view Publication 4221-PC Compliance Guide for 501 c) ,,3 Public Charities, wl-ich describes your recordkeeping, reporting; and disclos4re regL-cements wetter E436 -2- LEUCADIA ARTS AND CULTUPAL Sincerely, Jeffrey I. Cooper Director, Exempt Organizations R-slings and Agreements Letter 5436 - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM Y: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. Civic ■.Arts Grant Request Amount: 5000 Free of Charge: i. Yes No (Not to exceed$5.000) Program Title: Interactive Art Pavilion at the LeucadiART Walk ADMC-FOOPLARM;only non-profit.and/or tax exempt organizations naay apply. Identify the legal status of your organization: R Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 06-1733027 r IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. L Organization Name: Leucadia-Encinitas Hwy 01 Main Street Association (Must match name filed under the Tax/Employer Identification Number) Street Address: 386 N Coast Hwy 101 Encinitas, CA 92024 Mailing Address: 386 N Coast Hwy 101 Fncinitas, CA 92024 Doing Business as (dba) Name: Leucadia 101 Main Street Association Please list the names and titles of the organizatior's Board of Directors: Nick Winfrey, President Todd Derr, Secretary William Morrison, Vice President Jill Holland Kevin Doyle, Treasureer Cyndi Darlington C Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROG"'SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided). The Leucadia 101 Main Street will be hosting the 12th Annual LeucadiART Walk on August 28th.This event draws close to 7,000 people to N.Coast Hwy 1C1.The event in the past has been lackirg in interactive and educational visual arts programming.We do provide music and some children's arts and crafts but in order to make this a comprehensive arts festival we need to create a space for unique and interactive visual arts. This event is free and open to the public and this high quality visual arts programming will be available to the entire public.We would like to concentrate most of the performances in an Interactive Art Pavilion but we would also like to have artists working on live art installations along Hwy 101 during the event as well The Pavilion will consist of performances in dance,poetry puppetry and will also include live art demonstrations including mural making,collage, pottery and surfboard shaping.We would like to display pieces made it the interactive pavilion in our Main Street office and at local businesses throughout the year for everyone to enjoy The nteractive art pavilion will create increased exposure for the event and elevate the public experience when attending the event The arts is a huge economic driver for the N Coast Hwy 101 corridor in Leucadia.The LeucadiART Walk is the only fine art event of its kind in North County San Diego and we are honored to host this event each year. Organizational History, The Leucadia 10" Main Street was founded in 2003 and has a 15 person volunteer board of directors and two staff members.We are dedicated to the historic preservation and revitalization of the N Coast Hwy 101 Corridor.We are a nationally accredited Main Street program connecting our community with small historic towns across the country Application Form, Page One of Fwo APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM W20Q IWORMATION: Location: Hwy 101 in Leucadia Total Est. Cost: 8000 Time Frame August 28, 2016 Number of Encinitas Residents Served 10,000 Fundraising Activity: '■ No Yes If yes, please explain. MW STATEMENTS: Contact Person. (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Carris Rhodes, Executive Director Mailing Address: 386 N Coast Hwy 101 Encinitas, Ca 92024 Telephone Number: (760)436-2320 Email Address: carris @leucadia101.com ❑� Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Carris Rhodes Title: Executive Director (Please print) Signature: �� ? , �_ - - Date: 4/12/16 ' A JIE GN LY; Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements, LJ Yes LJ No Reasons Application Form, Page Two of Two _ APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Leucadia-Encinitas Hwy 101 Main Street Association PROJECT TITLE: Interactive Art Pavilion at the LeucadiART Walk PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required, INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information,) TYPE SOURCE STATUS AMOUNT Grant City of Encinito5 & Mizel Fooidy Foundation Grant Program Pending $5,000 Sponsorship TIED Pending $1,500 In-kind Donation Painting Supplies Pending $300 Matching Funds The Leucadia Main Street has set aside$1000 for this new art walk element Secured Is 1,000 IN-Kind Donation Our event rental company provides us with a 20Sf off discount for being considered a sponsor or,the event secured $200 INCOME TOTAL*: $$,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Paint Supplies We will need supplies for painting walls,large canvases,and the raw materials to make the large canvases($300 is in-kind) $1,800 Equipment rental We will need to rent a stage shade covers,tables,chairs and other items to complete the pavilion($200 is in-kind) $1,000 Performing artists We will be having dancers,performers and musicians on the stage at the interactive art pavilion $1,500 Fine Artists We would like to pay at least three artists to paint live at the event either through mural work or on large Eft canvases $3,000 Stage Manager We will need to have someone keeping the performances on time and in order $300 Signage We will need directional signage for this pavilion $400 EXPENSE TOTAL*: $s,000 Budget Form *Your Total Income and Total Expenses should be equal. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Leucadia-Encinitas Hwy 101 Main Street Association TITLE of GRANT PROGRAM: LeucadiART Walk Interactive Art Pavilion UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn.. City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Carris Rhodes Title: Executive Director 4/12/16 Signature. . c. F - �` :- Date, RESOLUTION OF THE BOARD OF DIRECTORS OF Leucadia-Encinitas Hwy 101 Mainstreet Association WHEREAS, the Leucadia-Encinitas Hwy 101 Mainstreet Association Is a legally constituted nonprofit corporation or public/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BF IT RESOLVED, that the Board of Directors of the Leucadia-Encinitas Hwy 101 Mainstreet Association hereby approves the filing of an application for the City of Encinitas Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on the April 13,2016 Nick Winfrey, Presideni , lard of Directors STATE OF CALIFORNIA FRANCHISE TAX BOARD PO BOX 1286 RANCHO CORDOVA CA 95741-1286 In reply refer to 755 : 6 : EU November 18, 2008 THE LEUCADIA-ENCINITAS HIGHWAY 101 MAINSTREET ASSOCIATION 386 N COAST HIGHWAY 101 ENCINITAS CA 92024-2527 Purpose BUSINESS LEAGUE Code Section 2370le Form of Organization Corporation Accounting Period Ending : December 31 Organization Number 2580959 EXEMPT DETERMINA71ON LETTER e determined you are exempt from California franchise or income tax under the California Revenue and Taxation Code section shown above . The tax-exempt status is effective as of 2/4:2004 . To retain exempt status, organizations are required to be organized and operating for nonprofit purposes within the provisions of the above section . An inactive organization is not entitled to exemption . This decision is based on information you submitted and assumes that your Present operations continue unchanged or conform to those proposed in your application . Any change in operation, character , or purpose of the organization must be reported immediately to this office so th.at we may determine the effect on your exempt status . Any change of name or address must also be reported . In the event of a change in relevant statutory, administrative, judicial case law, a change in federal interpretation of federal law in cases where our opinion is based upon such an interpretation , or a change in the material facts or circumstances relating to your application upon which this opinion is based , this opinion may no longer be applicable . It is your responsibility to be aware of these changes should they occur . This EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date Organization: ?Leucadia-Encinitas Hwy 101 Mainstreet Association (L101 Mainstreet) Address: ty. C C LS� U City: } State C-A Zip Phone: Fax A/A- Email: oceFC&,le)I - L/A-L/L State the goals and objectives of your project and whether they have been met. IJ Ct �L•� =�.� .,t,. f��-.} ,�.{ � � `��']4'i�V� �-�'�-tS�7G � e t�i�2,Xi�c.�.trbl.� .L h C.¢� How were the goals and objectives of your project measured? 4� &vt.�:s - ��✓J C j, `✓L� e 4odi� - 1� All �'7 Who participated in the evaluation process? .� / 1 � lJ�'�.'w 3'�✓L How was the City's funding for this project utilized? Lit ` J s T:\CGP\OICGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. VF Civic ❑Arts Grant Request Amount: $5,000 Free of Charge: ❑ Yes ■ No (Not to exceed$5,000) Program Title: Safe swim initiative for 140 low income children in Encinitas ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: .■l Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 26-3486036 2 IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Los Angelitos De Encinitas (Must match name filed under the Tax/Employer Identification Number) Street Address: PO Box 232682 Mailing Address: Leucadia, CA 92023 Doing Business as (dba)Name: Los Angelitos Please list the names and titles of the organization's Board of Directors: Janisse Martinez T- c e�fl�- Josh Devall � TC'�f Gaby Beas Bill Sparks John Earnhart 9 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Los Angelitos De Encinitas In partnership with the Magdalena Ecke Family YMCA is providing 140 low income children in Encinitas with affordable swim classes for calendar year February 2016-Februrary 2017. Organizational History: Los Angelitos De Encinitas was incorporated in September of 2008. Our organiz4v has provided over 2500 low income children with opportunities to participate in youth sports, affordable— after school care and academic assistance over that time for the benefit of our community. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 WoCITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Magdalena Ecke Family YMCA Total Est. Cost: $48,000 Time Frame: February 2016-February 2017 Number of Encinitas Residents Served: 140 Fundraising Activity: R No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Bill Sparks Mailing Address: 451 Neptune Ave. Encinitas, CA 92024 Telephone Number: 760-815-1109 Email Address: bsleucadia @hotmail.com V Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. 1 hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Bill Sparks Title: Founder/Director (Please print) Signature: Date: 4/14/2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: � �v��a� PROJECT TITLE � � `T1G �� 14c� (-cJ Bbl i!E_' 1t , PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership feesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending n in ontri tic ag a ena c e ami y YMCA $10,000 rant rant an iego r. i eguar ssociation egistration e s articipants rant s nge itos a ncinitas INCOME TOTAL*: $ 4jM I_lk_rl_l EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST ow income swim c asses a e ag a ena c e ami y �1 EXPENSE TOTAL*: $ Budget Form *Your Total Income and Total Expenses should be equal. IiMRNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. BOX 2508 CINCINNATI, OH 45201 MAR 0 9 20 09 Employer Identification Number: Date: 26-3486036 DLN: 17053030337029 LOS ANGHLITOS DS ENCINITAS INC Contact Person: 451 NEPTUNE AVE WINNIE W LSE ID# 31208 ENCINITAS, CA. 92024 Contact Telephone Number: (977) 629-5500 Accounting Period Ending: December 31 Public Charity Statue: 170(b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: September 16, 2008 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant= we are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221-PC, Compliance Guide for 501 CO (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Letter 947 (DO/CG) �f RESOLTUION OF THE BOARD OF DIRECTORS FOR LOS ANGELITOS DE ENCINITAS WHERAS,THE LOS ANGELITOS DE ENCINITAS IS A LEGALLY CONSTITUTED CORPORATION OR PUBLIC/GOVERNMENT ENTITY, UNDER THE LAWS OF THE STATE OF CALIFORONIA,AND IS IN COMPLETE CONTROL OF IT'S AFFAIRS THROUGHT IT'S OWN OFFICER AND MEMBERS, NOW THEREFORE, BE IT RESOLVED,THAT THE BOARD OF DIRECTORS OF LOS ANGELITOS DE ENCINITAS HEREBY APPROVES THE FILING OF AN APPLICATION FOR THE CITY OF ENCINITAS AND MIIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FUNDING FOR THE CITY'S 2016-2017 FISCAL YEAR. ADOPTED ON THIS 13, DAY OF APRIL, 2016 BILL SPk.KS-FOUNDER/DIRECTOR LOS ANGELITOS DE ENCINITAS ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: TITLE OF GRANT PROGRAMS V\- 'I t3 t 1 f — 1.- J VC)CbM2 UNDERSTANDING OF INSURANCE REQUIREMENT- -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person Title: Founder/Director f. 4/14/2016 - Si nature Date' EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date Z Organization: Los Angelitos de Encinitas (The Little Angels of Encinitas) Address: City: J��pd �� State Zip q Z0 Z-j Phone: pFax��, Email: �DS V i'63� X� ' 64C)(VI State the goals and objectives of your project and whether they have been met. H,w re the goals and obj ctives of your project measured? W o p-rticipated in the evaluation press? How was the City's funding for this project utilized? A-7D bed T:\CGP\O1 CGPTemplates+Fornis\Agreement Return Letter with forms.doc --- APPLICATION FOR FISCAL YEAR 2016-2017 =' CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts proqram. Choose only one option. ❑Civic Arts Grant Request Amount: $5,000 Free of Charge: 0 Yes ❑ No (Not to exceed$5,000) Program Title: Season 10 Free Community Days ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: A Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0802336 ❑ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Lux Art Institute (Must match name filed under the Tax/Employer Identification Number) Street Address: 1550 South El Camino Real Mailing Address: 1550 South El Camino Real Doing Business as(dba)Name: Lux Art Institute Please list the names and titles of the organization's Board of Directors: Reesey Shaw, Director Steve Black Linda Brandes, President Andy Schreck John McDonough, Treasurer Melissa Swanson ■❑ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program(Limit to the space provided): Lux Art Institute,seeks funding in the amount of$5,000 to support Free Family Open Houses, each during the tenure of our five, 2015/16 residency artists. These free programs are designed as an opportunity for families to interact with the resident artists, view world class exhibitions. and enjoy a guided tour of the studio, live music, refreshments, and artmaking in the Lux studios.These programs are specifically designed to promote Lux Art Institute's mission:to redefine the museum experience and make art more accessible and personally meaningful. It's also a chance for students and families of Lux Art Institute's children's education classes to mingle and introduce their friends to these outstanding youth art education classes and camps. Lux's children and teen art programs fufill an important role in the Encinitas community as students of all ages experience for themselves the artistic process and families enjoy the richness of Encinitas'creative community. This partnership between the City of Encinitas and Mizel Family Foundation Community Grant Program would is critical to making this offering available to the public. Organizational History: Lux Art Institute was founded in 1998 to create an art museum focused on the living artist. The Artist Pavilion housing Lux's ambitious residency program opened in 2007, followed by the opening of the Lux Education Pavilion in 2014,designed to fufilll the vision of providing an art education program to adults,children and teens. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 _ - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Lux Art Institute PROJECT TITLE: Free Family Open House PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is reQulrarl_ INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants,matching funds, in-kind donations of goods and services,ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas&Mizel Family Foundation Grant Program Pending $5,000 In-Kind Grater Grilled Cheese Food Truck Committed $1,200 Volunteer In-Kind National Charity League service donated est$10/hr Committed $925 In-Kind Collateral materials produced by MiresBall Design Agency,est.$10/hr Committed $100 INCOME TOTAL*: $7,225 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Decorations Decorations for Open House:balloons,streamers,etc.($25/event) $125 Art Supplies Estimated at$5 per attendee,(minimum 150 attendees per event) $3,750 Consumables Complimentary water bottles for guests and ice $100 Talent Local band or talent($751hr,est 2hr per Open House) $750 Rentals Tables, Umbrellas,&audio equipment for performance $500 Staff Staff Time(including planning and execution) $1,500 Preparation and misc Preparation expenses,insurance,utilities,games,outside vendors $500 EXPENSE TOTAL*: $7,225 Buug4 4 Fur lip mir Total Income and Total Expenses should be equal. APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: XYZ ORGANIZATION PROJECT TITLE: XYZ PROGRAM SAMPLE PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is retmired. INCOME: List all types and its source of Income, secured or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services,ticket revenue, membership fees/dues, and all other types of income. TYPE ISOURCE ISTATUS JAMOUNT Grant City of Encinitas& Mize/Family Foundation Grant Program JPending 1$2,000 In-kind Printing Service donated by AAA Printers Isecured $500 Matching Funds 1131313 Corp ISecured $500 Ticket Revenue Estimated ticket revenue from performance lPending $100 Grant CCC Agency Grant Program ISecured $500 In-kind Service donation by Instructor(40 hrs/$15 per hr) Isecured $600 INCOME TOTAL : $4,200 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM IDESCRIPTION ICOST Printing In-kind printing of brochures donatedby AAA printers $500 Equipment Rental Chairs,Tables, Lighting J$1,000 Room Rental Room Rental at abc $750 Insurance Liability Insurance $500 Instructor Fees In-kind service donated by Instructor(40 hrs/$15 per hr) $600 Supplies Paper,Food,software $500 Marketing Marketing Advertisement in xxx magazine $350 EXPEivS'E TOTAL°':1$4,2u0 SAMPLE BUDGET DO NOT SUBMIT *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE b...,VICE. DEPARTMENT OF THE TREASURY DISTRICT DIRECTOR P. 0. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: OCT 0 8 1998 33-0802336 DLNt LUX ART INSTITUTE 17053253030018 C/O KRISTINA A HANCOCK Contact Person: COWLEY & CHIDESTER D. A. DOWNING PO BOX 2329 Contact Telephone Number: RANCHO SANTA FE, CA 92067 (513) 241-5199 Accounting Period Ending: December 31 Addendum Ap'plies: Yes Dear Applicant: Based on information you supplied, and assuming your operations will be as stated in your application for recognition of exemption, we have determined you are exempt from federal income tax under section 501(a) of the Internal Revenue Code as an organization described in section 501(c)(3)• We also determined that you are a private foundation within the meaning of section 509(1) of the Code. Based on the information you submitted with your application, we have determined that you are likely to qualify as a private operating foundation described in section 4942(1)(3) of the Code. Accordingly, you are treated as a private. operating foundation for your first year. After that, you will be treated as a private operating foundation as long as you continue to meet the requirements of section 4942(j)(3). This ruling satisfies the good faith determination requirement of section 53.4942(b)-3(b)(2) of the Excise-Tax Regulations. If you change your sources of support, your purposes, character, or method of operation, please let us know so we can consider the effect of the change on your exempt status and foundation status. •If you amend your organizational document or bylaws, please send us a copy of the amended document or bylaws. Also, let us know any changes in your name or address. As of January 1, 1984, you are liable for social security taxes under the Federal Insurance Contributions Act on amounts of $100 or more you pay to each of your employees during a calendar year. You are not liable for the tax imposed under the Federal Unemployment Tax Act (FUTA). However, since you are a private foundation, you are subject to excise taxes under Chapter 42 of the Code. You also may be subject to other'Federal excise taxes. If you have any questions about excise, employment, or other Federal taxes, please let us know. Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. Donors may deduct contributions only to the extent their contributions are gifts, with no consideration received. Ticket purchases and similar payments T 14 199E Letter 1075 (DO/CC) -3- . LUX ART INSTITUTE If you have any questions, p'leaie contact the person whose name and telephone number are shown in the heading of this letter. Sincerely yours' r District Director Letter 1075 (DO/CO) ATTACHMENT B RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF LUX ART INSTITUTE WHEREAS,the Lux Art Institute is a legally constituted corporation or public/governmental entity,under the laws of the State of California,and is complete control of its affairs through its own officers and members, NOW THEREFORE,BE IT RESOLVED,that the Board of Directors of the Lux Art Institute hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 14th day of April,2016 Reesey Shaw Secretary,Board of Directors Lux Art Institute Lux Art Institute Board Meeting Minutes February 19, 2016 at 8:OOAM Members Present: Members Absent: Melissa Swanson Steve Black(came after Reesey Shaw meeting) Joanne Warren Andy Schreck(called in) Linda Brandes John McDonough I. WELCOME — LINDA BRANDES 1. The meeting was called to order at 8:OOAM 2. Denise Jackson announcement 3. Emphasized need to recruit new board members II. APPROVAL OF MINUTES 1. Melissa motioned to approve;John seconded. III. TREASURER'S REPORT —JOHN MCDONOUGH 1. Approximately 6 months of operating cash; 2. Keeping payroll at BannerBank 3. Discussed in depth budget proposal for 2016; 4. Joanne Warren moved to approve the 2016 budget; John seconded. IV. PRESIDENT'S REPORT— LINDA BRANDES i. Emphasized board dues for first quarter ii. Emphasized support of Lux After Dark Gala V. DIRECTOR'S REPORT— REESEY SHAW i. Discussed Sophia Narrett's residency&works produced ii. Presented Art of Elan article iii. Presented Margaret Griffith installations for both Education and Artist Pavilion iv. Presented 10th Anniversary Season v. Updated on Education Pavilion reorg& jobs posted vi. Announced board meeting schedule through July vii. Announced MiresBall coffee table book for 10" anniversary season viii. Announced Jenessa Goodman opening VI. ADVANCEMENT REPORT — KATE BEAVER 1. Update on Excellence Campaign 2. Update on Membership 3. Update on Grants 4. Focused on Lux After Dark presentation & call to action; Melissa Swanson presented event theme and overview for April 30'h VII. EDUCATION REPORT ENCLOSED IN PACKET VIII. NEXT BOARD MEETING 1. March 18, 2016 IX. ADJOURN 1. The meeting was adjourned at 9:OOAM;Joanne moved to adjourn,John seconds. O O ' a _ E a> c Q m m m w Q « > W _ ° ° c o E> E 4 w e7 z EEc � u.. « c9 Free q� ezx o — 9m 1. p°D N= U m G 10 N O z o F F u z'u Y= N `° o o °O Y ri u C E c -9 3 n m n a a Y+ 3 °o � 1 FN @- ' w z ffR GG m g N 9 co N n. E -E Q WE W = N u n d ¢ W o >s E u= OZ €rc E l t7i1 u w p3PFa " r O F y " o E 1^9 S_ Z p C !q W p W G ~4q` E F C W h• 3 3 u b H f �3 m f m r 2f h O - ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Lux All Institute TITLE OF GRANT PROGRAM: Free Family Open House UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4)Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Kate Beaver Title: Development Manager r� Signature: Date• ,A��1�� � r EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2O14/15 Date 18 June 2015 Organization: Lux Art Institute Address: 1550 S El Camino Real City: Encinitas State CA Zip 92024 Phone: 760436-6611 Fax Email: kbeaver(&JUXartitlstitute.org State the goals and objectives of your project and whether they have been met. Lux's core mission is to make fine art accessible to the community.The objective of hosting free family days known as our community"Open House",is two-fold:(1)to engage audiences who might not otherwise be able to visit or attend a class at Lux,and(2)enhance Lux's relationship with other individuals and organizations in the community through collaboration and on site programming. Over the course of the 2014-2015 funding cycle,Lux saw record attendance at our five Open Houses with over 1000 attendees,which for the first time were situated in the Artist and Education Pavilion,the Education Pavilion having just opened in April 2015. Unlike our fee-based classes which assess curriculum and student feedback,the most important factor for Lux in the community Open House is outreach,and the number of guests is how we gage the success of an event How were the goals and objectives of your project measured? We are able to gage the success of the events through briefing and debriefing with our collaborators before and after each event, feedback from volunteers,and also sollicitation of feedback from community attendees.For Lux educators,success of the artmakdng is calibrated by the feasibilty of the project within each Open House four hour period At each Open House,we use data capture to survey totals,our objective being to meet a minimum of 200 attendees per event Who participated in the evaluation process? Lux staff,Lux lead volunteers,and the Lux Board of Directors. How was the City's funding for this project utilized? The funding was applied toward supplies, vendors reimbursement, printing of visitor guide (example enclosed), staffing, subsidization of free admission for visitation of the Artist and Education Pavilion, and artist projects for each attendee. T:\CGP\O I CGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM Civic ❑Arts Grant Request Amount: $5000 Free of Charge: Z Yes ❑ No (Not to exceed$5,000) Program Title: Drug and Alcohol Prevention and Education Conference n root findlor ax xOrripf orgariizatidlis magi Identify the legal status of your organization: K Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 43-19997495 ❑ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. Organization Name: Mano a Mano Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: 1103 Quail Gardens Ct. Encinitas,CA 92024 Mailing Address: same Doing Business as(dba) Name: Please list the names and titles of the organization's Board of Directors: Jorge Jiron, President Carole Franks, Treasurer Linda Lohrman, Secretary ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. -.- Summary of Program (Limit to the space provided): The 14th yearly educational conference will be providing information to the Latino community about the dangers of drugs and alcohol.We are inviting the Encinitas Sheriffs to talk about"social hosting"law and the consequences of breaking the law. Police officers from the Carlsbad Police Department will have a very detail presentation of every single and the consequences.They also will set up tables with many drug paraphernalia and the ways the youngsters hide drugs. We will have the testimony of different students who are paying the consequences of using drugs.We will also have several parents giving their testimonies about putting their children into rehabilitation centers and how painful is to deal with a son or daughter that is using drugs.The conference also provides community resources to all the parents.We will have 15 community based agencies that provide services. Every family will recieve a folder with information of every drug,a DVD with information about prevention of drug abuse and a list of community resources. For the second year, we will invite our Community College to set up a resource table and the California State San Marcos information table.This is an educational conference that the goal is to provide education resources to all participants. Organizational History: Mano a Mano was established in the year 2000 to provide needed cultural sensitive English/Spanish educational and supportive services to the Latino community in San Diego.We provide skill building parent and student programs to be able to accomplish the American dream. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROG"10 Location: Encinitas Senior and Community Center Total Est. Cost: $5000 Time Frame: December 2016 Number of Encinitas Residents Served: 300 Fundraising Activity: 0 No ❑ Yes If yes, please explain: CONT IN �`i/i �I�D STAj �UI fITS:�• . '-;- Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Drug and Alcohol Prevention and Education Conference Mailing Address: 1103 Quail Garden Ct. Encinitas, CA 92024 Telephone Number: (760)492-8897 Email Address: Beatrizvillarreal @yahoo.com ❑■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Beatriz Villarreal Title: Program Director ,(Please pript�_ Signature Date: April 10th, 2016 r r D Zte Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Mano a Mano Foundation PROJECT TITLE: Drug and Alcohol Prevention and Education Conference PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 In-kind-Service Donation Dr.Beatriz Villarreal Secured $2,000 In-kind-Service Donation California Highway Patrol Secured $500 In-kind-Service Donation Drug Free World Foundation(materials) Secured $500 In-kind-Service Donation Encinitas Sheriffs Secured $500 In-kind-Service Donation Carlsbad Police Secured $1,000 In-kind-Service Donation San Diego Juvenile Probation Secured $500 INCOME TOTAL*: $ 10,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Supplies paper,posters,printing supplies,toner,copies for handouts,folders,pens,pencils $2,000 Recognition awards Honoring plaques $800 Rental conference rooms One big banquet room and two rooms for child care $1,000 Snacks Water,coffe,cookies,napkins,punch,popcorn,plates,cups $300 Marketing Advertising $500 Child care 6 child care providers $400 In-kind-Service Donation Dr.Beatriz Villarreal $2,000 In-kind-Service Donation Drug Free World Foundation materials $500 In-kind-Service Donation Encinitas Sheriffs $500 In-kind-Service Donation Carlsbad Police $1,000 In-kind-Service Donation San Diego Juvenile Probation $500 In-kind-Service Donation California Highway Patrol $500 EXPENSE TOTAL*: $10,000 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH '45201 q Q Employer Identification Number: Date: FEB O xOOB 43-1997495 DLN: 17053356707017 MANO A MANO FOUNDATION Contact Person: 1103 QUAIL GARDEN CT JACOB A MCDONALD ID# 31649 ENCINITAS, CA 92024-0000 Contact Telephone Number: (877) 829-5500 public Charity Status: 170(b) (1) (A) (vi) Dear Applicant: Our letter dated April 2003, stated you would be exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code, and you would be treated as a public charity, rather than as a private foundation, during an advance ruling period. Based on the information you submitted, you are classified as a public charity under the Code section listed in the heading of this letter. Since your exempt status was not under consideration, you continue to be classified as an organization exempt from Federal income tax under section 501(c) (3) of the Code. Publication 557, Tax-Exempt Status for Your Organization, provides detailed information about your rights and responsibilities as an exempt organization. You may request a copy by calling the toll-free number for forms, (800) 829-3676. Information is also available on our Internet Web Site at www.irs.gov. If you have general questions about exempt organizations, please call our toll-free number shown in the heading. Please keep this letter in your permanent records. Sincerely yours, Robert Choi Director, Exempt Organizations Rulings and Agreements Letter 1050 (DO/CG) MINUTES OF ANNUAL MEETING OF THE BOARD OF DIRECTORS OF MANO A MANO FOUNDATION A CALIFORNIA NON-PROFIT PUBLIC BENEFIT CORPORATION The Annual Meeting of the Directors of MANO A MANO FOUNDATION A CALIFORNIA NON-PROFIT CORPORATION, a California Corporation,was held on the date and at the time and place indicated below: DATE: January 18, 2016 TIME: 10:00 a.m. PLACE:Office of the Corporation The following named Directors of the Corporation were present or participated via telephone, to wit: JORGE JIRON LINDA LOHRMAN CAROLE FRANKS WAIVER OF NOTICE On motion duly made, seconded and unanimously carried, it was resolved that by signature to these minutes notice of time and place of meeting would be waived and the minutes approved. RE-NOMINATION AND RE-ELECTION OF OFFICERS The Chairman called for the re-nomination of officers to serve for one more year or until their successors are elected and qualified. The Secretary announced the following persons were nominated to continue their service for the positions indicated: PRESIDENT: JORGE JIRON SECRETARY: LINDA LORHMAN CHIEF FINANCIAL OFFICER: CAROLE FRANKS The Chairman called for further nominations, but none were made. The above named persons were then unanimously elected to continue as the officers of the corporation. RATIFICATION OF THE OFFICERS'ACTIONS The Chairman then reported to the meeting the other activities of the Corporation's Officers and proposed that the Directors ratify those actions. Upon motion duly made and seconded, the following resolution was unanimously adopted: RESOLVED: That all the acts of the Corporation's Officers during the course of the second fiscal year are hereby ratified and approved in all respects. COMPLIANCE WITH LOCAL SOLICITATION ORDINANCES On motion duly made, seconded and unanimously carried, the board adopted a resolution directing the President to continue to ascertain the legal requirements imposed on organizations soliciting funds for charitable purposes in the City of Encinitas, and the County of San Diego, as well as any other jurisdictions in which the corporation may solicit funds, and authorized and directed the President to continue making any necessary filings and to obtain necessary permit authorizing the Corporation to make public solicitations for contributions. ADJOURNMENT There being no further business to come before the meeting, upon motion duly made, seconded and unanimously carried, the meeting was adjourned. MINUTES APPROVED: _ ;r i Jorge A. Jiron, Director Linda Lohrman, Secretary ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION — COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Mano a Mano Foundation TITLE OF GRANT PROGRAM: Drug and Alcohol Prevention and Education Conference UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Dr. Beatriz Villarreal Title: Program Director SignatL1re �.:L . t ' I `} Date: April 10th, 2016 i r MANOO-1 OP ID: BL CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 07/30/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEACT Robyn Kettering Kettering-Rose Insurance PHONE o 619-291-7777 ac No:619-291-7776 3545 Camino Del Rio S.,Ste.A A/C N Exc: E-MAIL rob nk kr-ins.com San Diego,CA 92108 ADDRESS: Robyn Kettering INSURERS AFFORDING COVERAGE NAIC# INSURER A:Travelers Casualty and Surety INSURED Mano A Mano Foundation INSURERS: Servicios Latinos INSURERC: 1103 Quail Gardens Ct Encinitas,CA 92024 INSURER D: INSURER E: INSURER F: a C0,4CR CES CERTIFICATE NI IMRFR' REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN R! A S BR POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE X OCCUR X 6802AO93750 06/15/2015 06/1512016 PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT — OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Par accident) $ AUTOS AUTOS — NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE _ $ DIED I i RETENTION$ _ $ WORKERS COMPENSATION STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETORIPARTNER/EXECUTIVE ❑ N1 A HEL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E .DISEASE-POLICY LIMIT $ A Property Section 6802A093750 06115/2015 06/1512016 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) Certificate holder is additional inusured. CERTIFICATE HOLDER CANCELLATION CITYOEN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Encinitas&The Mizel Family Foundation, City AUTHORIZED REPRESENTATIVE Managers Department 505 South Vulcan Road Q-40 kxV/ �ff Encinitas CA 92024 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD OR EVALUATION FORM - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015116 Date 1/21/2016 Organization: Mano a Mano Foundation Address: 1103 Quail Gardens ct City: Encinitas State CA Zip 92024 Phone: (760)492-8897 Fax (760)942-0540 Email: BeatlizvillanrA @yahoo.com State the goals and objectives of your project and whether they have been met. The goal of the confeence was to educate the families about the danger of drug abuse,the consequences of using dnigs,and how,as parents and family members,we can prevent substance abuse and promote positive and healthy lifestyles.One of the objectievs was to provide educational resources and testimonials so parents can talk to their kids about the dangers of drugs. We beLive it is a community problem"and together we need to intervene.We believe that the drug prevention starts at home by being aware of what dangers are outside.Also the parents received a folder with educational materials,DVD and community resources.We invited other community agencies to set up information tables.The participants have the chance to talk to different representatives and received community resources. Ve have the support from the Carlsbad Police Department Police Officer Felix Salazar,and also the officers from the California High Way Patrol.Both talked about the dangers of drugs and driving under the influence.The Encinitas Sheriffs also explained the parents the"Social Hosting Lard'. More than 300 people from Encinitas and other North Coastal communities attended the conference. How were the goals and objectives of your project measured? We had the participation of 45 community volunteers,teachers from Migrant Education,counselors,and the person organizing this event.They registered every single person attending the conference and gave them a folder with all the conference handouts and educational material(sample provided with this report).The goals and objectives were measured by the number of participants,the number of the community resources available to parents and students and the feedback from the participants in the evaluation forms.95%of the participants named 2 to 4 things that they learned at the conference and almost 98%of people will recommend other people to participate next year.The participants evaluate the conference with a 98(100 is excellent),meaning that the conference content and organization was very good. Who participated in the evaluation process? We had the participation of 45 community volunteers,teachers from Migrant Education,counselors,and the person organizing this event.They registered every single person attending the conference and gave them a folder with all the conference handouts and educational material(sample provided with this report). FYI 5-16 CGP REIMBURSMENT ANDEVALUATION FORMS APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY UFOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories: Civic or Arts program..Choose only.one option. Civic ❑Arts Grant Request Amount: $5,000.00 Free of Charge: ❑ Yes No (Not to exceed$5,000) Program Title: Feeding Homebound Seniors in Encinitas ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: N Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 952660509 ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Meals-on-Wheels Greater San Diego, Inc. (Must match name filed under the Tax/Employer Identification Number) Street Address: 2254 San Diego Avenue, Ste 200, San Diego, Ca 92110 Mailing Address: 2254 San Diego Avenue, Ste 200, San Diego, Ca 92110 Doing Business as(dba) Name: Meals-on-Wheels Greater San Diego, Inc. Please list the names and titles of the organization's Board of Directors: Gail Ives Board Chair Kristi Pieper Secretary Nanci Porter Services Chair&Vice Chair ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Meals-on-Wheels Greater San Diego, Inc.(MOWGSD)provides the daily delivery of up to two meals a day to extremely-low to moderate income homebound seniors living throughout San Diego County accompanied by daily safety checks with referrals to other social service providers if necessary and daily social visits to alleviate social isolation. MOWGSD subsidies all meals and corresponding services by 60%and provides further subsidies to those who qualify. Of all seniors served,84%are considered extremely-low to moderate income according to the Department of Housing and Urban Development(HUD) income guidelines. According to the San Diego Health and Human Services Agency(2015),the number of seniors aged 65 and older is expected to double between 2010 and 2030. MOWGSD is experiencing a significant increase in the number of older adults aging into its services. In particular,MOWGSD has experienced a 15%increase in the North County of San Diego from its FY2014 to FY2015. The North County is MOWGSD fastest growing service area and another 15%increase is expected for FY2016. Currently its biggest challenge is building organizational capacity in order to meet the current demand. The challenge requires growth in funding and infrastructure. Philanthropic giving in SD County is not keeping pace or fully recognizing the significant challenges that occur with the aging population. Organizational History: MOWGSD was founded in 1960 and incorporated as a nonprofit in 1970. Its mission is to support the independence and wellbeing of seniors by addressing food insecurity, declining health, and social isolation by supporting For FY2015 MOWGSD served over 3,181 unduplicated seniors with 430,073 meals and corresponding services using 2,842 volunteers. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Total Est. Cost: $74,022.00 Time Frame: July 1, 2016 through June 16, 2017 Number of Encinitas Residents Served: 65 Fundraising Activity: N No ❑ Yes If yes, please explain: CONTACT,INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Debbie Case, CEO& President Mailing Address: 2254 San Diego Avenue, #200, San Diego, Ca 92110 Telephone Number: 619-260-6110 Email Address: dcase @meals-on-wheels.org 0 Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Debbie Case Title: CEO and President (Please print) Signature:g F G Date: April 8, 2016 �_�.�� . THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) ✓leets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 .__ 4 CITY OF ENCINITAS AND MIZEL FAMILY ' FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Meals-on-Wheels Greater San Diego, Inc. PROJECT TITLE: Feeding Homebound Seniors in Encinitas PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Grant FY2017 Community Development Block Grant Confirmed $6,445 Grant Zable Foundation Confirmed $12,577 Grant Birdwell Family Foundation,Inc. Confirmed $50,000 INCOME TOTAL*: 1$74,022 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Food&Packaging Food and disposable containers for individually packaged meals to be delivered to home of $74,022 homebound seniors living in the City of Encinitas. Estimated cost per meal is$2.08. Total cost of the project for 65 unduplicated homebound seniors is$74,022(65 X 365 days a year X$2.08 x average food delivery of 1.5 meals a day per client) EXPENSE TOTAL*: $74,022 Budget Form *Your Total Income and Total Expenses should be equal, AwrrAt M Boor SA Internal Revenue Service Department of the Treasury P.O. Box 2508 Cincinnati, OH 45201 Date: December 29, 2008 Person to Contact: David Slaughter ID#0203346 MEALS-ON-WHEELS GREATER SAN DIEGO INC Toll Free Telephone Number: 2254 SAN DIEGO AVE STE 200 877-829-5500 SAN DIEGO CA 92110-2944 Employer Identification Number: 95-2660509 Dear Sir or Madam: This is in response to your request of December 17, 2008, regarding your tax-exempt status. Our records indicate that a determination* letter was issued in January 1972 that recognized you as exempt from Federal income tax, and reflect that you are currently exempt under section 501(c)(3)of the Internal Revenue Code. Our records also indicate you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section 509(6)(2). Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely, jndy Westcott nager, Exempt Organizations Determinations 5 Meals-on-Wheels Greater San Diego, Inc""' $ s MEALS ON WHEELS AMERICA 2o16 ttEm6cn please fet it be resolved,that Meals-on-Wheels Greater San Diego, Incorporated{"Agency"; a corporation duly organized and existing under and by virtue of the laws of the State of California} hereby authorizes Meats-on-Wheels Greater San Diego, Inc.staff to apply for City of Encinitas and Mizel Family Foundation Community tyrant Program funding. The follovring.agency individuals are authorized to negotiate For and contractually bind Meals-on- Whcels Greater San Diego, Inc.and execute requests for payment:17ebbie Case. Presiden;Fr CEO The following agency individuals are authorized to execute requests for payment.Matt Topper, CFO Corporate Certification I, ICristi Pieper,,Secretary of Meals-on-Wheels Greater San Diego, Inc.,certify that I am the keeper of the corporate records of this Corporation and that as such, I am authorized to execute th4certificatlon on behalf of this Corporation; The above resolution is a true, and correct copy of a board resolution duly adopted by the Executive Committee of the Board of Trustees of this Corporation,duly called and held Or] _�1-1 G in accordance with its charter and by-laws, by which a quorum voted:that said resolu-fan as not been in any way amended, annulled, modified, rescinded or revoked, but is in full force and effect. I further certify that the Board of Trustees of this Corporation has, and at the time of adoption of this resolution had, Full power and lawful authority to adopt the foregoing resolution and to confer the powers granted to the persons named who have full power and,lawful authority to exercise the same, f er w subscribe m name on this 7 � 2/ 13' h do V 'j IN WIT"=5,�� WNE1tEDF,�' �1 Y Kristi Pieper, 5ecretal� f 2254 San Diego Avenue,Suite 200 San Diego,CA 92110 (619)260-6110 www.meals-on-wheels.org ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Meals-on-Wheels Greater San Diego, Inc. TITLE OF GRANT PROGRAM: Feeding Homebound Seniors in Encinitas UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, -505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Debbie Case Title: CEO and President Signature: .c_. Date: April 8, 2016 -- APPLICATION FOR FISCAL YEAR 2016-2017 F CITY OF ENCINITAS AND MIZEL FAMILY ' FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. ❑Civic Arts Grant Request Amount: 5,000 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: SEPIA: Seniors Exploring Photography, Identity,and Appreciation ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: V Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-2889390 K IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Museum of Photographic Arts (Must match name filed under the Tax/Employer Identification Number) Street Address: 1649 EI Prado, San Diego, CA 92101 Mailing Address: 1649 El Prado, San Diego, CA 92101 Doing Business as(dba)Name: Please list the names and titles of the organization's Board of Directors: Gail Bryan (President) Teri Evons (Secretary) Lawrence Friedman(Vice President) (9)at-large board members(full list available) Jeff Maysent(Treasurer) X Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): SEPIA(Seniors Exploring Photography, Identity,and Appreciation)brings creative and socially-engaging programs to senior who are traditionally underserved by art organizations,including those with memory loss and Alzheimer's. Seniors participate in photography classes,workshops, and art talks held at nursing homes, assited living facilities,and community centers throughout San Diego County.Since 2013,SEPIA has partnered with Silverado-Encinitas Memory Care Community,a facility dedicated to caring for seniors with memory issues.MOPA works with Silverado's residents with mid-to-severe memory loss,as as well as members of their Friday Morning Club for loss with early memory loss who are not yet living in residence. In FY2016-2017,SEPIA will continue this partnership to Silverado as well as add on a second location within Encinitas, such as the Encinitas Community and Senior Center,bringing year-round programming including 4 hands-on workshops and 6 art talks, in which resdients dicuss a theme explored through images from MOPA at each site.All programs will be free of charge at Silverado and the Community Center and will reach approximately 150-200 seniors at each location. Organizational History: The Museum of Photographic Arts(MOPA)opened in Balboa Park in 1983 as one of the only museum dedicated exclusively to lens-based media.The Museum has gained an international reputation for excellence in exhibitions and educational programming,and is accredited by the American Association of Museums. Application Form,Page One of Two - - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Silverado-Encinitas Memory Care Community and Encinitas Community and Senior Center Total Est. Cost: $12.860($6,475per,ite) Time Frame.- July 2016-June 2017 Number of Encinitas Residents Served: 300 Fundraising Activity: X No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Vivienne Esrig Mailing Address: 1649 El Prado, San Diego, CA 92101 Telephone Number: 619-238-7559 Email Address: Esrig@mopa.org X Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Vivienne Esrig Title: Deputy Director (Please print) Signaturr-__.f Date: April 1, 2016 THIS SECTION FOR OFFICIAL USE O LY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 - _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Museum of Photographic Arts PROJECT TITLE: SEPIA: Seniors Exploring Photography, Identity, and Appreciation PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services,ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Grant Carlsbad Community Foundation(portion of grant) Pending $2,000 Grant Tippett Foundation(portion of grant) Pending $1,000 Grant May and Stanley Smith Charitable Trust(portion of grant) Secured $3,000 Grant County of San Diego,Community Enhancement Program(portion of grant) Secured $450 Grant Institute of Museum&Library Services(portion of total grant) Secured $1,500 INCOME TOTAL*: 1$12,950 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Personnel/Staffing Kevin Linde,Lifespan Learning Manager($44,100.00 salary and$11,025 benefits= $55,125)@ 14% $7,717 Program Supplies Consumable supplies for art workshops-e.g.photo paper,printer ink,album-making materials $813 Office Supplies Office and presentation materials-e.g.curriculum handouts,reproductions,pens,paper $200 Mileage Mileage-(24 classes/workshops x 100(average)miles round-trip x$.575/mile) $1,380 Program Evaluation 5%of professional evaluation to be contracted($5,000 annually) $250 Administration Administration @ 20%of direct costs-e.g.utilities,office space,supervision,insurance,equipment $2,590 EXPENSE TOTAL*: $12,950 Budget Form *Your Total Income and Total Expenses should be equal. Internal Revenue Service Department of the Treasury District 300 N. Los Angeles Street, MS 7043 Director Los Angeles, CA 90012 Person to Contact: 11j . Barragan MUSEUM O: : D.DGR.A_ _C ARTS Telephone Number: (213 ) 894 -233G 1649 EL RA.D0 3ALBOA PARK SAN D_EGO, CA 92101-1621 ReferReplyto: ED ( 0512 ) -97 Date: May 28 , 19 9 7 EIN : 95-2889390 !ar taxpayer : This _ecnar is . in response to your request for a copy of determi nation _e-ter for the above named organization ., Our r6cords i-ndicate this organization was recognized to be exempt ==om ederal Income Tax in FEBRUARY 1974 as described in Interna? Revenue Cade Section 501 (c) (3 ) . It is further classified as an organization that is not a private foundation as defined. _n Section 509 (a) of the Code , because it is an organizatiz;: described in Section 170 (b) (1) (A) (vi) . The exe-mpt sta_-us for the determination letter issued in 3RUARY 14 cont,_.ues to be in effect . naed her assistance , n?ease contact our office at: z:he acc% = a.^ -ess c, telephone number . Sincerely, L . 3arr agan Disclosure Assistant 1649 EL PRADO SAN DIEGO CA 92101 114USEUM OF PHOTOGRAPHIC ARTS Becky Moores Center for Visual Learning RESOLUTION OF THE BOARD OF DIRECTORS OF THE MUSEUM OF PHOTOGRAPHIC ARTS AUTHORIZING GRANT APPLICATION TO THE CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION WHEREAS, the Museum of Photographic Arts a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Museum of Photographic Arts hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 2711day of March, 2016 Teri Evons Secretary ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Museum of Photographic Arts TITLE OF GRANT PROGRAM: SEPIA: Seniors Exploring Photography, Identity, and Appreciation UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Vivienne Esrig Title: Deputy Director -�.•--� Aril 1, 2016 Signa�'ure: .. - L � r. Date: p EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date 6.18.2015 Organization: Museum of Photographic Arts (MOPA) Address: 1649 El Prado City: San Diego State CA Zip 92101 Phone: 619-238-7559 Fax 619-238-8777 Email: holsenback@mopa.org State the goals and objectives of your project and whether they have been met. The goal ofthe project was to bring high-quality arts programming to seniors at the Silverado Memory Care Community in Encinitas.Program objectives were to serve 75 seniors through(1)SEPIA digital photography course,(2)SEPIA photography workshops,and(8)SEPIA Art Talks in which residents are invited to have a discussion around a theme and images from the Museum's permanent collection. During the grant term,MOPA provided(6)SEPIA Art Talks,serving 87 seniors at Silverado Memory Care Community.The single-session Art Talks were identified as the best approach for this population,which encompasses seniors with early to mid- stage Alzheimers and demendia.The program served full-time residents of Silverado,as well as participants in their Friday Morning Club. How were the goals and objectives of your project measured? Goals and objectives were measured through attendance records,observations by MOPA and Silverado program staff,and participant surveys. Who participated in the evaluation process? Kevin Linde,Lifespan Learning Coordinator,was the instructor for all of the Art Talks and coordinated the evaluation process. Mr.Linde documented attendance and participation.He also distributed evaluation forms to the Silverado staffto complete with residents following the art talks.To date,we have yet to receive the surveys,but we will report that information to the City of Encinitas when recieved.The Friday Mornings Club facilitator,Brent Honeycutt,was present for all the Art Talks for that group,and has agreed to contribute feedback and we are looking forward to hearing back from him. How was the City's funding for this project utilized? The City of Encinitas and Mizel Family Foundation Community Grant Program funding was used towards the salary of Kevin Linde,Lifespan Learning Coordinator. :\CGP\O1 CGPTemplates+Forms\Agreement Return Letter with forms.doc - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEdORY erantrm;*sts a 410rrvt3-ca'*ries: Civic or Arts program. Choose only-onecoption. ❑Civic IW Arts Grant Request Amount: $5,000 Free of Charge: N Yes ❑ No (Not to exceed$5,000) Program Title: "Two centuries in the Musical Life of the City of Leipzig"(Song Recital,Vocal Master Class, Lecture) Identify the legal status of your organization: Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 45-5003760 X IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION IWF Organization Name: The Musical Oratory Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: 1717 Daybreak Place, Escondido, CA 92027 Mailing Address: PO Box 1305, Escondido, CA 92033 Doing Business as(dba) Name: Please list the names and titles of the organization's Board of Directors: Dr. Elisabeth Kotzakidou Pace, President Jean Weng, Esq., Secretary Timothy McConnell, Treasurer n Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B_ PROGRAA&15►LI1I#MARY I Nj IGNAL HISTORY: Summary of Program (Limit to the space provided): A Weekend of Music:Song Recital,Vocal Master Class, Lecture (1)An eclectic song recital celebrating the musical legacy of the city of of Leipzig—from J. S. Bach to Schumann, Mendelssohn, and Grieg—featuring acclaimed German-American tenor Nils Neubert and his pianist Yuri Kim. (2)The recital will be supplemented by a separate public lecture by musicologist Dr. Elisabeth K. Pace. (3) On the following day, Mr. Neubert will offer a public masterclass showcasing a select group of local college-level singers focusing on the German repertoire with special emphasis on German diction. Dr. Pace is a published scholar specializing in German music theory, whose work covers topics ranging from the late Renaissance to the mid 20th-century. Mrs. Kim serves on the Piano faculty of the Mannes School of Music in New York City. Mr. Neubert is on the Vocal Arts faculty of both the Juilliard and Mannes Schools of Music in New York City, and the Music Academy of the West in Santa Barbara. Organizational History: Founded by alumni of The Juilliard School, The Musical Oratory Foundation disseminates the European Art Music tradition to diverse audiences in San Diego County. Since 2012 we have produced numerous concerts, recitals, lectures and master classes of exceptional quality in Encinitas, Rancho Santa Fe, Escondido, La Jolla, and Point Loma. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAMINFQRM,�T10N: Location: Encinitas Library Community Room Total Est. Cost: $0 Time Frame: Two days in Jan 2017 Number of Encinitas Residents Served: 550 Fundraising Activity: W No ❑ Yes If yes, please explain: CONTACT INFQP4pAJION AITAT!*IiiILNXS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Dr. Elisabeth Kotzakidou Pace, President Mailing Address: 1717 Daybreak Place, Escondido, CA, 92027 Telephone Number: 858-414-1704 Email Address: ekpace @musicaloratory.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Dr. Elisabeth Kotzakidou Pace Title: President (Please print) Signature: �.4'� cAt �QCcZ Date: April 12, 2016 THIS SECTION FOR OFFIrj46 UkF� Y: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: The Musical Oratory Foundation PROJECT TITLE: "Two centuries in the Musical Life of the City of Leipzig" (Song Recital, Vocal Master Class, Lecture) PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership€eesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 In-kind Artistic Director&Event Curator fee,donated by the director Secured $1,000 In-kind Program Notes Annotator,donated by the annotator Secured $200 In-kind Lecturer fee,donated by the lecturer Secured $400 In-kind Lodging for the artists,donated by The Musical Oratory Foundation(MOF) Secured $560 In-kind Administrative Support wages(40 hours @$20/hour),donated by The MOF Secured $800 Grant The Musical Oratory Foundation Secured $802 INCOME TOTAL*: 1$8.762 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Personnel Artist fees . $3,000 Transportation Airfare for two artists(NYC-SAN) $900 Local Transportation(Auto) One car rental(4 days @$60/day) $240 Meals Meals(for 2 artists calculated as per diem for 4 days @$64/day/person) $512 Insurance Liability Insurance $700 Printing Concert and Masterclass Programs $450 Personnel Artistic Director&Event Curator fee $1,000 Personnel Program notes annotator $200 Personnel Lecturer fee $400 Lodging Artists'lodging(hotel for two people for 4 nights @ 140 1night) $560 Personnel Administrative support(40 hours @$20/hour) $800 EXPENSE TOTAL*: $8,762 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: OCT 2�iZ 45-5003760 Lv DLN: 17053268332002 THE MUSICAL ORATORY FOUNDATION Contact Person: C/O ELISABETH K PACE JOHN J KOESTER ID4 31364 1717 DAYBREAK PL Contact Telephone Number: ESCONDIDO, CA 92027-1050 (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170 (b) (1) (A) (-i) Form' 990 Required: , Yes Effective Date of Exemption: January 27, 2012 Contribution_ Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Letter 947 (DO/CG) ATTACHMENT B The members of the Board of Directors of The Musical Oratory Foundation have given verbal approval for this application. Formal approval is pending the next board meeting. We expect to forward the formal Board approval for this application no later than April 27, 2016. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:The Musical Oratory Foundation TITLE OF GRANT PROGRAM: Two centuries in the Musical Life of the City of Leipzig UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Dr. Elisabeth Kotzakidou Pace Title: President Signature: Date: April 12, 2016 APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY COPY FOUNDATION COMMUNITY GRANT PROGRAM ,,ATEGORY: Grant requests are classified into two categories: Civic or Arts proqram. Choose only one option. 0 Civic ❑Arts Grant Request Amount: 4,566 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: NCHS Encinitas Health Center Oto/Ophthalmoscopes ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-2847102 0 IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: North County Health Project,Inc. (Must match name filed under the Tax/Employer Identification Number) Street Address: 150 Valpreda Road, San Marcos, CA 92069 Mailing Address: same as above Doing Business as (dba) Name: North County Health Services (NCHS) Please list the names and titles of the organization's Board of Directors: Sheila Brown, Chair; Donald Stump, Vice Chair; Andrew S. Rinde, Secretary; Harriet Carter, Treasurer ,-',driana Andres-Paulson; Steve Kildoo; Roberto Ramirez;Walt Steffen; Craig Jung; Craig Garcia; Jenny Smerud; Victor Botello ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): NCHS respectfully requests a$4,566 grant from the City of Encinitas/Mize) Family Foundation to purchase 5 new oto/opthalmoscopes for NCHS Encinitas Health Center exam rooms. Oto/Ophthalmoscopes are diagnostic tools used for almost every infant, child,adolescent and adult patient to look for signs of abnormalities or infections in the ears(otoscope)and eyes(opthalmoscope). Additionally,observing the vessels in the retina of the eye can provide valuable clues to diseases and conditions,such as concussion,diabetes,hypertension,glaucoma,macular degeneration,and stroke. Only 8 of the clinic's 15 exam rooms currently have working oto/ophthalmoscopes. NCHS is requesting the funds to purchase five of these vital instruments to provide efficient examinations and accurate diagnosis within arm's reach,saving valuable time. The modular,easy-to-install systems are cost efficient and environmentally friendly. The units come complete with an otoscope,ophthalmoscope,and transformer to vary lighting intensity. They will be wall mounted to prevent loss or theft. Five(5)new oto/ophthalmoscopes will ensure that most of Encinitas'Health Center exam rooms will be equipped with these vital diagnostic tools for at least seven years. With the City of Encinitas/Mize) Family Foundation's support, NCHS will continue improving the quality and efficiency of care for Encinitas'underserved population. Organizational History: NCHS was established in 1971 to improve the health status of our diverse community through high quality,comprehensive,affordable care.NCHS Encinitas Health Center opened in 1974 and now has 15 exam rooms. It offers primary care, obstetrics, gynecology, perinatology,family planning,mental health, mobile dental, and enabling services to assist access. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 + _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT 'PROGRAM �ROVRAM iNFOiNiA Aviv: Location: NCHS Encinitas Health Center Total Est. Cost: 4,566 Time Frame: July 1, 2016 ongoing once oto/opthalmoscopes are installed Number of Encinitas Residents Served: 5,800 1year Fundraising Activity: No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Irma Cota, President& CEO Mailing Address: 150 Valpreda Road, San Marcos, CA 92069 Telephone Number: (760)736-6751 Email Address: irma.cota @nchs-health.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Irma Cota, MPH Title: President&Chief Executive Officer (Please print) C't-+� �� i� 7 ZCZ �'l�r2Z 0I4-te op�j�'-,/�r tiS 0 (Z Signature: „ A- 607!° Date: April 11, 2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) 'eets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two _ APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZE'L FAMILY FOUNDATION COMMUNITY GRANT PROGRAM l .,GANI ATIOAI NAME: North County Health Project, Inc. PROJECT TITLE: NCHS Encinitas Health Center Oto/Ophthalmoscopes PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership feesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $4,566 INCOME TOTAL*: $4,566 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Equipment Five(5)-#807287 Welch Allyn 77792-MNOBP Diagnostic System,Opht/oto W/accessories,$845.60 each $4,228 8%Sales Tax $338 EXPENSE TOTAL*: $4,566 Budget Form *Your Total Income and Total Expenses should be equal. Ofyi n IRS D��.runent of[he Treti,ury ATTACHMENT A - City f Encinitas & Mizel Family Fdn. Internal Revenue Service Y Y In reply refer to: 0437.870217 OGDEN UT 84201-0038 Sep . 15, 2011 LTR 4168C 0 95-2847102 000000 00 00025203 BODC: TE NORTH COUNTY HEALTH PROJECT INC 150 VALPREDA ROAD &12 SAN MARCOS CA 92069-2973 002592 Employer Identification Number : 95-2847102 Person to Contact : Exempt Organization Toll Free Telephone Number : 1-877-829-5500 Dear Taxpayer: This is in response to your Sep . 06, 2011, request for information regarding your tax-exempt status . Our records indicate that you were recognized as exempt under section 501 (c) (3) of the Internal Revenue Code in a determination letter issued in July, 1973. Our records also indicate that you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section(s) 509(a) (1) and 170Cb) ( 1) (A) (vi) . Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. Please refer to our website www.irs. gov/eo for information regarding filing requirements. Specifically, section 6033(j ) of the Code provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the filing due date of the third return for organizations required to file. We will publish a list of organizations whose tax-exempt status was revoked under section 6033(j) of the Code on our website beginning in early 2011 . 0437870217 Sep . 15, 2011 LTR 4168C 0 95-2847102 000000 00 00025204 NORTH COUNTY HEALTH PROJECT INC 150 VALPREDA ROAD SAN MARCOS CA 92069-2973 If you have any questions , please call us at the telephone number shown in the heading of this letter . Sincerely yours , �4 Sharon Davies Accounts Management I Attachment B RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF North County Health Project, Inc. WHEREAS, North County Health Project, Inc. is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of North County Health Project, Inc. hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 9th Day of February, 2016 f � Andrew S. Rinde Secretary, Board of Directors North County Health Project, Inc. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION _ COMMUNITY GRANT PROGRAM ORGANIZATION NAME: North County Health Project, Inc. TITLE OF GRANT PROGRAM: NCHS Encinitas Health Center Oto/Ophthalmoscopes UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Irma Cota, MPH Title: President & Chief Executive 60 gG� D�zeq S A41--fc-) cl-h EF" 6PCkZ,4:ra>t�AS Dot ca Signature:.° M C Date: April 11, 2016 EVALUATION FORM ' CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date December 3 , 2014 Organization: North County Health Project, Inc. (dba: North County Health Services) Address: 150 Valpreda Road City: San Marcos State CA Zip 92069 Phone: (760) 736-8723 Fax (760) 736-8633 Email: alta.farley @nchs-health.ora State the goals and objectives of your project and whether they have been met. NCHS purchased a wireless, portable vital signs machine for its newly expanded Encinitas Health Center. The goal was to save an average of 4 minutes per patient, thereby increasing capacity to serve additional underserved patients. The new vital signs machine was installed September 15, 2014 and has been saving an average of 4 minutes per patient per day. This time saving is being utilized to serve additional patients, which is especially valuable during flu season. How were the goals and objectives of your project measured? NCHS measures the length of time that a patient is in the examination room and calculates the average per provider (physician, physician assistant or nurse practitioner) . After the vital signs machine was installed, the average time per patient decreased by approximately 4 minutes per patient, regardless of provider. Who participated in the evaluation process? The medical assistant on each patient ' s care team enters the time each patient checks in, when he/she enters the exam room, and when he/she checks out. This information is automatically fed into a table on NCHS ' practice analytics system. Staff can access the aggregate (not personal) data. How was the City's funding for this project utilized? City of Encinitas/Mizel Family Foundation funding paid for 1/2 of the cost of the vital signs machine, or $1, 800 . T:\CGP\01 CGPTemplates+Foiins\Agreement Return Letter with fonns.doc APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ..ATEGORY: Grant requests are classified into two cateqories: Civic or Arts proqram. Choose only one option. ❑Civic Arts Grant Request Amount: $5000 Free of Charge: ❑ Yes No (Not to exceed$5,000) Program Title: Furthering the Musical Presence of NCSO in Encinitas ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt orqanizations may apply. Identify the legal status of your organization: N Non-profit I-Tax-exempt Tax/Employer Identification Number(TIN/EIN): 23-7375019 ❑■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: North Shore Symphony (Must match name filed under the Tax/Employer Identification Number) Street Address: Rehearses/ performs at Seacoast Community Church, 1050 Regal Rd. Encinitas, Ca. 9'd Mailing Address: P.O. Box 503, Solana Beach, CA 92075 Doing Business as (dba)Name: North Coast Symphony Orchestra Please list the names and titles of the organization's Board of Directors: David Colborn, President Robert Clarke, Treasurer ,,indy Fisher, Vice President Kathryn Ringrose, Secretary William Gilmer Denise Day Gabrielle Genevich ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): 1) Further improve the ECC summer and Christmas concerts 2) Enlarge EC Library music program with additional ensembles 3) Promote awareness of NCSO in local Seniors residences by offering reduced rates for groups 4) Enter a float in the Encinitas Holiday Parade 5) Include more well known soloists in next years programs 6) Further our website appeal by adding ability to reserve tickets on-line Organizational History: The orchestra was founded in 1947 by Alfred Williams. For 30 years until 2009 it was affiliated with Mira Costa College. It is now independent and based in Encinitas. All musicians are volunteers. New and young musicians are most welcome to join. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 -�' CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: rehearsals and concerts at Seacoast Community Church Total Est. Cost: $5000 Time Frame: 2016117 concert Season Number of Encinitas Residents Served: 1300 Fundraising Activity: ❑ No Yes If yes, please explain: modest admission to partly cover of conductor and venues CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Robert Clarke, Treasurer Mailing Address: P.O Box 503, Solana Beach, CA 92075 Telephone Number: 858-997-7629 Email Address: carolandbob.clarke @gmail.com ❑■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that 1 am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Robert Clarke Title: Treasurer (Please print) Signature: /Fk-b 4_� Date: 2 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C(Statement of Understanding) fleets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM )R ' NIZATION NAME: 'ROJECT TITLE: PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. NCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, nd all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT ,rant City of Encinitas& Mizel Family Foundation Grant Program Pending E.C.Center Summer and Christmas concert anticipated $1200 E. Library Donations at door anticipate In Kind Effort to prepare publicity, flyers, handouts,float secured In Kind Further website developement secured INCOME TOTAL*: $ u :XPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be icluded as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Center Space rent for 2 concerts soloists for these concerts paid ads for t es concerts music In Kind - preparation of publicity, flyers, handouts 300 E. Library Space rent for community room 100 music 300 Pamphlets for handout 0 Sen.Res. Initiative In kind - Meetings with Senior Residence personnel, prep. materials 300 Reduced rate cost $3.00 ticket x 200 600 Holiday Float Truck rental, decorations, Top Hats 450 Regular conce s Ads 1400 Soloists 60 bsite Devel. In Kind - 200 EXPENSE TOTAL*: $ WJuU ;udget Form *Your Total Income and Total Expenses should be equal. Internal Revenue Service Department of the Treasury Washington, DC 20224 Person to Contact: Jankawlta ° north Shore Symphony (2M)aft-6,160 c/o David C. horning Telephone Number: 607 Solana Glen Court Solana Beach, CA 92075 Refer Reply to: OF:E:EO:R:1 Date: MAY 2 8 1986 Gentlemen: This is in reply to your letter of April 11, 1936, in which you re- quested a ruling as to whether you are an exempt operating foundation . under section 4940(d) of the Internal Revenue Code and therefore,exempt from the tcaa percent excise tax imposed by section 4940(a) on the net investment income of private foundations. You are a private foundation which has been recognized as exempt from federal income tax under section 501(c)(3) of the Code, and you are classified as a private operating foundation under section 4942(j)(3) of the Code. You have been classified as a private operating foundation for at least ten taxable years. You are governed by a Board of Directors which is broadly representative of the general public, consisting of retirees, housewives, a pharmacist, a physicist, an energy consultant, a music tea- cher and an engineer. None of the members of your Board of Directors are disqualified individuals and at no time during the taxable year have you had any officer who was a disqualified person. Section 4940(d)(1) of the Code provides that a private foundation that qualifies as an exempt operating foundation under section 4940(d)(2) for the taxable year is exempt from the two percent excise tax on net investment income imposed by section 4940(a). Section 4940(d)(2) of the Code provides that the term "exempt .operat- ing foundation" means, with respect to any taxable year, any private foundation if-- (A) such foundation is an operating foundation as defined in section 4942(j)(3), (B) such foundation has been publicly supported under section 170(b)(1)(A)(vi) or 509(a)(2) for at least ten years, (C) at all times during the taxable year, the governing body of such foundation (i) consists of individuals at least 75 per- cent of whom are not disqualified individuals under section 4940(d)(3)(B), and (ii) is broadly representative of the gen- eral public, and -9- North Shore Symphony (D) at no time during the taxable year does such foundation have an officer who is a disqualified individual under section 4940(d)(3)(B). Section 4940(d)(3)(B) of the Code provides that the term "disqualified individual" means, with respect to any private foundation, an individual who is-- (i) a substantial contributor to the foundation under section 507(d)(2). an owner of more than 20% of:-<s (I) the total combined voting power of a corporation, (II) the profits interest of a partnership, or (III) the beneficial interest of a trust or unincorporated enter- prise, which is a substantial contributor to the foundation, or (iii) a member of the family (as defined in section 4946(d)) of any person described in clause (i) or (ii). Section 302(c)(3) of the Tax Reform Act of 1984, Public Law 98-369, provides that a private foundation that was an operating foundation as defined in section 4942(j)(3) as of January 1, 1983, shall be treated as meeting the requirements of section 4940(d)(2)(B). Section 1.170A-9(a)(3)(v) of the Income Tax Regulations indicates, in another context, that the governing body of an organization may be considered to represent the broad interest of the public if it is composed of community leaders, such as elected or appointed officials, clergymen, educators, civic leaders, or other such persons representing a broad cross- section of the views and interests of the community. Because you are a private operating foundation within the meaning of section 4942(j)(3) and have been such for at least ten taxable years; your governing body is broadly representative of the general public; and none of your members or officers is a disqualified individual, we conclude that you -meet the requirements of section 4940(d)(2) to qualify as an exempt operating foundation. Based on the above, we rule as follows: 1. The North Shore Symphony qualifies as an exempt operating founda- tion under section 4940(d) of the Code. + -3- l North Shore Symphony 2.. The North Shore Symphony will not be subject to the excise tax imposed by section 4940(a) of the Code. These rulings are issued on the understanding that there will be no material changes in the facts upon which they are based. Any such changes should be reported to your key District Director. We are informing your key District Director of this action. Please keep a copy of this ruling with your permanent records. Sincerely yours, 0, 6-4 - � E. D. Coleman Director, Exempt organizations Technical Division P.O. Box 503 Solana Beach, CA 92075 coast _ - - -- - - 'Siy Addendum to minutes of the March 8 meeting of the Board of Directors of the the North Coast Symphony Orchestra. The Board of Directors hereby authorizes the members of the Grants Committee to apply for a grant from the Mizel Foundation for the coming fiscal year. Ms.Elizabeth Gilpin has been asked to prepare the materials to be sent to the Mizel Foundation. Signed, Members of the Board of Directors David Colborn (President) � ' � ::r :� •f Cindy Fisher (Vice-President) Bob Clarke(Treasurer) Kathryn Ringrose(Secretary) Dan Swem (Conductor) _. Bill Gilmer ,,'�"V ",+ ` . f�, - ' Denise Day ` Gabrielle Genevich ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 ` - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM MOW ORGANIZATION NAME: North Shore Symphony TITLE OF GRANT PROGRAM: UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Robert Clarke Title: Treasurer Signature: Mfr° Date: EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date f Organization: North Shores Symphony (dba: North Coast Symphony) Address: t• ���, 5 �'3 City: 5o l cr r F &e State Zip 2 7 Phone: "i1-75_`-7y2. 3S ' S Fax Email: v,�' C,�,Ilnorpl dl State the goals and objectives of your project and whether they have been met. We aimed to attract a wider segment of the Encinitas Community to our concerts by performing four"pops"concerts in the Encinitas Community and Senior Center. While turn out at the Summer concert was good,our numbers were not what we anticipated for the holiday concert,perhaps due to rainy weather. Also,the heat was off leading some people to leave before they even bought tickets and others to leave during the performance. How were the goals and objectives of your project measured? We counted the attendees and asked them how they heard about the concerts. 35%of attendees saw an ad (paid or unpaid,could not distinguish) in the newspaper,40% came, because of a relative or friend in the orchestra,5%due to an email notice, 13%due to postings on electronic bulletin boards,and 7%due to"other" publicity. Who participated in the evaluation process? Our Board of Directors and a volunteer orchestra member participated in the evaluation process. How was the City's funding for this project utilized? The grant funding was utilized to rent the space in the Encinitas Community and Senior Center,pay for special vocal soloists,buy/rent music for the concers and to advertise the concert in the Union Tribune (North Co edition) and the Coast News. n....moo. 4-D„4- T o++o,.. 41, r a..,. =� APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories. Civic or Arts program. Choose oniv one option. ❑Civic Arts Grant Request Amount: $5,000.00 Free of Charge: Yes ❑ No (Not to exceed$$5,000) Program Title: Oak Crest Foundation Inc(aka Oak Crest Parent Foundation) ELIGIBILITY DETERMINATION: CMy non-profit anchor toX-exempt'organizations may .vory. Identify the legal status of your organization: ■ Non-profit f Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0004167 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGAWMr6NW0RKATKft Organization Name: Oak Crest Foundation Inc. (Must match name filed under the Tax/Employer Identification Number) Street Address: 625 Vulcan Ave., Leucadia, CA 92024 Mailing Address: Oak Crest Middle School, 675 Balour Drive, Encinitas, CA 92024 Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: President-Chris Possemato Secretary-Tami Alderton Treasurer-Anita Laird Membership- Lisa Kendall Vice President-Open Volunteers- Heather Thiele ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided).- The Oak Crest Parent Foundation raises money to enhance the educational Experience at Oak Crest. All money raised by the Parent Foundation stays at Oak Crest to benefit our school and we do our best to spend all money raised in that same year. Oak Crest faculty and staff can request funds through the Principal, who brings requests to the Foundation Board monthly. From PE equipment to technology to art supplies to books, we fund across the curriculum with the goal of impacting as many students as possible. Our school needs your support in order to continue to fund these requests and enrich the student experience at Oak Crest. The Oak Crest Parent Foundation Music Boosters program supports the music programs at Oak Crest MS, including beginning band, symphonic/advanced band, and the jazz band. We raise money each year to pay for music coaches, instruments, repairs, and performance expenses, and we strive to ensure that all students are able to participate in all activities, including music events and performances throughout the year. Organizational History: Since 1987, the Oak Crest Foundation has supported enrichment activities at Oak Crest Middle School through financial support. Working with school staff, parent volunteers, and students, the OC Foundation has funded enrichment activities for students with the goal of supporting our students of today to become leaders of tomorrow. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Oak Crest Middle School, 675 Balour Ave., Encinitas, CA 92024 Total Est. Cost: $5,000.00 Time Frame: July 1, 2016 through June 30, 2017 Number of Encinitas Residents Served: Fundraising Activity: ❑ No 11 Yes If yes, please explain: The Oak Crest Parent Foundation and Music boosters conduct fundraisers through community partnerships throughout the year. .CONTACT INFORMATION AND STATEMENTS:. Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Julie Yeager/Oak Crest Middle School Band Director Mailing Address: 675 Balour Ave., Encinitas, CA 92024 Telephone Number: 760-753-6241 Email Address: lulie.yaeger @sduhsd.net ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that 1 am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Julie Yeager Title: Oak Crest MS Band Director (Please print) Signature: 01"� v U� Date: 4/14/16 THIS SECTION FOR OFFICIAL USE ONLY. Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Oak Crest Middle School Parent Foundation PROJECT TITLE: Music Boosters Program PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $5,000 Mandatory Reserves Prior year fundraising,grant awards,etc. Secured $3,000 Grant Coastal Community Foundation Secured $774 Donations General Band Donations from Oak Crest Band Student Families Pending $3,679 Donations Jazz Band Donations from Oak Crest Band student families Pending $1,100 Donations Instrument donations from Oak Crest Band student Families Pending $825 Donations Winter Concert Donations by attendees Pending $347 Donations Winter Concert DVD Sales Pending $50 Fundraiser Sees Candy Sales donations Pending $2,300 Fundraiser Jamba Juice Sales Donations Pending $1,960 indraiser Spirit Wear Sales Donations(Stickers,decals,etc.) Pending $405 Fundraiser T-shirt and Polo Shirt Sales required for band performances funded by student families Pending $980 Fundraiser Restaurant nights at Oggi's Pizza, Pei Wei,and Brett's BBQ Pending $520 INCOME TOTAL*: $20,940 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Instructor Fees Musical Coaching Salaries $8,800 Equipment Band Instruments purchased and repaired at Bertrand's Music $3,200 Classroom Supplies Sheet Music from JW Pepper $650 Classroom Supplies Miscellaneous supplies(music books,reeds,mouthpieces,etc.) $250 Teacher memberships SCSBOA $200 Parade Expenses City of Encinitas $300 Activity Fees CBDA All State,El Camino HS Bus El Camino HS reg fee $860 Scholarships Mandated for low-income students $1,000 Instructor Fees Jazz Band Director $2,500 Activity Fees KSDS Jazz 88 Jazz Festival Fee $180 Reserves Mandatory Reserves amount needed to start new year $3,000 EXPENSE TOTAL*: $20,940 Budget Form *Your Total Income and Total Expenses should be equal. y Interff al Revenue Service )artment of the Treasury Distr t Director P D Bx 486 `S AELES, C A 900530486 Employer IdentiFication Number: Dater33-0004167 DEC. 16, 1987 Case Number: OAK C1 'EST FOUNDATION INC 957307018 Contact Person: 625 U CAN JOYCE DARBY LEUCA IA, CA 920240000 Contact Telephone Number: �r (213) 894-4152 i Our Letter Dated: Oct. 10, 1985 Caveat Applies_: No Dear . 3plicant: T is modifies our letter of the above date in which we stated that you would :e treated as an organization which is not a private foundation until the ei iration of your advance ruling period. sed on the information you submitted, we have determined that you are a rivate foundation within the meaning of section 509(a) of the Internal 4en � Code, because you are an organization of the type described in section 5J9(a) (2) . Your exempt status under section 501tc) (3) of the code is still in effect antors and contributors may rely on this determination until the Intern I Revenue Service publishes notice to the contrary. However, a granto or a contributor may not rely on this determination if he or she was in part responsible for, or was aware of, the act of failure to act that r .sulted in your loss of section 509(a) (2) status, or acquired knowledge that the Internal Revenue Service had given notice that you would a removed from classification as a section 509(a) (2) organization_ 8 cause this letter could help resolve any questions about your private f ounda ion status, please keep it in your permanent records. I the heading of this' Istter indicates that a caveat applies, the caveat below r on the enclosure is an integral part of this letter. I , you have any questions, please contact the person whose name and telephone number are shown above. I Sincerely your.-, Freder ck C. Nielsen District Director Letter 1050(CG) Aikoim%T RESOLUTION OF THE BOARD OF DIRECTORS OF OAK CREST PARENT FOUNDATION, INC. WHEREAS, the OAK CREST PARENT FOUNDATION, INC., is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the OAK CREST PARENT FOUNDATION, INC., hereby approves the filing of an application for the City of Encintas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 14th day of April, 2016 Pending Signature Chris Possemato President, Board of Directors Oak Crest Parent Foundation, Inc. ATTACHMENT B ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 EY Adeftk CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Oak- ((e S- i' a r e n4 Py nC1 gfi3OK'1 TITLE OF GRANT PROGRAM: I y k 4S l L Q D O S f-e i S UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. �ke& (� Oak Crest Middle School Ba Contact Person: I 2 Title: Signatur Date: 4/14/16 #4"� 6 ' APPLIUA fi N FoR FE3Lw:� f EAR :w I b 26 1 CATY OF ENCINITAS AND MiZEL FAMILY �-OUNDATIUN COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categones: Civic or Arts program. Choose only one option. ❑Civic Arts Grant Request Amount: 4000 Free of Charge: ❑ Yes ❑i No (Not to exceed$5,000) Program Title: 17th San Diego Asian Film Festival ELMOKM OW i1`NNTit Only non=profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-1001523 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANMM10N,1NFQ&"TKW. Organization Name: Pacific Arts Movement (Must match name filed under the Tax/Employer Identification Number) Street Address. 2508 Historic Decatur Rd., Suite 140 San Diego, CA 92106 Mailing Address: same as above Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: Kent Lee (Board Chair), Boy Scouts of America Harlen Bayha (Treasurer), Wells Fargo Marketing Deb Hall (Board Vice Chair), Union Bank Stephen Chin (Chairman Emeritus), Sharp Health Plan Miranda Ko (Secretary), Alere Inc. ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. Summary of Program (Limit to the space provided): As the largest exhibition of Asian cinema on the West Coast,the 17th San Diego Asian Film Festival will take place November 3-12, 2016 with an estimated 150 films from 20 countries to be presented at venues throughout San Diego County. Since 2013, we have been building our festival's presence in North County, and in particular, Encinitas. Last year was the second time we brought our festival to the historic La Paloma Theater with four film screening, serving nearly 800 attendees, many of whom contributed to the city's economy by eating and shopping in Encinitas before and after their film. We want to build upon our growing base in Encinitas, and continue hosting the end our Festival at La Paloma, bringing high quality international cinema with visiting filmmakers who will participate in Q&A sessions with the audience. We would also like to offer a special discount for Encinitas residents who would like to attend the film festival. Organizational History: Since 2000, Pacific Arts Movement has resevered more than 250,000 people and has preimered more than 1,000 films from around the world in San Diego through film exhibitions, youth education, and community outreach programs.We strive to serve the broadest audience possible, and aspire to play a key role in enriching San Diego's growing global community. Application Form. Page One of Two CITY OF ENCINITAS AND MIZEL FAMILY r°GUNDATION '--GMMUNIT Y ;RANT PROGRAM PROD AlyA INI`OIskTION: Location. La Paloma Theater, 471 S Coast Hwy 101, Encinitas, CA 92024 (including venues across San Diego County) Total Est. Cost: $135,500 Time Frame: November 3 - 12, 2016 Number of Encinitas Residents Served: 800 Fundraising Activity: W, No ❑ Yes If yes, please explain: C OWAOT INFOMKWO AM INFO VIVA ' . M' : Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Cynthia Kashiwagi, Development& Engagement Manager Mailing Address: 2508 Historic Decatur Rd., Suite 140, San Diego, CA 92106 Telephone Number: 619-400-5912 Email Address: cynthia @pacarts.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Cynthia Kashiwagi Title: Development & Engagement Manager (Please print) Signature: Date: l l / )?,, I lee THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed & dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements• ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPf!ACA TION FOR F!SCAL FEAR 2616-26 r il ITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM 1RU ANIZATION r4AME Pacific Arts Movement rRVJEG 1 ril LE 17th San Diego Asian Film Festival PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinita, �'- Mi;el t arrtily Foundaiiurt Grant Pi ogrurn Pending $4,000 Grant County of San Diego, Community Enhancement Pending $ 15,000 Grant National Endowment for the Arts Confirmed $25,000 In Kind RT Flights on Southwest Airlines for up to 20 filmmakers confirmed $8,000 Membership Fees Dues from Pacific Arts Movement Members confirmed $20,000 Ticket Sales Revenues from film festival admissions pending $55,000 Sponsorship Cox Communications confirmed $4,000 Sponsorship Wawanesa Insurance confirmed $3,500 Sponsorship AT&T confirmed $1,000 INCOME TOTAL*: $135,500 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Film Licensing Licensing per film runs from$250-$1500 each $20,000 Theater Rental Venue fees for various theaters over 10 days including La Paloma, UltraStar,and MOCASD $30,000 Contractors Projectionists,Graphic Designers,Will-Call,Facilities Coordinator,Volunteer Coordinator,PR,House Managers $30,000 Domestic Air Travel RT Flights for up to 20 filmmakers in within the continental US at$400 ea $8,000 Printing Program booklets,mini guides,posters,banners,flyers, and general signage $18,000 Shipping Domestic and International shipping costs for films $4,000 Equipment Rental AV,Lighting,and HD Cam Rentals for 10 days $5,000 Liability Insurance $3,000 Lodging Hotel and lodging fees for up to 20 filmmakers,at 3 nights each at$150 $9,000 Marketing Advertising including Coast News,direct mail,and radio $8,500 EXPENSE 'TOTAL ':,$135,500 ATTACHMFNT A 1E IRDepartment of the Treasury SInternal Revenue Scrvlce In reply refer to : 0423286414 OGDEN UT 84201--0046 Oct . 15, 2012 LTR 252C 0 33-1001523 000000 00 00005160 BODC: TE PACIFIC ARTS MOVEMENT LEE ANN KIM _^ 2508 HISTORIC DECATUR RD STE 140 SAN DIEGO CA 92106-6138 005560 Taxpayer Identification Number : 33-1001523 Dear Taxpayer: Thank you' for the inquiry dated Aug . 19, 2012 . We have changed the name on your account as requested . The number shown above is valid for use on all tax documents . If you need forms, schedules , or publications, you may get them by visiting the IRS website at www. irs .gov or by calling toll-free at 1-800-TAX-FORM (1-800-829-3676) . If you have any questions, please call us toll free at 1-877-829--5500 . If you prefer , you may write to us at the address shown at the top of the first page of this letter . Whenever you write, please include this letter and , in the spaces below, give us your telephone number with the hours we can reach you . Also , you may want to keep a copy of this letter for your records. Telephone Number f ) Hours m Sincerely yours , ;r-,,awr-t Sheila Bronson Dept , Manager, Code & Edit/Entity 3 Enclosure(s) : Copy of this letter �"J(Jlfh�J TT]C Department of the Treasury 11117 Lilernal Revenue Service P.O . Box 2508 In reply refer to : 0248464862 Cincinnati OH 45201 Feb . 09, 2011 LTR 41680 EO 33-1001523 000000 00 00016360 BODC: TE SAN DIEGO ASIAN FILM FOUNDATION LEE ANN KIM 7290 ENGINEER RD STE A f SAN DIEGO CA 92111-1413 036781 Employer Identification Number : 33-1001523 Person to Contact : Miss Campbell Toll Free Telephone Number: 1--877-829-5500 Dear Taxpayer: This is in response to your Jan . 31 , 2011, request for information regarding your tax-exempt status . Our records indicate that you were recognized as exempt under section 501 (c) (3) of the Internal Revenue Code in a determination letter issued in April 2002. Our records also indicate that you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section(s) 509(a) ( 1) and 170 (b) ( 1) (A) (vi) . Donors may deduct contributions to you as provided in section 170 of the Code . Bequests , legacies , devises , transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106 , and 2522 of the Code . Please refer to our website www.irs.gov/eo for information regarding filing requirements . Specifically, section 6033(7) of the Code provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt Status as of the filing due date of the third return for organizations required to file . We will publish a list of organizations whose tax-exempt status was revoked under section 6033(7 ) of the Code on our website beginning in early 2011 . 0248464862 Feb. 09, 2011 LTR 4168C ED 33-1001523 000000 00 00016361 SAN DIEGO ASIAN FILM FOUNDATION LEE ANN KIM 7290 ENGINEER RD STE A SAN DIEGO CA 92111-1413 If you have any questions, please call us at the telephone number, shown in the heading of this letter. Sincerely yours , Michele M . Sullivan , Oper . Mgr . Accounts Management Operations I ATTACHMENT B ti RESOLUTION FROM THE BOARD OF DIRECROR AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF PACIFIC ARTS MOVEMNT WHEREAS, the PACIFIC ARTS MOVEMENT is a legally constituted corporation or public/government entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFOR, BE IT RESOLVED, that the Board of Directors pf the PACIFIC ARTS MOVEMENT hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 121' day of April, 2016 ' I 77 1 Lt,;1 Secretai)), Board of Directors PACIFIC ARTS MOVEMENT APPLICATION FOR FISCAL Y EAR 206- t01' J - t I� �)F ENCINITAS AND MIZEL FAMILY FOUNDA i IOP COMMUNITY GRANT PROGRAM oRGANIZATrON NAME 1�_ ►�I� � t ` 1` � '� {f � , r 1 i'IYLE OF GRANT PROGRAM UNDERSTANDING OF INSURANCE REQUIREMENT -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. ', ► -�-►, ��.�, �G'���'L ��-4 L. tA Contact Person: � , � Title: Development & Engagemen I Signature: TV ( ` Date: 'I 5 EVALUATION FORM - `° CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2014/15 Date f 2 Organization: Pacific Arts Movement Address: 2 5 0 g M 5 Aor n,L- /4c) City: j-�) State cv� Zip -rl2 Phone: �1G 4-QQ '- 5-`j /I Fax /)l/q- Email: Pat -Arhr orlt op- I LeGl na6l pd l- -/yrai5. 6119 State the goals and objectives of your project and whether they have been me l. � a h l ii lglm �Jil - -1b `ff� In a- I Cam- lb tlornA- J/t 0u12- 61 K-9 &M �hel /P/1'�G�- Corn How were thals and objectives of your project measured? Oct oils aid chi& ac&v l and Who participated in the evaluation process? r��74 7) reG0, , Wew- ln'o Itl� 4rclUalMx) How was the City's funding for this project utilized? J06 1)/0 or qlu- 4-Dil k� -fi�)V AS Pa to atr,(- --r-A.1 f 1 T:\CGP\OI CGPTemplates+Forms\Agreement Return Letter with forms.doc - - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two cateqories: Civic or Arts program. Choose only one option. ❑Civic Z Arts Grant Request Amount: 5000 Free of Charge: g Yes ❑ No (Not to exceed$5,000) Program Title: Write On! ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: K Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0394250 ❑■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Playwrights Project (Must match name filed under the Tax/Employer Identification Number) Street Address: 3675 Ruffin Road, Suite 330, San Diego, CA 92123 Mailing Address: same Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: Gene Summ, President; Kathy Krevat, Vice President; Susan Finkelstein, member; Mary Harrison, member; Teofla Rich, Treasurer; Ishita Dayal, Secretary; Ann Hornby, member; Holly Smith Jones, member; Lynne Bath, member; Dave Carr, member; Vaishnav Srinivas, member Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Students from five classes at two Encinitas schools will participate in Write On! classroom playwriting residencies. Exploring theatre as playwrights, each student will craft his or her own original play, creating characters, resolving conflicts, and discovering universal themes. The residencies consist of 10 sessions; 8 hours of instruction plus two final sessions with professional actors performing scripts from each of the students. Through incremental learning in a creative environment, students draw from their own experiences, observations and imaginations to craft their individual plays about fictional characters. Organizational History: Playwrights Project was founded in 1985. Educators have praised our education programs, which inspire students throughout San Diego County to write plays. Our work impacts people of all ages,from all backgrounds:from youth who are discovering the power of live theatre for the first time to adults moved by the sophisticated content tackled by teenage writers. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 4 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Ada Harris Elementary/Oak Crest Middle/Encinitas Country Day Total Est. Cost: $5,530 Time Frame: September 1, 2016 - June 30, 2017 Number of Encinitas Residents Served: 180 Fundraising Activity: I No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Cecelia Kouma, Executive Director Mailing Address: 3675 Ruffin Road, Suite 330, San Diego, CA 92123 Telephone Number: 858-384-2970 Email Address: ckouma @playwrightsproject.org X Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: l eC�c j 6, ko, ,,,, e— Title: Executive Director (Please print) Signature: Date: 4/12/16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed & dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes L No Reasons: Application Form, Page Two of Two _ APPLICATION FOR FISCAL YEAR 2016-2017 -' CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: �'��h� t, t� P�o,�<<.` PROJECT TITLE: wI-�Ae- CA � PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $5,000 matching funds anonymous individual pending $530 INCOME TOTAL*: $5,530 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Administration Program Coordinator $850 Curriculum development Executive Director(curriculum planning) $500 Clerical Clerical support $300 Instructor fees Teaching Artists($30-$40/hr.and prep time,grading) $2,600 Actor fees Actors($25-$35/hr) $1,050 Supplies Copying student scrips and hand-outs $ 150 Mileage Mileage reimbursement $30 Space Rental Coordinating and planning with Teaching Artists $50 EXPENSE TOTAL*:1$5,530 Budget Form *Your Total Income and Total Expenses should be equal. 1 JRQ Department of the Treasury k3 Internal Revenue Service P.-O. Box 2508 In reply refer to: 0248344558 Cincinnati OH 45201 Apr . 01 , 2011 LTR 4168C EO 33-0394250 000000 00 00012968 BODC: TE PLAYWRIGHTS PROJECT 2590 TRUXTUN RD STE 202 SAN DIEGO CA 92106-6145 )24310 Employer Identification "-Numbers 33-0394250 Person to Contact : Mr . Burns Toll Free Telephone Number : 1-877-829-5500 iDear Taxpayer': This is in response to 'your 'Mar. 24, 2011 , request for information regarding your tax=exempt. status . Our records indicate that you were recognized as. exempt under section 501 (c) (3) of the Internal Revenue Code in a determination letter issued in March 1994. Our records also indicate that you are not a private foundation within the meaning of section 509(a) of th.e Code because you are described in section(s) 509(a) (1) and 170 (b) (1) (A) (vi) . Donors may deduct contributions to you as provid-ed in section 170 of .the Code. Bequests, legacies, devises, transfers., or gifts to you or for your use are' -de'ductible for Federal estate and gift tax. 'purposes if they meet the applicable provisions of sections 2055, 2106, . and 2522 of the Code . Please refer to our website www. irs .gov/eo for information regarding filing requirements. .Specifically, section 6033(j) of the Code provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the filing due date .of the third_ return for organizations required to file . We will putil sh a list of organizations whose 't ax-e ellipt ( -- status was revoked under section 6033(j) of the Code oq our website beginning in early -2011 .� If you have any ques'tions, ' please call us at. the telep'ho:ne number shown in the heading' of this letter . Sincerel.y .,yours , dam!/s� S. A. Martin, -Operations Manager Accounts:"Management 'dperations RESOLUTION FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF Playwrights Project WHEREAS, Playwrights Project is a legally constituted corporation or under the laws of the State of California, and is in complete control of its affairs through its own officers and members; NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of Playwrights Project hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 17th day of February, 2016 t I -4D 0,14 2 Ge a Summ President, B and of Directors ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 =. - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Playwrights Project TITLE OF GRANT PROGRAM: Write On! UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT-Q 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Cecelia Kouma Title: Executive Director Signature: �- Date: 4/12/16 Playwrights Project–Final Report to City of Encinitas June 2015 State the objectives/goals of your project/program and whether they have been met. Playwrights Project's objective was to engage Encinitas students in playwriting residencies, offering students the opportunity to craft their own original plays—creating fictional characters, resolving conflicts, and through it all discovering universal themes. We originally proposed five Write On!programs for 5t'graders at two schools, Capri and Ocean Knoll. Although the grant awarded was less than we had requested ($3,500 vs. $5,000), we were able to bring the program to two 5t' grade classrooms at Ocean Knoll and two 5t' grades at Capri. Both schools have benefited from our program in the past, and when we informed them this grant would cover two classes each,they happily accepted. The City of Encinitas and Mizel Family Foundation grant, plus leveraged funds from Ocean Knoll (which provided actors modeling live theatre in the introductory session), enabled us to provide our playwriting residencies in four classrooms with a total of 125 Encinitas students. We met our goal of providing an exploration of theatre from the perspective of playwrights. The program led 125 students to write individual one-act plays about fictional characters. Through 9 hours of instruction(including visits by professional actors), students learned about the arc of a story as their characters overcame obstacles to attain their goals. They gained an appreciation of the need for revision as they heard their plays read in class and prepared their scripts for the actors. Students were enthusiastic about performing in front of the class. The classroom teachers invited other students and parents to attend the final performances of student scripts, resulting in an additional 30 adults celebrating the students' work. How were the objectives/goals of your project/program measured? The success of the program was measured by the students' high level of engagement and participation,their enthusiasm for the writing process and students' successful completion of their plays, which were graded with a standardized rubric. Teachers and students completed surveys and gave verbal feedback about their satisfaction with the program; Playwrights Project Teaching Artists also complete evaluations following the conclusion of the residency. Who participated in the evaluation process? The Playwrights Project Teaching Artists,the classroom teachers and students completed written evaluation forms. 1 Playwrights Project—Final Report to City of Encinitas June 2015 In response to the question"What did you learn about yourself in the playwriting program," students wrote: —I learned that I am a good writer. That even if my topic sounds weird, I can always turn it into a great play! —I learned that friendship matters. —I can use dialogue well and that I can melt into the story I am writing. —I thought I couldn't write a play because I don't have creativity. But I was wrong. How was the City's funding for this program utilized? The funding provided by the City of Encinitas paid for Teaching Artists who conducted the writing programs and the actors who performed the students' work. It also partially funded the staff's scheduling of artists and ongoing consultation with the Teaching Artists and classroom teachers regarding curriculum and implementation. A small portion went towards copying of scripts and handouts for students. How many Encinitas residents did you expect to serve through your program? We expected to serve 120 students plus 25 family, peers and educators. How many Encinitas residents did you actually serve through your program? We served 125 students, plus 30 family, peers and educators Based on the outcome of this year's program, what changes/improvements will you make next year? We will continue to work directly with the schools to assure our programs contribute to the Superintendent's goals for arts programs in the District. We will work with the schools to ensure that the first session of the residencies includes modeling of live theatre, so the students have a framework upon which to build their own scripts. 3 i0li"N. KPPL'1100.7:00 FOF, r S%k,L YEP:R 206-2017 FOUP'Cy.A '01q C0,41r III uL-771 G7RAP"E PRQE.7Pa:melt CATEGORY: Grant requests are classified into two cateqories: Civic or Arts proqram. Choose only one option. AN Civic ❑Arts Grant Request Amount: $5,000 Free of Charge.- ❑ Yes No (Not to exceed$5,000) Program Title: Performing Arts for Teens and Adults with Autism ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: Non-profit A Tax-exempt Tax/Employer Identification Number(TIN/EIN): 37-1566774 ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Positive Action Community Theatre(PACT) (Must match name filed under the Ta)/Employer Identification Number) Street Address: 2061 Village Park Way,#227, Encinitas, CA 92024 Mailing Address: same Doing Business as (dba) Name: n/a Please list the names and titles of the organization's Board of Directors: William Simonson, Board Chair Paul Goul, Board Member Darren Thierry, Board Treasurer Elaine Primiano, Board Member Maggie Murphy Meartz, Board Secretary Kathryn Campion, Board Member, Executive Director ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): We provide performing arts workshops throughout the year that teach life and social skills to teens and young adults with autism.Program evaluations show a consistent increase in our participants'self-esteem, cooperation,fitness, and creativity.They also master an art,which will be a powerful ally for them in living with the challenges of autism.Over the years we have developed a community of performing arts enthusiasts with autism that is of great value to its members. We have brought many isolated individuals back into meaningful contact with others.Parents report improvements in their overall wellbeing and confidence.Each year we provide four 8-week cycles of theatre workshops and four 8-week cycles of performing arts(dance and group singing)workshops.We utilize improvisational theatre because it provides on-going opportunities to practice social interaction,the main challenge of those with autism. We recruit volunteers to serve as peer mentors at the workshops,but some of our best peer mentors have autism.We recently hired a young man with autism to serve as assistant workshop director. Many of these teens and adults show great talent in the arts.At the end of each year we perform at a local nursing home.We recently formed a Beyond Bullying Theatre Troupe that is currently preparing sketches they will perform at local schools and community centers with the goal of preventing peer bullying. Organizational History: Our mission is to empower individuals with autism and create community through the performing arts. Since 2008 we have been improving the lives of those with autism by giving them access to high quality arts training and expression,where they learn vital life skills in a supportive environment.We also serve their families by providing much needed community and family fun. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017' -__ C7Y OF ENCIN'_TAS AND WZEL FAMILY FOUNDATION COMMlr N!TY GRANT PRCGRAm PROGRAM INFORMATION: Location: Dance North County, 535 Encinitas Blvd., Ste. 101, Encinitas, CA 92024 Total Est. Cost: $16,910 Time Frame: July 1 to December 31, 2016 Number of Encinitas Residents Served: 120 Fundraising Activity: 0 No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Kathryn Campion, Executive/Project Director Mailing Address: 2061 Village Park Way,#227, Encinitas, CA 92024 Telephone Number: 760-815-8512 Email Address: info @pacthouse.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Kathryn Campion Title: Executive/Project Director (Please print) Signature: —,/ i, Date- 03/23/16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed & dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 w_ CITY OF ENCINITAS AND MIZEL FAMILY - FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Positive Action Community Theatre (PACT) PROJECT TITLE: Performing Arts for Teens and Adults with Autism 'PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership feesidues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Income Tuition for Summer and Fall Theatre and Performing Arts Workshops Pending $2,000 In-kind Donation of 40 volunteer hours @$40/hr-Project Director Secured $1,600 In-kind Donation of 25 volunteer hours @$40/hr-Workshop Director Secured $1,000 Grant Foundation for Developmental Disabilities Pending $5,000 Donations Individual/corporate donations Pending/secured $2,310 INCOME TOTAL*: $16,910 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST personnel Workshop Director:50 hours @$40/hr $2,000 in-kind income Service donation-Workshop Director:25 in-kind hours @$40/hr $1,000 personnel Project Director:75 hours @$40/hr $3,000 in-kind income Service donation-Project Director 40 in-kind hours @$40/hr $1,600 personnel Assistant Workshop Director:24 hours @$15/hr $360 personnel Payroll Taxes and health benefits $1,000 supplies and services Insurance $500 supplies and services Workshop room rental:40 hours at$20/hour $800 supplies and services Mileage:300 miles @.60/mile $180 supplies and services Program and office supplies and repairs $800 supplies and services Marketing $600 supplies and services Office rent:$500/month for 6 months $3,000 supplies and services Meetings and training $300 upplies and services Payroll services $300 supplies and services Monthly for 6 months:Telephones:$95, Internet/Website:$120, Fax:$30 $1,470 EXPENSE TOTAL*: $16,910 Budget Form *Your Total income and Total Expenses should be equal. F INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 FEB � ��Q� Employer Identification Number: Date: 37-1566774 DLN: 17053172309038 POSITIVE ACTION COMMUNITY THEATRE Contact Person: PACT JEFFERY A CULLEN ID# 31215 C/O KATHRYN CAMPION Contact Telephone Number: 2061 VILLAGE PARK WAY STE 227 (877) 829-5500 ENCINITAS, CA 92024 Accounting Period Ending: December 31 Public Charity Status: 170 (b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: May 13, 2008 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Letter 947 (DO/CG) ATTACHMENT B RESOLUTION FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF Positive Action Community Theatre (PACT) WHEREAS, Positive Action Community Theatre (PACT) is a legally constituted corporation, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED that the Board of Directors of Positive Action Community Theatre (PACT) hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 9th day of March, 2016 / n M ggi urphy Maert Secretary, Board of Directors Positive Action Community Theatre (PACT) ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Positive Action Community Theatre (PACT) TITLE OF GRANT PROGRAM: Performing Arts for Teens and Adults with Autism UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Kathryn Campion Title: Executive/Project Director Si nature 1` ': -{ +- � � `` ' - Date: 03/23/16 EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015-16 Date: December 20, 2015 Organization: Positive Action Community Theatre (PACT) Address: 2061 Village Park Way, #227 City: Encinitas State: CA Zip: 92024 Phone: 760-815-8512 Fax: 760-436-4869 Email: info @pacthouse.org State the goals and objectives of your project and whether they have been met. Our goals and objectives were met in that: Over 100 Encinitas residents were served by our programs. We provided four 8-week cycles of theatre workshops and four 8-week cycles of performing arts workshops. Program evaluations have shown a consistent increase in the life skills the workshops are designed to teach. How were the goals and objectives of your project measured? Who participated in the evaluation process? We assess our success in improving our participants' life skills through a program evaluation form that is filled out by the parents. This evaluation method, originally designed by Dr. Myra White of Harvard University, has proven a valuable tool for measuring life skills development for our organization since 2008. In the form, parents are requested to rate their observations of their child based on ten statements designed to measure life skills. In addition to measuring life skills development the form requests narrative feedback on how the life skills learned are translating to more success in the rest of their lives. We have received many reports of major improvement in our participants' ability to reach their full potential in all aspects of their lives. We also are in constant communication with the parents and families and receive verbal acknowledgment about the progress our participants are making in their sense of well- 1 APPLICATIOR FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMLI "ITY GRAHT PROGRAM CATEGORY: Grant requests are classed into two categories: Civic or Arts program. Choose only one option. 0 Civic D Arts Grant Request Amount: $5,000 Free of Charge: Yes No (Not to exceed$5,000) Program Title: Partial underwriting of music and programs for 2016 Thursday Family Fun Nights (June 2-August 25) ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-6120581 0 IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Quail Gardens Foundation Inc. (Must match name filed under the Tax/Employer Identification Number) Street Address: 230 Quail Gardens Drive Mailing Address: PO Box 230005, Encinitas, CA.92023-0005 Doing Business as (dba) Name: San Diego Botanic Garden Please list the names and titles of the organization's Board of Directors: Sharon May Lowe (Chair), Vann Parker(1st Vice Chair) Randi Coopersmith,John DeWald,Carol Dickinson,Mary Friestedt, Mark Petrie(2nd Vice Chair and Treasurer),Joyce Wilder(Secretary) Shaun Henry, Jane Hunt, Frank Mannen, Tom Applegate, Marcia Hall Brockett, Larry Campbell, William Rawlings,Jim Ruecker,Matt Stamper,and Kathleen Thuner • Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): A family-friendly summer series,Thursday Family Fun Nights(TFFN)features local and national musical groups and other entertainment set in a world-class botanic garden.This year,since there will be construction for the Garden's new Dickinson Family Education Conservatory in the north part of Hamilton Children's Garden,the Garden is partnering with neighboring San Dieguito Heritage Museum to host the performances on the Museum's site,while the rest of the Garden will be open to attendees.TFFN exemplifies the Garden's mission"to inspire people of all ages to connect with plants and nature"by engaging children and adults in a natural setting filled with interactive exhibits that help them more fully experience the outdoors.TFFN is also the only time that the Garden offers extended visiting hours, closing at 8 pm rather than 5 pm between Memorial Day and Labor Day,which allows families to visit during the week who might not otherwise be able to due to work or school.This popular event continues to grow,and drew approximately 3,960 children and adults from Encinitas and the surrounding communities in 2015,a 10%increase over 2014.The cost of TFFN is included in regular admission for non-members and is free for members.The Garden has more than 6,000 member households,nearly 25% of which are Encinitas residents.The City of Encinitas'and Mizel Family Foundation's past support has been crucial to TFFN's success. Organizational History: Ruth Larabee left the property to the county in 1957 to preserve it as natural space. Quail Gardens Foundation Incorporated in 1961. Quail Park opened in 1971, and became Quail Botanical Gardens in 1984. In 1993,the Garden became a self-sustaining nonprofit in response to the County's financial problems. In 2009,we became San Diego Botanic Garden. Application Form, Page One of Two :.F F L,ICA.`i 10V FOR FISCAL 'YEI.R 20W-2000-7 C11Y OF EF'Clifl AS AUT 1611EL rti.i wLY 1:0U1"DAMP COPJAUP171"Y GRP,PT F'ROGrJ16 PRrGRA,n INFORO.IATIOM: Location: Encinitas Total Est. Cost: $20,960 Time Frame: Every Thursday Night from June 2 to August 25, 2016 Number of Encinitas Residents Served: 1,650 Fundraising Activity: M No ❑ Yes If yes, please explain: CONTACT INFORMATION'AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Julian Duval, President and CEO Mailing Address: PO Box 230005, Encinitas, CA 92023-0005 Telephone Number: (760)436-3036, ext. 202 Email Address: Jduval @SDBGarden.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Julian Duval Title: President and CEO (Please print) Signature* Date: THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed & dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: :'%pp'icaiion norm, rage .wo o Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY •' FOUNDATION COMMUNITY GRAFT PROGRAM ORGANIZATION NAME: Quail Gardens Foundation Inc. F ROJECT TITLE: Partial underwriting of music and programs for Thursday Family Fun Nights (June 2-August 25, 2016) PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required- ih'CO16'E: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Ticket Revenue Event admissions from non-members Pending $3,000 Membership Dues Memberships sold during Thursday Family Fun Nights Pending $8,800 In-kind Time donated by Garden Volunteers:416 hours @$10/hour Pending $4,160 INCOME TOTAL*: $20,960 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Advertising $850 Music and programs Family-friendly musical acts,including Hullabaloo and performances by youth theatre groups $4,550 Staffing Manager on Duty,Concert Manager,Two Program Managers $5,000 Garden maintenance Indirect costs for Garden maintenance and upkeep for the 13-night event series $6,000 Misc. Straw bales for audience seating $400 In-kind Time donated by Garden Volunteers:416 hours @$10/hour $4,160 EXPENSE TOTAL*: $20,960 Sudgui Form Yvur Total Income and Total Expenses should be equal. atinr4iiTw Dcparhncrd oflhe Treasury .. t�Internal Ncrcnue Sen9cc P. O. Box 2508 In reply refer to : 0248454921 Cincinnati OH 45201 Aug . 16, 2010 LTR 4ld8C ED 95-6120581 000000 00 00015416 BODC: TE QUAIL GARDENS FOUNDATION INC 230 QUAIL GARDENS DR ENCINITAS CA 92024-2707 017717 Employer Identification Number : 95-6120581 Person to Contact : MS. EVANS Toll Free Telephone Number : 1-877-829-5500 Dear TAXPAYER: This is in response to your Aug . 05, 2010 ) request for information regarding your tax-exempt status . Our records indicate that you were recognized as exempt under section 501 (c) (3) of the Internal Revenue Code in a determination letter issued in JULY 1963. Our records also indicate that you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section 509(a) (2) . Donors may deduct contributions to. you as provided in section 170 of the Code . Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. Please refer to our website www.irs .gov/eo for information regarding filing requirements . Specifically, section 6033(j) of the Code Provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the filinu due date of the third return for organizations required to file. If you have any questions , please call us at the telephone number shown in the heading of this letter . Sincerely yours, Michele M. Sullivan, Oper . Mgr . Accounts Management Operations I ATTACHMENT B RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF San Diego Botanic Garden WHEREAS, the San Diego Botanic Garden is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the San Diego Botanic Garden hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 25th day of March, 2016 f L) Joyce lder +Secretary, Board of Directors San Diego Botanic Garden ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATi IOP' COMMUNITY GRANT PROGRAM, � ORGAN'IZf.TIOP P/.W,E: Quail Gardens Foundation, Inc. IYLE OF GFJ.PT PROGRAM: Partial Underwriting of music and programs for 2016 Thursday Family Fun Nights U ER.STANnING OF INSURANCE REQUIREMENT_ - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Julian Duval Title: President and CEO Signature-'tl �- Date: EVALUATION FORM y= CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2013/14 Date 6/11/14 Organization: Quail Gardens Foundation, Inc. dba San Diego Botanic Garden Address: 230 Quail Gardens Drive City: Encinitas State CA Zip 92024 Phone: (760)436-3036,ext.202 Fax (760)632-0917 Email: idden.org State the goals and objectives of your project and whether they have been met. Goals: • Through San Diego Botanic Garden's summer event series,Thursday Family Fun Nights,provide family-0riented activities in an outdoor setting that encourage families to be together. • Offer people who are busy during the daytime an opportunity to visit a world-class botanic garden in Encinitas. F Showcase San Diego Botanic Garden as an educational and community resource. • Provide three Environmental Science Programs during three Thursday Family Fun Nights. Objectives: • Offer 13 acts,performances,and/or presentations to entertain and engage young families. • Provide staff and volunteers to supervise the Garden after hours on 13 Thursday evenings. • Market the events through social media,the Garden Quail Tracks newsletter,press releases,banners,and fliers. Create six"bids on"activity stations on three nights incentivized with a`passporP'system to encourage children to visit each station. How were the goals and objectives of your project measured? The goals and objectives were measured by whether or not we achieved them as outlined,by tracking overall attendance,by our staff and volunteers gathering informal feedback from our attendees and by tracking the number ofpeople participating in the Envimomental Science Programs. Who participated in the evaluation process? Staff, volunteers and visitors assisted in the evaluation process. How was the City's funding for this project utilized? The City's funding was used to help underwrite 9 musical performances or other entertainment during the summer Thursday Family Fun Night series, as well as some supplies to make puppets for our July 25, 2013 "Twilight Tales"puppet show. T:\CGP\O1 CGPTemplates+Forms\ARreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM RE-1 Civic ❑Arts Grant Request Amount: $5,000 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Adoptable Animal and Pet Therapy Animal Vests and Leashes ELIGISIUTY DETERMIU:TIC°" Identify the legal status of your organization: Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-2151583 ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION. Organization Name: Rancho Coastal Humane Society (Must match name filed under the Tax/Employer Identification Number) Street Address: 389 Requeza Street Encinitas, CA 92024 Mailing Address: 389 Requeza Street Encinitas, CA 92024 Doing Business as(dba)Name: Rancho Coastal Humane Society Please list the names and titles of the organization's Board of Directors: Dean Janis- Chair Susan Colross-Treasurer Michael Berg-Vice Chair Lou Palestini,Allison Andrews-Canter, Dawn Danielson-RVT Judi Sanzo-Secretary Sylvia Steding-Thieme,Vicki Armstrong, Gina McBride ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROURM 8Utri ARY AND ORGANIZATIONAL HISTORY; Summa of Program Limit to the space roved HISTORY- Summary 9 ( p provided):ed): Animal Adoptions-RCHS is a limited admission shelter,which enables us to keep adoptable animals until they can be placed with their new families. Each of the dogs,cats and bunnies is given a"second chance"for adoption,and a new opportunity to find a loving home. Pet Assisted Therapy-Pets make us laugh,they ease our troubles and enrich our lives. Research shows that pets are good for us both physically and emotionally. Pets have been found to lower blood pressure, reduce anxiety and increase relaxation in humans. For those of us who are ill or isolated,the simple presence of a pet can be invaluable.A visit from an animal can brighten someone's day or provide therapy to help them through a difficult time.The Rancho Coastal Humane Society(RCHS) Pet Assisted Therapy(PAT)Program introduces teams of volunteers and their trained therapy dogs to those people who can benefit most from spending time with animals. By recognizing that pets can contribute to healthier, happier and more fulfilling lives,our program offers help and hope to those who need it most. Organizational History: Rancho Coastal Humane Society(RCHS)was formed in 1960 by a group of hardworking volunteers, led by a group of hardworking volunteers, led by animal lover Maria K. Lloyd.The goal was and continues to be to care for the homeless animal L population of San Diego County and to educate the public about pet over-population and responsible companion animal care. Application Form, Page One of Two 1-- APPLICATION FOR FISCAL YEAR 2016-20V CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAI'.', E- Location: Rancho Coastal Humane Society and the North County region of San Diego County Total Est. Cost: 6000 Time Frame: 2016-2017 Number of Encinitas Residents Served: 5000 Fundraising Activity: © No ❑ Yes If yes, please explain: CONTACT INFORMATION ARID STATEMENTS. Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Nick Winfrey, Vice President of Planning and Development Mailing Address: 389 Requeza Street Telephone Number: 760.753.6413 Email Address: nwinfrey @sdpets.org 0 Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Nick Winfrey Title: VP of Planning and Development (Please print) Signature: Date: April 14, 2016 { MSr SEC-nON FOR 4FFICIAt.USE ONLY. Y. Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 0_0 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Rancho Coastal Humane Society PROJECT TITLE: Pet Therapy and Animal Adoption Awareness PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants,matching funds, in-kind donations of goods and services,ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Givnt City of Encinitas F, 10i2el Family Foundation Grant Program Pending $5,000 Grant Petco Foundation Confirmed $1,000 INCOME TOTAL*: $6,000 EXPENSE: List all projected expenditures. if you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Animal Vests Vests that advertise adoptable animals throughout the public $2,000 Pet Therapy vests Custom and personalized vests for our volunteer pet therapy animals $2,000 Leash Sleeves Custom leash sleeves to advertise animal adoptability $400 Volunteer aprons/shirts Volunteer aprons and custom emrboidered shirts for our volunteer teams-dog walkers,pet therapy volunteers $1,200 Dog Collars color coordinated colors to distinguish different"handling levels"needed for our adoptable animals $400 EXPENSE TO T RL*- $6,000 °i'° c 4 F c`rm Your Total Income and Total Expenses should be equal. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 = CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION = COMMUNITY GRANT PROGRAM ' ORGANIZATION NAME: Rancho Coastal Humane Society TITLE OF GRANT PROGRAM: Program awareness - Adoptions and Pet Therapy UNDERSTANDING OF INSURANCE REQUIREMENTS ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Nick Winfrey Title: VP of Planning and Developr� Signatur•' _ Date: April 14, 2016 +{ Inlemel Rt" nuo Service Department of the Treasury , D rams P.O.Ow 23%Los Ant is.wilt 9M3 Dirr e4or Rancho Coastal Humans Society Pprse"in C+ t1,oc R Gilda Lewis Tdephorw Nunbr Encinitas, CA J"007 - 1213)994-2336 Q fL� !� Raier Amply to: 83022895 1;2 0 2 ff Dnfe., March 2, 1595 RE: Rancho Costal Nuawne Society EIN: 95-2151583 War 'Taxpayer: This letter is in responne to your request for a copy of the determination letter for the above named organization. Our records indicate that thin: organization was recognized to bo +"xe t frog Fedoral Incoss Tax in Jul 1960 as described ttt Internal Rerenus Cone Section 501(c) (3) . it Jr- further classified ae an organization that iw not a private foundation as defined in Section 509(a) of the cods, b9caung it is an organization doacribed in section 170(b) (1) (A) (vi) . The €x*vVt statur for tho determination loo+tier .issued in July 1960 continues to bas in effect. If You nerd further a sssirtance, please contact our office at the: abov& address or telephone nunber. Sinc#srely, Gilda L,-wju bii$closure Assistant RANCHO COASTAL HUMANE SOCIETY Swft sa*wm Cdf mie shcs 1960 MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF RANCHO COASTAL HUMANE SOCIETY WHEARAS,The Rancho Coastal Humane Society is a legally constituted Non-Profit 501(c)3, under the laws of the State of California,and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED,that the Board of Directors of Rancho Coastal Humane Society hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 16th day of March,2011 Jim Silveira President and CEO Rancho Coastal Humane Society EVALUATION FORM _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015-16 Date /S Organization: Rancho Coastal Humane Society Address: 3n City: Fn c.i APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY T FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. ❑Civic X Arts Grant Request Amount: $5,000 Free of Charge: ❑ Yes it No (Not to exceed$5,000) Program Title: Rock n' Roll Camp for Girls Summer 2016 ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: ff Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 47-5488897 ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Rock n' Roll Camp for Girls San Diego (Must match name filed under the Tax/Employer Identification Number) Street Address: Mailing Address: PO Box 232342, Encinitas, CA 92023 Doing Business as(dba) Name: Please list the names and titles of the organization's Board of Directors: Melissa Grove, President Allison Reed, Secretary Sandy Haasis, Vice President Kim Arnett, Treasurer ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): According to Real Girls, Real Pressure: National Report on the State of Self-Esteem by the Dove Self Esteem Fund, seven in ten girls believe they are not good enough or do not measure up in some way. With a mission to empower girls through music education, Rock n' Roll Camp for Girls San Diego will host a weeklong day camp in Encinitas this summer for girls ages 8 to 17. In one week of camp,the girls will form bands, learn instruments, create original songs and perform live! No prior musical experience is required. Our camp environment will foster creativity while nurturing self-esteem and self-expression. Our campers will use music as a powerful way to communicate and collaborate while being guided by inspirational female mentors. In addition to receiving music coaching, the girls will also learn about topics such as self-defense, body image, community impact, and media literacy. Rock n' Roll Camp for Girls San Diego is using a proven model;we are one of over 70 member camps from around the world in the Girls Rock Camp Alliance(www.grca.org). As a young San Diego rocker who participated in the 2015 Los Angeles camp,9-year-old Sienna Carlston described the camp as,"the best week of my life!" We are excited to welcome 40 young rockers to our inaugural San Diego County camp, which is confirmed to take place July 25-29 at Evenlife Fellowship in Encinitas. We need your help to make it an incredible experience! Organizational History: Encinitas resident Melissa Grove participated in and experienced the impact of Girls Rock Camp LA. She gathered a team of musicians and nonprofit professionals to bring this amazing opportunity to girls in SD County. The organization has recruited a board, launched a website and started enrollment. We are now very focused on camper recruitment in Encinitas. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Evenlife Christian Fellowship, 777 Santa Fe Dr., Encinitas, CA 92024 Total Est. Cost: $38,000 Time Frame: July 25-29, 2016 (finale performance on July 30) Number of Encinitas Residents Served: 160 Fundraising Activity: A No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Melissa Grove, President Mailing Address: PO Box 232342, Encinitas, CA 92023 Telephone Number: 760.456.9168 Email Address: rockcampforgirlssd @gmail.com ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Melissa Grove Title: President (Please print) Signature:— t T_.+. � LC L'. Date:gII5 h(Q THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed &dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 4 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Rock n' Roll Camp for Girls San Diego PROJECT TITLE: Summer Camp 2016 PROGRAM BUDGET Before you be+Iin,I-lease refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Tuition Camper Registration Fees($350 per camper x 40 campers) Being Collected $14,000 Scholarships Financial Aid (average$200 per camper in need x 15 campers) Committed -$3,000 In-Kind Music Coaches/Mentors(40 volunteers x 4 hours per day x 5 days x$25 per hour) Committed $20,000 Ticket Sales Finale Showcase ticket sales($10 per ticket x 200 tickets) Pending $2,000 INCOME TOTAL*: 1$38,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Instrument Rental Guitars, Basses, Drum Kits,Microphones, Keyboards,and Amps $4,000 Site Rental Rental fee Evenlife Christian Fellowship July 25-29 $3,000 Camper Materials Name badges,t-shirts,water bottles,composition books,silk screening materials $2,500 Background Checks All volunteers must complete fingerprinting/background check($75 per volunteer x 40 volunteers) $3,000 Camp Insurance Summer music camp liability policy K&S $2,000 In-Kind Music Coaches/Mentors(40 volunteers x 4 hours per day x 5 days x$25 per hour) $20,000 Bank Charges Credit card processing(3%x$10,000 tuition) $300 Venue Fee Finale Showcase venue fee $2,000 Volunteer Expenses Volunteer food,t-shirts,manuals,and training session $1,200 EXPENSE TOTAL*:,$38,000 Budget Form *Your Total Income and Total Expenses should be equal. ATTACHMENT A INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 NOV 1 9 Employer Identification Number: Date: 2015 47-5488897 DLN: 26053720002745 ROCK N ROLL CAMP FOR GIRLS SAN Contact Person: DIEGO CUSTOMER SERVICE ID# 31954 PO BOX 232342 Contact Telephone Number: ENCINITAS, CA 92023-0000 (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 509(a) (2) Form 990/990-EZ/990-N Required: Yes Effective Date of Exemption: November 3, 2015 _ Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c) (3) . Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests, devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your exempt status. Please keep it for your records. Organizations exempt under IRC Section 501(c) (3) are further classified as either public charities or private foundations. We determined you're a public charity under the IRC Section listed at the top of this letter. If we indicated at the top of this letter that you're required to file Form 990/990-EZ/990-N, our records show you're required to file an annual information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard) . If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked. If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter 114221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 5436 ATTACHMENT B Rod ROLL kt jQti Girls SAN Empowering Girls Through Music RESOLUTION OF THE BOARD OF DIRECTORS OF ROCK N' ROLL CAMP FOR GIRLS SAN DIEGO WHEREAS, Rock n' Roll Camp for Girls San Diego is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Rock n' Roll Camp for Girls San Diego hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 10th day of April, 2016 Allison Reed Secretary, Board of Directors Rock n' Roll Camp for Girls San Diego ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Rock n' Roll Camp for Girls San Diego TITLE OF GRANT PROGRAM: Summer Camp 2016 UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Melissa Grove Title: President 5 ' ' Signature:- _ A Date- 1 APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY L:11 '� pit, UJA FOUNDATION COMMUNITY GRANT PROGRAM CIS ` L-LE-." r r. r CATEGOFf11:-Czr3�tt r ues i {�j o� yo'.tateg .C" o�ptl�s�ropram'�O� _�ify,o o lion.' 4 rl. '. ❑Civic i Arts Grant Request Amount: $5,000 Free of Charge: ❑ Yes No (Not to exceed$5,000) Program Title: Baroque at the Library -EUGI�#I�JTY�E_TERAiflMATI�N 0 Ly'Af'rt�rrV6(tax-exerr Pf drq�rtiiation5 Y$P 7Y` `'" !"�. Identify the legal status of your organization: ■ Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 47-5557122 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. Organization Name: San Diego Baroque Soloists (Must match name riled under the Tax/Employer Identification Number) Street Address: 434 Jolina Way,Encinitas, CA 92024 Mailing Address: 434 Jolina Way, Encinitas Ca 92024 Doing Business as(dba) Name: San Diego Baroque Soloists Please list the names and titles of the organization's Board of Directors: Pierre Joubert 434 Jolina Way , CA 92024 Kevin McGoff 532 Broadway#6, El Cajon,CA 92021 Alan Dominicci 4105 Del Mar Trails Road,San Diego, 92130 ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. Summary of Program (Limit to the space provided): The San Diego Baroque Soloists main aim is to to brie high quality professional performances of Baroque instrumental music to the San Diego region and in particular Encinitas and North County. Between September 2016 and September 2017 we are planning a series of 4 concerts at the Encinitas Library. The first concert will feature music associated with Shakespeare who died 400 years ago in 1616 . Early in December we are planning a concert of Christmas music with a Latin American flavor and early in 2017 a concert featuring the 'Art Of Fugue' by J.S.Bach. Our season will conclude in May 2017 with a program of music by Handel, Purcell and their English contemporaries. The concerts will take place on Sunday afternoons and will be preceded by a talk and discussion about the program. Any funding will be used to help us keep ticket prices low and to encourage as wide an audience as possible to experience the world of Baroque Music and to hear it performed on original Baroque instruments in the appropriate style. Organizational History: The SDBS was formed in 2015 by 4 professional musicians and was granted non-profit status in November. They have performed in several venues in San Diego and individually members have performed all over North America and worldwide. Application Form,Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 =� CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM �RQGJIAM Location: Encinitas Library Total Est. Cost: $10,000 Time Frame: September 2016 - May 2017 Number of Encinitas Residents Served: 400 + Fundraising Activity: 0 No ❑ Yes If yes, please explain: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Kevin McGoff, Secretary to the Board of Directors Mailing Address: 532 Broadway#6. El Cajon, CA 92021 Telephone Number: 404 864 7279 Email Address: brokmcgoff @aol.com ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Pierre Joubert Title: SDBS Board Chairman (Please print) Signature Date: 04/13/2016 Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM vRGANIZATION NAME: 5C�A_ J, i f&�ll&D U�ti :il� -5-0t 013+S PROJECT TITLE: 1)tur�) PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending Ticket sales full price, Seniors 0 under 15s Pending Printing Programs Printing donated by SDSU Secured Reduced fees Musicians donating a part of ees for the project Secured INCOME TOTAL*: $ C)o - 5b EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Musicians Fees for 4 concerts Printing Posters, and postcards usic Sheet Music for 4 concerts Insurance is ility Insurance. Transportation Harpsichord and large instrument transport. EXPENSE TOTAL*: $ q'0a Aget Form *Your Total Income and Total Expenses should be equal. ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION 7%, COMMUNITY GRANT PROGRAM ORGANIZATION NAME:—;504\- �G�J _ c�-0 � TITLE OF GRANT PROGRAM: e cL+ UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000)for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4)Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Title: SDBS Board Chairman Signatu Date: 04/13/2016 INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: NOV 1 8 2015 47-5557122 DLN: 26053717002205 SAN DIEGO BAROQUE SOLOISTS Contact Person: 434 JOLINA WAY CUSTOMER SERVICE ID# 31954 ENCINITAS, CA 92024-0000 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 509 (a) (2) Form 990/990-EZ/990-N Required: Yes ffective Date of Exemption: November 11, 2015 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We're pleased to tell you we determined you're exempt from federal income tax under Internal Revenue Code (IRC) Section 501(c) (3) . Donors can deduct contributions they make to you under IRC Section 170. You're also qualified to receive tax deductible bequests, devises, transfers or gifts under Section 2055, 2106, or 2522. This letter could help resolve questions on your exempt status. Please keep it for your records. Organizations exempt under IRC Section 501(c) (3) are further classified as either public charities or private foundations. We determined you're a public charity under the IRC Section listed at the top of this letter. If we indicated at the top of this letter that you're required to file Form 990/990-EZ/990-N, our records show you're required to file an annual information return (Form 990 or Form 990-EZ) or electronic notice (Form 990-N, the e-Postcard) . If you don't file a required return or notice for three consecutive years, your exempt status will be automatically revoked. If we indicated at the top of this letter that an addendum applies, the enclosed addendum is an integral part of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter 114221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 5436 -2- SAN DIEGO BAROQUE SOLOISTS Sincerely, .f Jeffrey I. Cooper Director, Exempt Organizations Rulings and Agreements Letter 5436 Resolution of the Board of Directors of SAN DIEGO BAROQUE SOLOISTS WHEREAS, San Diego Baroque Soloists is a legally constituted corporation under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW,THEREFORE, BE IT RESOLVED, that the Board of Directors of San Diego Baroque Soloists hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016 - 2017 Fiscal Year. Adopted on this 4th day of April, 2016 Kevin G. McGoff Secretary, Board of Directors San Diego Baroque Soloists APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. ❑Civic Arts Grant Request Amount: 5000 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Encinitas Student Film Festival and Symposium ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: ■Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 80-0828986 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: San Diego Filmmakers (Must match name filed under the Tax/Employer Identification Number) Street Address: Mailing Address: Doing Business as (dba) Name: San Diego Filmmakers Please list the names and titles of the organization's Board of Directors: Francine Filsinger, President Kathleen Scott, Treasurer Bonnie Kristell, Secretary 6 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The San Diego Filmmakers(SDF)are submitting this grant on behalf of the Encinitas Student Film Festival and Symposium(ESFF). The ESFF is sponsored by the Encinitas Art Commission. There are two events;the film festival and the symposium. The festival provides a forum for students to screen their films. The symposium offers students a comprehensive filmmaking learning opportunity and teaches filmmaking from a hand on approach. Students have an opportunity to learn from experts through workshops and see the filmmaking process from pre to post production. Encinitas students are invited to screen their films at the festival. The ESFF is unique because not only do students get to screen their films, but the older students have the opportunity to learn from the best in the business including Emmy award winners,cinema professors, principles of production companies, award winning actors and a former CNN Bureau Chief. At the first event,there were 300 attendees at the festival and 220 at the symposium. We expect to have 600 attendees at the event in April 2016. We expect attendance to increase again at the 2017 event. The ongoing annual event mission is to provide students the opportunity to learn about a career in filmmaking such as videography, lighting, editing, acting, directing, etc... Organizational History: San Diego Filmmakers was established in September 2005 to create a synergistic resource for professional filmmakers. We encourage student filmmakers through scholarships and experience based learning opportunities. Monthly workshops with guest speakers are open to the public and highlight the various aspects of the art of filmmaking. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Community Center and La Paloma Theatre, Encinitas, California Total Est. Cost: 23,000 Time Frame: 2 days Number of Encinitas Residents Served: 1000 Fundraising Activity: A No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Francine Filsinger, President, San Diego Filmmakers Mailing Address: 5858 Mount Alifant Dr#130 Telephone Number.. Email Address: francine @sdflmmakers.org • Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. 1 hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Francine Filsinger Title: President (Please print) j Signature: ` ft���� �2� Date: 4/12/16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements:en Yes I 1 No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Diego Filmmakers PROJECT TITLE. Encinitas Student Film Festival and Symposium PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Grant County of San Diego-Community Enhancement Grants Pending $7,000 In Kind City of Encinitas-Community Center Secured $3,000 In Kind 20 workshop leaders,cast and crew($400 per day,per person) Secured $8,000 INCOME TOTAL*: $23,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST In Kind Community Center for symposium-rental $3,000 Theatre rental Theatre rental-La Paloma $2,000 Equipment rental Theatre supplies(red carpet,table cloths,cutlery,centerpieces) $400 Catering Breakfast and lunch $2,500 Meals-instructors Meals-Keynote speaker(2 days for 2 people at$50 per day) $200 Hotel-instructor Hotel-Keynote speaker(2 nights) $250 Gas stipend-instructors Gas stipend for keynote speakers $250 Printing and Advertising Flyers,agendas,brochures,poster($600),advertising($500) $1,100 In Kind 20 workshop leaders,cast and crew($400 per day,per person) $8,000 Trophies Trophies and certificates $1,200 PA system rental Professional PA system with technician $400 Videographer Videographer/Editor(2 people x$400) $800 Photographers Event photographers(2 people x$400) $800 quipment rental Professional projector,monitors,grip truck $1,600 insurance Insurance $500 EXPENSE TOTAL*: $23,000 Budget Form Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: �� �y 80-0828986 Z t ; DLN: 17053215383022 SAN DIEGO FILMMAKERS Contact Person: 8969 KENAMAR DR STE 104 DAVID SCHAEFF ID# 31691 SAN DIEGO, CA 92121-2453 Contact Telephone Number: (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 170 (b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: April 26, 2012 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Sincerely, ;4 V Director, Exempt Organizations Enclosure: Publication 4221-PC Letter 947 (DO/CG) Resolution from Board of Directors authorizing grant application RESOLUTION OF THE BOARD OF DIRECTORS OF SAN DIEGO FILMMAKERS WHEREAS, the San Diego Filmmakers is a legally constituted non-profit entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the San Diego Filmmakers hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 17th day of March, 2016 Francine Filsinger President, Board of Directors San Diego Filmmakers ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION . Ai COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Diego Filmmakers TITLE OF GRANT PROGRAM: Encinitas Student Film Festival and Symposium UNDERSTANDING OF INSURANCE REQUIREMENTS ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shalt have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Francine Filsinger Title: President Signatur4_. Date' 4/12/16 APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two cateqories: Civic or Arts proqram. Choose only one option. ❑Civic Arts Grant Request Amount: $5,000 Free of Charge: F Yes ❑ No (Not to exceed$5,000) Program Title: Provide free San Diego Symphony Orchestra Berton Family Young People's Concert tickets to Encinitas children ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: V Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-2040874 0 IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: San Diego Symphony Orchestra Association (Must match name filed under the Tax/Employer Identification Number) Street Address: 1245 Seventh Ave., San Diego, CA 92101 Mailing Address: 1245 Seventh Ave., San Diego, CA 92101 Doing Business as (dba) Name: San Diego Symphony Orchestra Please list the names and titles of the organization's Board of Directors: Warren O. Kessler, M.D., Chair of the Board David Snyder, Esq., Vice-Chair Sam Ersan, Vice-Chair James Wendler, Treasurer Deborah Pate, Vice-Chair Kathleen S. Davis, Secretary ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Designed for children ages seven and up, the San Diego Symphony Orchestra's Berton Family Young People's Concerts utilize mixed media, dramatic elements and classical music performance to address a wide variety of topics in the sciences and literary arts. Studies have shown that early access to music affects parts of the brain associated with logic, reasoning and critical reading skills. Berton Family Young People's Concerts contribute to a more well-rounded education. The San Diego Symphony Orchestra requests a $5,000 grant to help provide free Berton Family Young People's Concert tickets for 1,000 Encinitas children and their chaperones. The San Diego Symphony Orchestra will provide the necessary bus transportation from Encinitas to the Joan and Irwin Jacobs Music Center. Organizational History: Since 1910, the San Diego Symphony Orchestra has become one of the country's leading orchestras. It is committed to providing music experiences of superior quality for the greater San Diego community.Through a rich mixture of innovative and educational programming,the Symphony makes music an integral part of the cultural and intellectual fabric of the San Diego region. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Joan and Irwin Jacobs Music Center Total Est. Cost: $9581 Time Frame: October 2016-April 2017 Number of Encinitas Residents Served: 1,097 Fundraising Activity: W. No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Todd R. Schultz, VP for Institutional Advancement Mailing Address: 1245 Seventh Ave., San Diego, CA 92101 Telephone Number: 619-615-3902 Email Address: kkrumdieck @sandiegosymphony.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the '"mation contained in this application is true and correct, to the best of my knowledge, and that I am authoriz by �e organization named herein to make such representations and statements in this application. , Contact Person: T%'d �. Schultz Title: VP for Institutional Advancement (I'lease print) 4 Signature: ,� � � . _ Date: w THIS SECTION FOR OFFI&AL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Diego Symphony Orchestra Association PROJECT TITLE: Provide free San Diego Symphony Orchestra Berton Family Young People's Concert tickets to Encinitas children PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $5,000 Matching Funds Fund-A-Bus Campaign Secured $4,581 INCOME TOTAL*: $9,581 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Bus Transportation Transport Encinitas children to the Joan and Irwin Jacobs Music Center $4,581 Young People's Concert tickets $5/ticket for 1,000 children(chaperones included) $5,000 EXPENSE TOTAL*: $9,581 Budget Form *Your Total Income and Total Expenses should be equal. I R S Department ofthe Treasury InternalIteveliue Service P .O . Box 2508 In reply refer to : 0248164798 Cincinnati OH 45201 Mar . 31 , 2011 LTR 4168C EO 95-2040874 000000 00 00015588 BODC: TE SAN DIEGO SYMPHONY ORCHESTRA ASSOCIATION 1245 7TH AVE ; { SAN DIEGO CA 92101-4302 000042 Employer Identification Number : 95-2040874 Person to Contact : Mr Bayer Toll Free Telephone Number : 1-877-829-5500 Dear Taxpayer : This is in response to your Mar . 22, 2011 , request for information regarding your tax-exempt status . Our records indicate that you were recognized as exempt under section 501 (c) (3) of the Internal Revenue Code in a determination letter issued in August 1949. Our records also indicate that you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section(s) 509(a) ( 1) and 170(b) ( 1) (A) (vi) . Donors may deduct contributions to you as provided in section 170 of the Code . Bequests , legacies, devises , transfers , or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106 , and 2522 of the Code . Please refer to our website www. irs . gov/eo for information regarding filing requirements . Specifically, section 6033(j ) of the Code provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the filing due date of the third return for organizations required to file . We will publish a list of organizations whose tax-exempt status was revoked under section 6033(j ) of the Code on our website beginning in early 2011 . 0248164798 Mar . 31 , 2011 LTR 4168C EO 95-2040874 000000 00 00015589 SAN DIEGO SYMPHONY ORCHESTRA ASSOCIATION 1245 7TH AVE SAN DIEGO CA 92101-4302 If you have any questions , please call us at the telephone number shown in the heading of this letter . Sincerely yours , S. A. Martin, Operations Manager Accounts Management Operations Si A N R I [ 6 9 ~. S Y P H U N Y Jar HJA L NG, MLIS C DIRECTOR RESOLUTION FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF THE SAN DIEGO SYMPHONY ORCHESTRA WHEREAS, the SAN DIEGO SYMPHONY ORCHESTRA is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the SAN DIEGO SYMPHONY ORCHESTRA hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 24th day of March, 2016 , Kathleen S. Davis Secretary, Board of Directors San Diego Symphony Orchestra ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Diego Symphony Orchestra Association TITLE OF GRANT PROGRAM: Provide free San Diego Symphony Orchestra Berton Family Young People's Concert tickets to Encinitas children UNDERSTANDING OF INSURANCE REQUIREMENT. - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to { make such represen atilons in this application. 1 Contact Person: c d R. Schultz VP for Institutional Advance Title. L Signature: _. Date: SAN UIEGU " SYMPHONY JAHJA LING, MUSIC DIRECTOR I'Y-Icnelic" �L1,'1'Ll,/c'c. 5 SHEARN H. PLATT, BOARD CHAIR EDWARD B. GILL,CHIEF EXECUTIVE OFFICER JOAN & IRWIN JACOBS,HONORARYCHAIRS State the goals and objectives of your project and whether they have been met. The San Diego Symphony Orchestra used the $2,000 in grant funds awarded by the City of Encinitas and the Mizel Family Foundation to successfully provide Encinitas students with 400 free tickets to a Berton Family Young People's Concert program (Coming to America) during the 2014-2015 concert season. At the turn of the 201h century, many people came from all over the world to visit, live and work in this country. The Coming to America Berton Family Young People's Concert featured music by famous composers who were born to immigrant parents, or who visited America and were inspired to write music based on their experiences. Pieces by Tchaikovsky, Gershwin and Copland, among others, were featured in concert performance. Young people are provided few, if any, opportunities to hear live orchestral music due to drastic school budget cuts. Funds are not available for musical instruments or music teachers. The Symphony believes that the younger it can introduce children to great music, the more likely those children will appreciate music for life and perhaps become musicians themselves. Helping the San Diego Symphony Orchestra provide 400 Encinitas schoolchildren free tickets to Berton Family Young People's Concerts emphasizes our shared commitment to the need for more comprehensive music programming. Berton Family Young People's Concerts contribute to a more well-rounded education. How were the goals and objectives of your project measured? The Symphony tracks the success of its education programs through quantitative and qualitative data analysis. Ticket invoices and attendance reports are used to determine the number of Encinitas students that take part in each Berton Family Young People's Concert performance. Following each concert, the Director of Education and Community Engagement surveys teacher chaperones via an online program evaluation for written feedback. The Director of Education and Community Engagement speaks with musicians following each Berton Family Young People's Concert to learn how they felt about the students' response/participation. The written and verbal information gathered is very helpful in planning more effective children's music programming. Letters and pictures from participating students, expressing their newfound enthusiasm for classical music, are the most treasured and valuable feedback of all. 1245 SEVENTH AVENUE, SAN DIEGO, CA 92101 TEL. 619.235.0800 FAX 619.235.0005 WWW.SANDIEGOSYMPHONY.COM APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM -Ft�- 4 ,I.� ❑Civic Arts Grant Request Amount: $5,000 Free of Charge: 1K Yes ❑ No (Not to exceed$5,000) Program Title: HEALING ARTS PROGRAM WITH SCRIPPS ENCINITAS REHABILITATION PATIENTS Identify the legal status of your organization: Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 20-5910283 ❑■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. s_ - Organization Name: SAN DIEGO SYNERGY ARTS NETWORK (Must match name filed under the Tax(Employer Identification Number) Street Address: 2487 Montgomery Avenue,Cardiff by the Sea,CA 92007 Mailing Address: 251 Barbara Avenue, Solana Beach, CA 92075 Doing Business as(dba)Name: Synergy Art Foundation Please list the names and titles of the organization's Board of Directors: Naomi Nussbaum President Patricia Frischer Secretary Darwin Slindee Treasurer X■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. evil J Summa of Program Limit to the space provided): Collaborating with Scripps Memorial Hospital Encinitas Rehabilitation Summary 9 ( P P ) Services,Synergy Art Foundation(SAF)will offer healing arts programming to inpatients and outpatients. The inpatients served include those recovering from brain injuries,strokes,spinal cord injuries, neurological disorders and multiple traumas. The outpatients include all of the above as well as Multiple Sclerosis,Parkinson's and Cancer. SAF will retain Denise McMurtrie,a seasoned healing arts professional to provide creative and innovative projects,different from previous years. Plan: 1 st Saturday of each month: 9:30-11:00-Acute Inpatient; 11:00-12:30-Community. 2nd and 4th Tuesday of each month: 4:00-5:30-Community;5:30-6:30-Acute Inpatient. A minimum of one Scripps Rehab.staff will be present for all sessions. If the number of participants per session exceeds 20,additional sessions will be added. SAF in collaboration with Scripps will refine and expand the research component to evaluate the effectiveness to patients/caregivers/staff. Scripps has become increasingly interested in the positive impact this program has had on these patients. Estimated number of participants 100-300(may include caregivers,space permitting).Scripps Marketing to design,print&promote program.Scripps hopes to mount exhibition. Organizational History: Synergy Art Foundation was established in 2003 in response to the disastrous impact on numerous artists by the firestorms. Since then,the Encinitas-based organization has provided grants to professional artists and arts organizations(all disciplines)in crisis. Additional grant fund arts educational programming to at-risk and under-served populations. Application Form,Page One of Two -= APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION'. ' Location: SCRIPPS MEMORIAL HOSPITAL, 354 Santa Fe Dr, Encinitas, CA 92024 Total Est. Cost: $6,000 Time Frame: 12- 18 month period Number of Encinitas Residents Served: tbd* Fundraising Activity: ❑ No i Yes If yes, please explain: Encouraging Scripps Encinitas Foundation to contribute through philanthropy CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Naomi Nussbaum, President Mailing Address: 251 Barbara Avenue, Solana Beach, CA 92075 Telephone Number: 858 204 2058 Email Address: nnartdl@gmail.com ❑ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that 1 am authorized by the organization named herein to make such representations and statements in this application. Contact Person: NAOMI NUSSBAUM Title: President (Please print) Signature: Date: 4/7/2016 THIS SECTION FOR OFFICIAL USE ONLY: - Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 _ CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM JRGANIZATION NAME: SAN DIEGO SYNERGY ARTS NETWORK PROJECT TITLE: HEALING ARTS PROGRAM WITH SCRIPPS ENCINITAS REHAB. PATIENTS PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & ,'E-irzel Poodly Foundation Gran' Progrom, raii)g $5,000 grant Synergy Art Foundation secured $1,000 in-kind Synergy Art Foundation-research component&report secured $450 in-kind Liability insurance(SAF) secured $558 in-kind Scripps Encinitas Rehabilitation Staff(approx.73 sessions) secured $4,370 in-kind Scripps Marketing-design,print,promote secured $400 in-kind Scripps Staff-research and evaluation secured $1,250 in-kind Scripps Encinitas Rehabilitation Services on-site meeting room secured in-kind INCOME TOTAL*: 1$13,028 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Materials Art supplies $500 Instructor fees 110 hours @$50 per hour(including instructor's preparation donation) $5,500 Insurance Liability insurance(SAF) $558 in-kind Synergy Art Foundation-research component&report $450 in-kind Scripps Encinitas Rehabilitation Staff(approx.73 sessions) $4,370 in-kind Scripps Marketing-design,print,promote $400 in-kind Scripps Staff-research and evaluation $1,250 in-kind Scripps Encinitas Rehabilitation Services on-site meeting room in-kind EXPENSE TOTAL*: $13,028 Budget Form *Your Total Income and Total Expenses should be equal. v { T S nDepartment of the Treasury y �j interal Revenue Service In reply refer to: 0441970785 OGDEN UT 84201-0038 Apr. 26, 2011 LTR 4168C EO 20-5910283 000000 00 00029793 BODC: TE SAN DIEGO SYNERGY ARTS NETWORK INC NAOMI NUSSBAUM _ 2487 MONTGOMERY AVE ' CARDIFF CA 92007-2105 004419 Employer Identification Number : 20-5910283 Person to Contact: EO Accounts Poll Free Telephone Number: 1-877-829-5500 Dear Taxpayer: This is in response to your Apr. 15, 2011 , request for information regarding your tax-exempt status. Our records indicate that you were recognized as exempt under section 501(c) (3) of the Internal Revenue Code in a determination letter issued in July 2007. Our records also indicate that you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section(s) 509(a) (1) and 170 (b) (1) (A) Cvi) . Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises , transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106 , and 2522 of the Code. Please refer to our website www. irs.gov/eo for information regarding filing requirements . Specifically, section 6033(j) of the Code provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the filing due date of the third return for organizations required to file. We will publish a list of organizations whose tax-exempt status was revoked under section 6033(j ) of the Code on our website beginning in early 2011 . ON 5 Meeting of Board of Directors of San Diego Synergy Arts Network (SDSAN) We, the undersigned, being all the directors of SDSAN, gather for the meeting of the Board of Directors of the corporation and consent to the holding of said meeting at 2487 Montgomery Avenue, Cardiff by the Sea on April 1, 2016, at 3:00 PM., and consent to the application of the 2016 City of Encinitas Community Grant and any and all business by the directors at the meeting, including, without limitation, the election of officers. Dated: April 7, 2016 Signature Naomi Nussbaum, President Signature Patrici rischer, Secretary 5 'I''131LFfE Darwin Slindee, Treasurer 2487 Montgomery Avenue, Cardiff by the Sea, CA 92007 Tel&Fax 760.943.0148 www.SDSAN.org Public Charity 501(c)3 EIN#20-5910283 ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM ORGANIZATION NAME:SYNERGY ART FOUNDATION TITLE OF GRANT PROGRAM: HEALING ARTS PROGRAM WITH SCRIPPS ENCINITAS REHAB.PATIENTS UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Naomi Nussbaum Title: President Y Signature: Date: 4/7/2016 I certify that the costs outlined in this request have been incurred in accordance with the approved project/program proposal as set forth in the grant agreement document and that the information is accurate and complete. HIS FORM CANNOT BE EMAILED OR FAXED,WE NEED AN ORIGINAL SIGNATURE. Name: Naomi B. Nussbaum ignature: EVALUATION FORM k. - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION - COMMUNITY GRANT PROGRAM FY2014115 Date 6/92015 Organization: SAN DIEGO SYNERGY ARTS NETWORK Address: 251 BarbaraAvenue City: Solana Beach State A Zip 92075 Phone: 8582042058 Fax 8585091155 Email: nnartdl@_gmailcam State the goals and objectives of your project and whether they have been met. Goals and objectives of this project were to provide healing arts to as many of the brain injured patients within Scripps Encinitas Rehabilitation Department as well as to Encinitas citizens suffering with brain injuries. We believe that providing an opportunity hike this facilitates healing and improves,in some cases,motor-brain coordination,as well as provides a safe and comforting environment for patients to express themselves through arL Without doubt we achieved all of these goals and objectives. A very simple questionnaire was given to each attendee after each class to complete indicating their value of the class. 100%indicated improvement in mobility,enjoyment, meaningful,decrease in stress. How were the goals and objectives of your project measured? Questionnaire is attached Some quotes from participants: "Very interesting and helps my mind work" "Relaxing and enjoyable" "Dramatically improved my mobility" "I didn't realize this would be so helpful....thank you" "I had so much fun...thank you" "Please keep this program going!" Who participated in the evaluation process? Most participants completed a questionnaire Instructor, Encinitas Rehab. Director and myself reviewed all questionnaires. T:\CGP\O1 CGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICATION FOR FISCAL YEAR 2016-2017 =~r CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories:Civic or Arts program. Choose only one option,. ❑Civic Arts Grant Request Amount: $5,000 Free of Charge: Z Yes ❑ No (Not to exceed$5,000) Program Title: Wenger Legacy Classic Acoustic Band Shells for San Dieguito High School Academy ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply, Identify the legal status of your organization: X Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0629427 0 IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: San Dieguito Academy Foundation (Must match name filed under the Tax/Employer Identification Number) Street Address: 800 Santa Fe Drive Encinitas, CA 92024 Mailing Address: P.O. Box 235109 Encinitas, CA 92023 Doing Business as(dba) Name: Please list the names and titles of the organization's Board of Directors: Patrick Mock-President Rhea Stewart- Director Robert Zimmer-CFO Mary Page- Director Fran Goldstein -Secretary Carol Parker- Director ❑■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): San Dieguito Academy Foundation(SDAF)is requesting funds to buy 2 new Wenger Legacy Classic Acoustic Band Shells to replace broken shells of the 8 we have on campus at San Dieguito High School Academy(SDA.) These shells are extremely valuable for our musical performances and provide wide community benefit. Their main purpose is to project the sound from the stage area to the audience area.This is especially helpful in spaces that are not designed with performance acoustics in mind(i.e.gymnasium,multi-purpose room.)The acoustic sound shells at SDA are almost 15 years old. Over time,the shells have become damaged and/or worn down and pose a safety hazard given their age and use.We are working with the SDA principal to secure site and district funds,as well as with the SDA Music Boosters and other matching grant opportunities to replace all 8 shells.This will ensure a rewarding and safe listening experience for the SDA and Encinitas community for years to come. These band shells are essential in many of the school-wide performances such as Battle of the Bands, SDA Music concerts,and other Associated Student Body(ASB)events.The community has benefitted from performances on our campus,including concerts with George Winston, Eddie Vedder,the iPalpiti Orchestra,Encinitas Arts Festival and the Coastal Communities Concert Band that we host on campus each spring. Organizational History: SDA Foundation is a 501(c)3 non-profit educational foundation with a mission to collaborate to enrich every student's experience at San Dieguito High School Academy. Entering its 21st year,the Foundation's vision is to provide an enriched educational experience through programs and activities not otherwise available for every San Dieguito High School Academy student. Application Form,Page One of Two - APPLICATION FOR FISCAL YEAR 2016-2017 _. CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: San Dieguito High School Academy Total Est. Cost: $18,449 Time Frame: 2016-17 school year Number of Encinitas Residents Served: 2,800+ Fundraising Activity: 1K No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Leslie Saldana- Executive Director Mailing Address: P.O. Box 235109 Encinitas, CA 92023 Telephone Number: 760-753-1121 x5152 Email Address: sdafoundation @sduhsd.net X■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Leslie Saldana Title: Executive Director (Please print) Signature: �-'�G== �zL'� Date: 4/14/16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Dieguito Academy Foundation PROJECT TITLE: Wenger Legacy Classic Acoustic Band Shells for San Dieguito High School Academy PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.') TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Matching Fund San Dieguito Union High School District Pending $5,000 Grant San Diego County Neighborhood Reinvestment Grant Pending $5,000 Donation San Dieguito High School Academy(SDA)-Music Boosters Pending $3,000 In-Kind SDA Foundation-Coordination of procurement/receipt/installation;Leslie Saldana(5 hrs x$30/hr) Pending $150 In-Kind SDA Staff-Coordination of procurement/receipflinstallation;Jeremy Wuertz,Music Director(5 hrs x$431hr) Pending $215 In-Kind SDA Staff-2 custodians for support of delivery/set-up/storing;(2 hrs x$42/hr) Pending $84 INCOME TOTAL*: $18,449 EXPENSE List all projected expenditures.if you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Equipment Purchase of 8 Wenger Legacy Classic Acoustic Band Shells $18,000 In-Kind SDA Foundation-Coordination of procurement/receipUinstallation;Leslie Saldana(5 hrs x$30/hr) $150 In-Kind SDA Staff-Coordination of pro curement/receipt/installation;Jeremy Wuertz,Music Director(5 hrs x$43/hr) $215 In-Kind SDA Staff-2 custodians for support of delivery/set-up/storing;(2 hrs x$42/hr) $84 EXPENSE TOTAL*: $18,449 Budget Form *Your Total Income and Total Expenses should be equal. , n Internal Revenue Service Department of the Treasury P. O. Box 2508 Date: May 23, 2005 Cincinnati, OH 45201 Person to Contact: SAN DIEGUITO ACADEMY FOUNDATION Kathy Masters ID#31-04015 % KATHY HORINE Customer SeQVice Representative 800 SANTA FE DR Tall Free Telephone Number: ENCINITAS CA 92024-3841 8:30 a.m. to 5:30 p.m. ET 877-829-5500 Fax Number:, 513-263-3756 Federal Identification Number: •33-0629427 Dear Sir or Madam: This is in response to your request of May 3, 2005, regarding your organization's tax- exempt status. In December 1994 we issued a determination letter that,recognized your organization as . exempt from federal income tax. Our records indicate that your organization'is currently exempt under section 501(c)(3) of the Internal Revenue Code. Our records indicate that your organization is also classified as a.public charity under sections 509(a)(1) and 170(b)(1)(A)(vi) of the Internal Revenue Code. Our records indicate that contributions to your organization are deductible under section 170 of the Code, and that you are qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Internal Revenue Code. If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely, AX4-0,AlApAj Janna K. Skufca, Director, TE/GE Customer Account Services F 0 U No A Ar I ON RESOLUTION OF THE BOARD OF DIRECTORS OF SAN DIEGUITO ACADEMY FOUNDATION AUTHORIZING GRANT APPLICATION WHEREAS, the San Dieguito Academy Foundation is a legally constituted non- profit entity, under the laws of the State of California, and in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the San Dieguito Academy Foundation hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-17 Fiscal year. Adopted on the 12`" day of April, 2016. t Fran Goldstein Secretary, Board of Directors jan Dieguito Academy Foundation ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:San Dieguito Academy Foundation TITLE OF GRANT PROGRAM: Wenger Legacy Classic Acoustic Band Shells for San Dieguito High School Academy UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Leslie Saldana Title: Executive Director 4/14/16 Signature---,.,-,,,,- Date: EVALUATION FORM _�UIN CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION `^ COMMUNITY GRANT PROGRAM FY2014/15 Date 5/21/15 Organization: San Dieguito Academy Foundation Address: 800 Santa Fe Dr City: Encinitas State CA Zip 92024 Phone: 760-753-1121 ext. 5152 Fax 760-943-3555 Email: sdafoundation @sduhsd.net State the goals and objectives of your project and whether they have been met. Our goals were: 1) to provide avenue to showcase both student and professionl artists in Encinitas 2) to demonstrate"art inaction"with workshops where artists could demonstrate their talents 3) to outreach to the community including the neighborhood surrounding our school especially Hispanic families 4) to showcase our students,our school and our music and art programs How were the goals and objectives of your project measured? Our goals were measured by the increased diversity of the performers and addition of new ethnic dance groups includingthe recently formed ballet folklorico featuring students from the local community, the introduction of professional artists demonstrating their talents in on-site workshops, and by an increase in the number of student groups from our local high school. Who participated in the evaluation process? The San Dieguito Academy Foundation Board and their Executive Director,the City Art Administrator and staff, the San Dieguito Academy staff attending and participating in the event and the performers and attendees who provided feedback during and after the event. How was the City's funding for this project utilized? Funding was used to pay for performer fees, sound and audio equipment and technicians, band coordination, dance floor material and custodial support. T:1 CGP 101CGPTemplates+Forms\Agreement Return Letter with forms.doc (011% APPLICATION FOR FISCAL YEAR 2016-2017 _ CITY OF ENCINITAS AND MIZEL FAMILY ` FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into"two categories: Civic or Arts program Choose only one option Grant Request Amount: $5000 Free of Charge: [I Yes F■J No (Not to exceed$5,000) Program Title: Demos Dialogue& Art Identify the legal status of your organization: Fill Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-3169585 C1� IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: San Dieguito Art Guild (Must match name filed under the Tax/Ernployer Identification Number) Street Address: 937 South Coast Hwy 101, Suite C 103, Encinitas,CA 92024 Mailing Address: Same Doing Business as (dba)Name: Same Please list the names and titles of the organization's Board of Directors: Carol Korfin, President Susan Schulte, Secretary Karen Fidel, First Vice President, Membership Grace Swanson, Public Relations Linda Me erred, Treasurer 411 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): SDAG will present visual art lectures, demonstrations& workshops by master art instructors at the Encinitas library Open to the community, the program will be held the 3rd Sunday for 2 hours, featuring all mediums: oil,acrylic, watercolor, mixed media, clay, glass and more. Participants learn new techniques and skills and engage with instructors who field questions. Classes reach out to all skill levels. SDAG's intention is to broaden an individuals base in art education and share the power and positive effect that art brings into the community. SDAG is very proud to share the"Demos, Dialogue & Art" program, which has been well received in the community at large. Organizational History: SDAG, formed in 1965, is dedicated to furthering artistic understanding and fostering growth of members and the community at large by promoting interest, education and skills in the visual arts. Application Form, Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Community Library Total $10,400 Time Frame: July 2016-June 2017 Number of Encinitas Residents Served: 350 Fundraising Activity: No Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS; Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Carol Korfin, President Mailing Address: 937 South Coast Hwy 101, Suite C103, Encinitas, CA 92024 Telephone Number: 760-942-3636 Email Address: president @sandieguitoartguild.com !1 Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Carol Korfin Title: President (Please print) Signature: �' u- t Date: 4.5.16 7 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) _Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: Yes C No Reasons: 'wppiica;ion corm, rage 1'wo o'1 wo APPLICATION FOR FISCAL YEAR 2016-2017 w1 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Dieguito Art Guild PROJECT TITLE: Demos, Dialogue & Art PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE E7nding US AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program $5,CO0 In-kind Room Rental,Encinitas Community Library(10 sessions x 4 hours x S30) S 1,200 In-kind Volunteer Assistance/Program Setup&Breakdown 110 sessions x 4 hours x 510) Secured s 400 In-kind Administrative/Accounting services for programs 130 hours.$10) Secured $300 In-kind Demos,Dialogue&Art-Planning/Artist Committee(10 sessions x 5 hours x$10) Secured $500 Class participant fee 10 sessions x 30 people @$10 pending $3,000 INCOMMTOTAL*: $10,400 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST DDA Instructors 10 sessions with workshop instructors lz'3 hours ea @$250 per session S2,500 Art Materials/Supplies Paper,canvas,watercolor,acrylic,oil,mixed media,gloves,tape,brushes,adhesives,dropcloths,aprons S4,1300 Printing/Marketing Flyers,posters,handouts 10 sessions @$50 $500 Hospitality 10 sessions @ S20 $200 In-kind Room Rental,Encinitas Community Library(10 sessions x 4 hours x$301 S 1,200 In kind Volunteer Assistance,Program Setup&Breakdown(10 sessions x 4 hours x$10) S 400 In-kind Administrative I Accounting services for programs (30 hours''?$10) $300 In-kind Demos,Dialogue&Art-Planning/Artist Committee(10 sessions x 5 hours x$10) S 500 EXPENSE TOTAL*: $10,400 "J ?1 FU'Iii Your Total Income and Total Expenses should be equal. MEETING OF THE BOARD OF DIRECTORS OF SAN DIEGUITO ART GUILD AUTHORIZING GRANT APPLICATION Whereas a meeting of the Board of Directors of San Dieguito Art Guild was held on March 28th, 2016 Whereby, a resolution was passed authorizing approval for filing a grant application for the City of Encinitas and Mizel Foundation Community Grant Program funding for the city's 2016/2017 Fiscal Year Adopted on this 28th day of March, 2016 Authorized by her signature to enter into any and all contractual obligations on behalf of this corporation President, Board of irectors INTERNAL REVENUE SERVICE DE�APTMENT CF THE TREASURY P. C BOX 25^8 CI"CINNATI, OH 452Li Employer Identification Number: Date NOV 95-3169585 N s 4 cu' It DLN- 17 S3341353onl SAN DIEGUI';0 ART GUILD :ontact Person: C!0 CHERYL EHI.ERS P?:TER A ORLE-1 IDd 31436 91 , ; JAST riWY ].^1 JTE r'-'01 Ln'.aI'r ^e:eph.,ne Number ENL�NlrAS CA 92C2% 18'1, 829-5500 Accounting Period Ending- August 31 Publi7 Charity Status: 1*70(b) (l) (A) (V:l Frr- 59C kequiied: Ye^r Effective Date of Exemption: December 9 2011 Contribution Deductibility: Yes Addendum Applies: Yea Dear Applicar,t. We are rleieed tc inf-_-m ,rc� r lha� u,r.c f rC_j_ iI,F_, .a t_ r fc r raK :xemp: status we aavE dete..m. :.. , snot I(— are exempt trim Federal income tax ..nder section 501(c) (31 of the Internay Revenue Code. Ccntrrbutions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers o+- gifts under section 2055 2106 cr 2522 Cf t*ie Code. Because this letrer could help resolve any quest_ons regarding your exempt status, you should keep, It _n y-�,i - permane:.r re�-crds Organ_zations exempt unr,er sec't_c._ 5:.1 .c- ;3r �t the Code are F. rther III,ssified is either public charrt�es or private foundations We determined that you are a public charity under the Code section(s) listed in the heading of this setter. Please see enclosed Publication 4221 PC, Compliance Guide for 501 c� (3) Public Charities, for some helpful informat_or, abo,:t your responsibilit.Ps as an exempt organizat.on. AN "ICGT'TT') iclly Paz Exflmp* i no. n. Enr t L4 FeL� ia' Lrdt2 ze.t��: ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ' ORGANIZATION NAME: San Dlegulto Art Guild TITLE OF GRANT PROGRAM: Demos, Dialogue & Art UNDERSTANDING OF INSURANCE REQUIREMENTS ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024, If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person; Carol Korfin Title: President Signature Date- 4.5.16 L EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION Go COMMUNITY GRANT PROGRAM FY2014/15 Date .tune 12,2015 Organization: San Diequito Art Guild Address: 937 S. Coast Highway 101, C103 City: Encinitas State CA Zip 92024 Phone: 760-942-3636 Fax Email: Sandieguitoartguild @hotmail.ccm State the goals and objectives of your project and whether they have been met. The goal was to reach out to the community and provide art education and hands on workshops in a variety of mediums. SDAG successfully met those goals and exceed our expectations with this program, Demos Dialogue &Art. (DDA) How were the goals and objectives of your project measured? By the attendance and participation of the community. The response was outstanding with every(10) classes filled to capacity. Who participated in the evaluation process? The community participants provided comments from each class and the results were tallied with regard to participation, needs and what they did not like about the program. We had no negative responses. The Program Manager's re-evaluated each Workshop and Demo and assessed future needs. How was the City's funding for this project utilized? Art Supplies, Instruction Fees,Administration, Printing T:\CGP\O 1 CGPTTemplates+Forms\Agreement Return Letter with Forms.doc - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts program, Choose only one-option. 0 Civic ❑Arts Grant Request Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Study Buddy program ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: A Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0016843 ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION; Organization Name: San Dieguito for Drug Free Youth (Must match name filed under the Tax/Employer Identification Number) Street Address: 937 Springwood Lane, Encinitas 92024 Mailing Address: same Doing Business as(dba)Name: San Dieguito Alliance for Drug Free Youth Please list the names and titles of the organization's Board of Directors: v4;Cott, Han-.on, Board PrP$iriQnt, American Lung Leticia Robles, Board member, Bilingual Educator Monica Moore, Board, Secretary, Moore Media Peggy Walker, Board member, Educator Scott Preece, Board Treasurer, Banker Kathy Lippitt, Board member, Public Health 0 Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM.SUMMARY AND ORGANIZATIQNAL HISTORY: Summary of Program (Limit to the space provided): The Study Buddy Program is a cross age peer mentor/tutor after school program for elementary school students who have educational andlor socio emotional needs that require extra attention which is provided by a teen mentor/tutor.The teen Study Buddy mentor/tutor has the opportunity to provide meaningful assistance to a younger student.The teen Study Buddys are trained in tutorial and listening skills,and learn the satisfaction that community service can bring.The Study Buddy program reinforces the societal expectation that teens are capable of engaging in significant good works during a time when teens are are often experiencing negative peer pressures. The Study Buddy directors(adults)are encouraged to interact with the teens to encourage their success as a Study Buddy. San Dieguito for Drug Free Youth has found that Study Buddy teens can be'adult poor'in their own lives, and the adult Study Buddy directors can be the adult that relates to the teens in a positive and interested manner. As part of the Study Buddy application process,the teen signs a Pledge to be alcohol,tobacco and drug free,and to model enthusiastic academic behavior. In addition to the Pledge,the application must be signed by the teen's parent and a high school counselor who can vouch for their reliability and maturity. Organizational History: San Dieguito for Drug Free Youth is a community based non profit serving the youth and families in the San Dieguito Union High School District,including the five feeder elementary school districts like the Encinitas Union School District. It was founded in 1985. Application Form,Page One of Two _ APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Ada Harris Elementary, Capri Elementary, Park Dale lane Elementary, Paul Ecke Elementary Total Est. CosO'10,000 Time Frame: August 2016-June 2017 Number of Encinitas Residents Served: 320 Fundraising Activity: N No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Judi Strang, Executive Director Mailing Address: 937 Springwood Lane, Encinitas 92024 Telephone Number: 858.382.6598 Email Address: judistrang @earthlink.net X Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Judith Strang Title: Executive Director (Please print) Signature: � � �(�CC% Date: 12 April 2016 Z THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Dieguito for Drug Free Youth PROJECT TITLE: Study Buddy program PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Donation Four elementary schools'PTA/parent groups Secured $2,000 In kind donation Service time donated by Study Buddy directors(2 per program at four elementary schools), Secured $3,000 San Dieguito for Drug Free Youth staff,school staff from high schools'staff from two-La Costa Canyon HS and San Dieguito Academy HS,and elementary school staff from four elementary schools INCOME TOTAL*: 1$10,000 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST In kind donation of time Service time donated by Study Buddy directors(2 per program at four elementary schools),San Dieguito for $3,000 Drug Free Youth staff,high school staff from La Costa Canyon HS and San Dieguito Academy HS,and elementary school staff from four elementary schools Donation Food for four Study Buddy programs x two semesters from 4 PTA/parent groups $2,000 Training materials Trainings for:1)120 elementary school students;2)120 high school students;3)8 Adult Study Buddy directors $992 which includes instruction packets x 248 people x 2.00 per semester x 2 semesters Teen applications copying 500 teen Study Buddy applications at$.10 copy(4 pages)per semester x 2 semesters $400 Progam forms Copying and mailing of Parent Permission forms(120),Students Reminder cards(120),Teen Orientation $425 cards (120)=360 cards x$.10/copy for printing&postage @.49/card x 2 semesters Teacher Referral forms 200 x$.10/copy(3 pages)per semester x 2 semesters $120 Certificates of completion(for End of program certificates with photos=120 certificates x$.30 x 2 semesters $72 elementary school students) and participation(for teens) Program supplies Pencils,papers,crayons,rulers,glue,worksheets,flash cards,name tags,educational games= $2,991 $374 approx per program x 4 programs/semester(12 weeks)x 2 semesters EXPENSE TOTAL*: $10,000 Budget Form *Your Total Income and Total Ex, enses should be equal. DepOftont of 111111 TfMUry District Dfrectar p a Box n5o Rt= 5127 417111 E.O. LOS AIIGELES. CA 900SWISb EorpioYar Identification llaabert n-00151142 Dense ,till's. 5, 1990 Cass Humbert 950081073 SAN 019GUI79 FOR DRUG-FACE YOUTH Contact !'arson+ rD elf 2"D Hamm,r ftlHr y UM DEL hip, CA 9"14 Contset Tel phi %- Numbers 42131 7116-611i1>f Accounting Paried Endinat Fern 990 Rewired* YES Addondutl Alrp I i ear t so Dear FpplIcantR SomW on lnfornatfen suispIled, end eanusIng your onerstifts i►1II be as stated In your spplleaflon for recognition of exemption, we hays determined . you are sxdwprt free Fadarai Income tax under section 501(a) of the Internal 14eve nue Code as an organ t a!st e a n d Kr l bsd In section fg014o:)4 32. sip have further daterninod that you are, not a prIYate foundation within the meaning of section 509%) of the Code, because you ■rp art orleniastion dsaerlbed in sect-16no 502ta)(t) and i7tl(b) (i)f i)tvi). If your sources of suppartp or your purpeeee, char*cteir, ar path" af operstion change, pfosse lot us knoll 110 sea can avoldiir the offset of the change on your exempt status and foundation status. in the case of an o end- Aant to your orpenlxationol document or bylsks, plamm send teas a copy of the smanded document or byfIa". Also, you shout Inform us of aI1 changes in your reams or sdrlreso. he of Jounrr It 3904, you are Ilable for tower LvW*r the Fo&rei tnaurance Contributions hot tooeisl socurity taKee) aim renounoratiot at stoo or norm you pay to each of your amp Ioyaem during a cmI-i ar year. You ore not liable for the tax lnpomed urtdar the Federal 11nmapioyaont tax stet (RUTA). '-$i rmo you are not a private foundation, you are not subject to the axtl sa fatxia 6n4ar.'-Chapter 42 of the Code. Remover, you era not mutaf at ical ly oximpt free-other F*daraI anal as taxes. If you have any 4untlOn* about onalse, amp la~t, or enter Federal towns, plan" let go knee. Doors new deduct eontributlom to you es lrroalded In section 170 of the Cods., Ssquesty, lepaelsi, dorisae, transferp, or gifts to you or for your usa arm deductible for Fadaral estate and gift tex purpomss if they poet the appl1oab1ft proneI10110ne Of God* Settiens SO'i39 2106, and EM. ContrI but ton deduetiores are alIouabIa to donors onIY to the octant that .ii-ir contributions are gifts, Kith no conalderatiotl rar.slvsd. Ticket pur- Latter 947{CG) San Dieguito Alliance for Drug Free Youth Providing alcohol, tobacco and other drug prevention programs and education in Cardiff, Carmel Valley, Del Mar, Encinitas, La Costa, Rancho Santa Fe and Solana Beach 8 March 2016 Board Resolution Be it resolved that the Board of Directors authorizes Judith Strang, Executive Director, to serve as the authorized representative of San Dieguito Alliance for Drug Free Youth San Dieguito Alliance is a legally constituted non profit under the laws of the State of California and is in complete control of its affairs through it own officers and members &6L�a__A' tW Kenneth Hanson, President Board of Directors PO Box 2448 Del Mar 92014 858.755.6598 (Phone/Fax) SDAlliance4 @aol.com www.sandieguitoalliance.org ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 -. CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME:San Dieguito for Drug Free Youth TITLE OF GRANT PROGRAM: Study Buddy UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Judith Strang Title: Executive Director 12 April 2016 Signature: Date. APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. �Civic ❑Arts Grant Request Amount: $5000 Free of Charge: IS Yes ❑ No (Not to exceed$5,000) Program Title: "Families Make History"Weekend Program ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: III Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0310885 X IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: San Dieguito Heritage Museum (Must match name filed under the Tax/Employer Identification Number) Street Address: 450 Quail Gardens Drive Encinitas, CA 92024 Mailing Address: same Doing Business as (dba) Name: Please list the names and titles of the organization's Board of Directors: Ralph Stone - President Cathy Bourdon -Secretary Kerry Witkin - Treasurer ■❑ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The San Dieguito Heritage Museum will continue to offer free history activities for families on Saturdays and Sundays. We are open every weekend where there is a free hands-on activity that highlights and teaches the children aspects of San Dieguito History and our heritage. The museum has hired an Education Specialist,Susan Love,who creates the arts&crafts projects. Susan has a degree in art education and has worked professionally as an artist and taught her own after-school art program for 15 years. This program has been running for 5 years and has become a regular monthly activity for a number of families. Organizational History: The San Dieguito Heritage Museum was founded in 1988 to collect, preserve and interpret the local history of the San Dieguito River area. The founders have deep roots in the community and the museum has continued to grow since it began. Application Form, Page One of Two . -' APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY y FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: The San Dieguito Heritage Museum at 450 Quail Gardens Drive in Encinitas Total Est. Cost: $20,000 Time Frame: Year Round, every weekend Number of Encinitas Residents Served: too monthly Fundraising Activity: A No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Barbara Grice, Executive Director Mailing Address: 450 Quail Gardens Drive Encinitas, CA 92024 Telephone Number: 760-632-9711 Email Address: barb @sdheritage.org • Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. 1 hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Barbara Grice Title: Executive Director (Please print) f Signature: ( CSZ- Date: 4/14/2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: F-1 I—J Yes ❑ No Reasons: Application Form, Page Two of Two Yt APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Dieguito Heritage Museum PROJECT TITLE: Families Make History PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Matching Funds San Dieguito Heritage Museum Secured $13,000 Grant Solana Beach Optimist Club Secured $750 In-kind Docent Time (100 hours @$10 hr) Secured $1,000 In-kind Materials from local businesses Secured $500 INCOME TOTAL*: 1$20,250 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Personnel Education Specialist (810 hours x$15) $12,500 Admin Support Museum Director and Secretary's Time $1,000 Materials Supplies for activities $1,000 Promotion Flier,print ads and mailings $6,000 Personnel In-kind docent time $1,000 Materials In-kind supplies for activities from local businesses $750 EXPENSE TOTAL*: $22,250 Budget Form *Your Total Income and Total Expenses should be equal. n§ I RS inlet im�n, th•l 'nisi r( Inu•rn:,l Kronur tirr�irr P.O. Box 2508 In reply refer to: 0248674156 Cincinnati OH 45201 Apr. 06, 2011 LTR 4168C EO 33-0310885 000000 00 00015977 BODC: TE SAN DIEGUITO HERITAGE MUSEUM 450 QUAIL GARDENS DRIVE ENCINITAS CA 92024 h2 706656 Employer Identification Number : 33-0310885 Person to Contact : MR. LAM Toll Free Telephone Number: 1-877-829-5500 Dear TAXPAYER: This is in response to your Mar. 28, 2011 , request for information regarding your tax-exempt status. Our records indicate that you were recognized as exempt under section 501(c) (03) of the Internal Revenue Code in a determination letter issued in MARCH 1990. Our records also indicate that you are not a private foundation within the meaning of section 509(x) of the Code because you are described in section(s) 509(a) (1) and 170(b) (1) (A) (vi) . Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. Please refer to our website www.irs.gov/eo for information regarding filing requirements. Specifically, section 6033(] ) of the Code provides that failure to file an annual information return for three consecutive years results in revocation of tax-exempt status as of the filing due date of the third return for organizations required to file. We will publish a list of organizations whose tax-exempt status was revoked under section 6033(j ) of the Code on our website beginning in early 2011 . 0248674156 Apr. 06, 2011 LTR 4168C EO 33-0310885 000000 00 00015978 SAN DIEGUITO HERITAGE MUSEUM 450 QUAIL GARDENS DRIVE ENCINITAS CA 92024 If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely yours, S. A. Martin, Operations Manager Accounts Management Operations RESOLUTION OF THE BOARD OF DIRECTORS OF THE SAN DIEGUITO HERITAGE MUSEUM AUTHORIZING THE GRANT APPLICATION FROM THE CITY OF ENCINITAS AND THE MIZEL FAMILY FOUNDATION RESOLUTION OF THE BOARD OF DIRECTORS OF The San Dieguito Heritage Museum WHEREAS,the San Dieguito Heritage Museum is a legally constituted non-profit Public benefit corporation under the laws of the State of California, and is in complete control of its affairs through it own officers and members, NOW THEREFORE,BE IT RESOLVED,that the Board of Directors of the San Dieguito Heritage Museum hereby approves the filing of an application for the City of Encinitas and the Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 14`h day of March,2016 Ralph Stone President, Board of Directors San Dieguito Heritage Museum ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION 6 . COMMUNITY GRANT PROGRAM r ORGANIZATION NAME: San Dieguito Heritage Museum TITLE OF GRANT PROGRAM: "Families Make History" UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Barbara GriCe Title: Executive Director 4/14/2016 Signature: ~~� f ` ;r'; 4 Date: 4 y SDHERI1 OP ID:JD CERTIFICATE OF LIABILITY INSURANCE D0 10212016 ) 02/02/2016 FTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 'ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Mike Walsh Johnson&Wood Ins Serv,A Div of Hub Int'l Ins Sery Inc PHONE N E:t:760-603-0131 PAC,No,:760-603-8135 5731 Palmer Way,Suite D E-MAIL Carlsbad,CA 92010 ADDRESS: Mike Walsh INSURERIS)AFFORDING COVERAGE _ _ NAIC_# INSURER A;Sentinel Insurance Cc Limited _ 11.0_0.0 _ INSURED San Dieguit0 Heritage Museum INSURER B: Inc 450 Quail Gardens Dr INSURER C: Encinitas,CA 92024 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVIS1014 NUMBER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS TYPE OF INSURANCE ADDL SUB POLICY NUMBER MMIDDY EFF MMIDDY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,00 A I!l COMMERCIAL GENERAL LIABILITY X 72SBAA07858 04/03/2015 04/03/2016 PREMISES Ea occurrence S 1,000,00_ _ I CLAIMS-MADE X OCCUR ME_O EXP(Any one person)_ $ 10,00 PERSONAL&ADV INJURY IS 2,000,00 GENERAL AGGREGATE $ 4,000,00 tN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,00 POLICY I PRO LOG $ AUTOMOBILE LIABILITY Ea acccidentSINGLE LIMIT SS ANY AUTO BODILY INJURY(Per person) $ ALL OS SCHEDULED BODILY INJURY Per accident S .)AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE -$ HIRED AUTOS AUTOS (PER ACCIDENT I - S UMBRELLA LIAR' OCCUR EACH OCCURRENCE $ EXCESS LIAB i CLAIMS-MADE I I AGGREGATE _ $ I OED I I RETENTIONS $ I WORKERS COMPENSATION WC STATU- OTH- 'AND EMPLOYERS'LIABILITY YIN I _T9RY LIMITS _ER ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-FA EMPLOYEE $ Uyes,describe under - -- - — - - DYSCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) City of Encinitas is named additional insured as respects General Liability per IH1200 1185, when required by written contract. CERTIFICATE HOLDER CANCELLATION CITYEN1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Encinitas ACCORDANCE WITH THE POLICY PROVISIONS. Parks 8,Recreation Attn: Patty Mackey AUTHORIZED REPRESENTATIVE 1140 Oakcrest Park Drive Encinitas CA 92024 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD How many Encinitas residents did you expect to serve through the project? In our application,we anticipated that we would serve about 2,000 local residents. How many Encinitas residents did you actually serve through the project? We anticipated that 50 guests would visit and participate in the weekend program. There are a few weekend each year the Museum is not open,or does not offer the Families Make History(45 weekends x 50 visitors)=2,250 visitors. Actual participants for 2014-15 match up with the number of visitors we projected, but we did not take into account that not all of our visitors are from Encinitas. However,the vast majority of guests are from Encinitas(in excess of 70%)and more than 90%of our visitors are from the communities that make up the San Dieguito region (Encinitas,Del Mar,Cardiff, Leucadia,Rancho Santa Fe,Solana Beach,and Olivenhain). Based on the outcome of this year's project,what changes/improvements will you make next year? We intend to increase the quality and complexity of the craft projects we offer for our guests,and to increase the historical interpretation between the craft activity and some aspect of our local heritage, perhaps by creating an age-appropriate story that will accompany the activity. We have given thought to expanding the Families Make History to include activities for adults such as weaving;or to partner with other local groups to create combined activities(e.g.,a partnered painting activity with Lux Art Institute). We continue to promote the weekend craft activity with elementary school groups that come to the Museum on field trips. We find that many of these students come back with their parents to spend more time investigating the Museum exhibits. We will continue to keep this a free activity,and will seek support from sources such as the City of Encinitas and the Mizel Family Foundation to cover associated expenses. Positive outcomes? Children and parents participating in an activity that does not involve anything electronic! Parents and especially grandparents enjoy telling their own stories about life'back then'to the children. Families enjoy an educational outing at no cost. This activity raises the profile of the Museum in the community. Negative outcomes? We have capacity to share this activity with many more children during the weekends,and our hope is that as word of mouth continues,we will grow this program. The program takes place out-of-doors on picnic tables next to the Museum. For most of the year,this works, but there are times when it is either too hot or too cold to stay outside. In those cases,the activity moves indoors to a less than optimal setting, losing some of the historical element that appeals to our visitors. - APPLICATION FOR FISCAL YEAR 2016-2017 w CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: San Elijo Lagoon Nature Center-2710 Manchester Ave., Cardiff-by-the-Sea Total Est. Cost: $30,120 Time Frame: July 3, 2016-June 4, 2016 Number of Encinitas Residents Served: 3,500 Fundraising Activity: W No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Doug Gibson, Executive Director/Principal Scientist Mailing Address: P.O. Box 230634 Encinitas, CA 92023-0634 Telephone Number: 760-436-3944 x 707 Email Address: Doug @sanelijo.org L� Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Doug Gibson Title: Executive Director (Please print) Signature: - Date: D � a 1-Iho� ✓dl� TI jfD�a G ��1r ICJ , �j��SGvv THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed & dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application norm, Page Two of I wo APPLICATION FOR FISCAL YEAR 2016-2017 , CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Elijo Lagoon Conservancy PROJECT TITLE: Family Discovery Days & Sunday Family Fun Days PROGRAM BUDGET Before you begin, please refer to the instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $5,000 Matching Funds San Elijo Lagoon Conservancy Secured $4,000 Matching Funds County of San Diego Parks and Recreation Secured $5,000 Matching Funds San Diego County Parks Society Secured $3,500 In-Kind SELC Volunteer Contributions Secured $9,720 In-Kind Birch Aquarium at Scripps Pending $250 In-Kind Jimbo's Pending $1,000 In-Kind Home Depot Pending $1,200 In-Kind Local retail stores Pending $250 In-Kind Zoological Society of San Diego Pending $200 INCOME TOTAL*: $30,120 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Program Administration Event planning and staffing $9,500 Printing Flyers,booklets,handouts $500 Publicitiy Media outlets,schools,community $625 Speaker/presenter fees Wildlife experts $2,000 Ed.Materials Poster boards, learning hands-on visuals,SDNHM specimens,crafts $1,700 Volunteers Prep for and help staff the event $9,720 Food Drinks and snacks $1,575 Supplies Bird houses,prizes,giveaways,native seeds $2,000 Shuttle Transportation Shuttle from Mira Costa College to event $2,500 EXPENSE TOTAL*: $M0,120 Budget Form *Your Total Income and Total Expenses should be equal. ATTACHMENT A +,. P .0 , Box WEI In r plj i ,. for try : 112486675dij Cincinnati 011 fi!s2U ! NOV . 21) , U L 11; '(1168C 1:0 7, {1',�r+• .i f 011100VIII 00 UOt) 1 U000 1)001.: It THE SAN f l 1 Jil L AG11O11 G"IlWI RVAW d PO BOX 2`3063ri E11LIN1 TAS CA 9,V'3 Ui 3i, Employer Identification Number : 3a 015106t•U Person to Lunlact : Mr . tool h.,rt Tell r r ee Telephone Number : I F,71 AW &&loo Ua ar Taxpayer : This is in rusponso to +four Nov . 17 , }UIU , r,.riluont nr iniar•matlon ragardinJ your tax exempt Status . Our records inclicakv thnt you wore rorur,ni . cl r,ini ( odc r suction hltl Cc) ( i) of the Internal Reveiu,. Cum, ill ri"t, ,, in..,llon letter is:,uetd in August 1093. Our records also inilicatc that you LL.r .. not . oil ", foundation viltl, in the mennina of section bUti( a) of the c` :dv bvt,. 1. •rUU "it deocribetl in uvirLion( s ) 51)4(.7) 11 ) n"d 17111b ) ( 1 ) cTt ► cvc ) . Danors way do duLt contributions to yo" pi ou dr d 1" 4, 1 ion 170 X71 the Code . 11er111val-s , legarics , dvvj00% , 1r ,in5Ivf ' , uu girt to Va" or for your use are deductible ror Tcderal ontate "nd s1i , t c , ficrrposo% if they, meet the applicable Provision ., or atctlo"% oqb , .' lflu , and 21?22 of the Cork-. Ploa5v refer to our website www. irs.nov/ vc for rnlr►rmalr I. reriardin,J f it ino rcauirements . Spur tttc<tl ly , . C 110a 00ki( ) ) r:f th ( Ode provldqs that failure to fill ,n an"u" t inlol`+.i -Ki I, r ,'tu, I, for thrc,' consecutive yearn rooul i n i n revocat i n„ o f t., ,; , r i f t n t . l u s an of the filing clue date of tltt' th3i d return irir' nr o.,ni .rt ion, required to rile. Wo. will publie,lt a lilt of Who— tax . tnipl status was revoked under section 606at .i 1 aii lh,- C'r..d, on our srobsi ti, beg.innincl In aarll/ ?011 . ATTACHMENT A 02g8667580 Nnv . :9 , 2010 LTR 4168C FO 33-03418660 U00000 00 00018601 1111: SAN EL IJO LAGOON CONSFRVAII.Y p finx no():i4 CNCINITAS CA 9,'023 061l It you have . try question„ please call u!.. It the tc■levhonp number drown in the beading of this letter . Sincerely ,yours , 111e1ele M. StilllvW1 , I]Per . tlgr . Accouni -. Up4triltions I Page 9 of 90 I' San Elijo Lagoon CONSERVANCY - _ Con nectim.,to�mmullities. M-otectirl, nalurc. A RESOLUTION ADOPTED BY BOARD OF DIRECTORS OF THE SAN ELIJO LAGOON CONSERVANCY On February 11, 2016 Grant Application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year WHEREAS, at a special meeting of the Board of Directors of the San Elijo Lagoon Conservancy on February 11, 2016 to take certain steps to transact such business as it shall deem necessary and proper; WHEREAS, a Grant Application to the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 fiscal year was considered; WHEREAS, the above item was put to a vote and it carried with written consent of the Board of Directors and was approved; BE IT RESOLVED that the Board of Directors of the San Elijo Lagoon Conservancy hereby approves the filing of a grant application for the city of Encinitas and Mizel Family Foundation Community Grant Program for the city's 2016-2017 Fiscal Year. IN WITNESS WHEREOF, I David Kramer, Secretary of the San Elijo Lagoon Conservancy, a nonprofit Public Benefit Corporation of the State of California, certify that the foregoing is a true copy of a resolution as it appears in the records of the corporation and was duly and legally adopted by unanimous written consent of the Board of Directors of the corporation on February 11, 2016, pursuant to and in accordance with the By-laws of said Corporation. By David Kramer Secretary, San El 4 agoon Conservancy ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION . - COMMUNITY GRANT PROGRAM ORGANIZATION NAME: San Elijo Lagoon Conservancy TITLE OF GRANT PROGRAM: Family Discovery Days & Sunday Family Fun Days UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Doug Gibson Title: Executive Director Signature:_ Date: y ��Ols (/U•�, �l7cf �✓Qh �5�41v� �J✓•. N7 �• l�'f'bcS�/►•�/ EVALUATION FORM ■. . CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2O14/15 Date ';Y zo � Organization: San Elijo Lagoon Conservancy Address: 777 S.Highway 101 City: Solana Beach State CA Zip 92075 Phone: 760-436-3944 x 701 Fax 760-944-9606 Email: tw sanehjo.org State the goals and objectives of your project and whether they have been met. The goal of these events was to expose and educate Encinitas residents about both the conspicuous and more elusive residents of the Reserve, and gain an appreciation of the value and beauty this coastal wetland provides to the community of Encinitas. The objective was to connect visitors to nature by offering interesting, informative, and inspirational experiences at the San Elijo Lagoon. Thousands of community members had the opportunity to enjoy three Family Discovery Day events designed to engage and educate Encinitas residents about the value of the Reserve and to promote ecological literacy and environmental responsibility. The goals and objectives were met by providing three free weekend events allowing families to enjoy the outdoors while learning about the important functions of their local wetland. How were the goals and objectives of your project measured? The goals and objectives were measured by our volunteer survey conducted after each event. Volunteers are asked to report public engagement, excitement and personal experiences from each activity they volunteered at. Volunteers are also asked to share any comments or questions community members shared during each event. It is frequently reported that families continually thank our volunteers for helping host such a wonderful free event and inquire about future events. Many residents who have never visited before leave with a better appreciation for protecting their local Reserve and an eagerness to return. Who participated in the evaluation process? County Staff, San Elijo Lagoon Conservancy staff and Board Members, County and Conservancy volunteers, along with San Dieguito High School students and California State University San Marcos students. How was the City's funding for this project utilized? Speaker/presenter fees, PR and printing costs, educational and craft materials, and program administration. T:\CC'TP\Ol CGPTemnlates+Forms\Agreement Return Letter with forms.doc /0%, APPLICATION FOR FISCAL YEAR 2016-2017 UJ! CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. Al Civic ❑Arts Grant Request Amount: $3,500 Free of Charge: It Yes ❑ No (Not to exceed$5,000) Program Title: Silver Age Yoga for Encinitas Seniors ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: K, Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 84-1642673 X IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Silver Age Yoga Community Outreach (Must match name filed under the Tax/Employer Identification Number) Street Address: 1007 Cloverhurst Way, San Diego, CA 92130 Mailing Address: P.O. Box 160, Del Mar, CA 92014 Doing Business as (dba) Name: Silver Age Yoga Please list the names and titles of the organization's Board of Directors: Joanne Stark, Board Chair Sandy Watson, Member-at-large Bob Spindler, Treasurer Jim Simcoe, Cathy Spatuzzi, Members-at-large Barbara Chenault-Miller, Secretary Butch Whitmore, Member-at-large ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Increase the number of classes to four for seniors in Encinitas. Silver Age Yoga currently offers 3 classes in Encinitas: 1)Monday-1 PM,Encinitas Senior Center;2)Tuesday-1 PM,Encinitas Library,and 3)Wednesday-1:30PM, Encinitas Library. We would like to offer an additional class, ideally at the Encinitas Senior Center. Silver Age Yoga has a long history of teaching donation-based yoga classes in Encinitas and throughout San Diego. In prior years funding from government grants and corporations was a significant portion of SAYCO's revenue. During 2015,just over 2%of donations came from grants and corporations. SAYCO is not permitted to charge students for classes in public libraries. We request funding in order to fund another class. We also request funding to pay for substitute teachers and administrative costs. The 2010 census reported over 45% of Encinitas residents are ages 45 or older. Of those, 12.8% are 65 or older. According to the CDC, 1 in every 3 adults aged 65 or older fall every year in the U.S. Among this same age group,falls are the leading cause of death, as well as the most common cause of hospitalization. Yoga is widely regarded as an effective, low risk activity for seniors and one of the most effective fall prevention exercises. Organizational History: Silver Age Yoga founders Frank and Serpil Iszak taught their first class to seniors in 2003. Silver Age Yoga-certified instructors have taught 12,000+ hours of yoga to undeserved seniors, enhancing the health and enriching the lives of thousands of seniors who would have otherwise been unable to afford or access yoga instruction. Application Form,Page One of Two Location: Encinitas Library(x2); Encinitas Senior Center-currently 1, proposing x2. Total Est. Cost: $11,500 Time Frame: July 1, 2016—June 15, 2017 Number of Encinitas Residents Served 250 + Fundraising Activity 7 No Xl Yes If yes, please explain: We leave donation envelopes out;we do mail campaigns to donors once or twice per year. Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title Joanne Stark Mailing Address: P.U. Box 160, Del Mar, CA 92014 Telephone Number 858-525-3938 Email Address. JoanneS@SilverAgeYoga.org 4 Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. 1 hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statement:;in this application. Contact Person. Joanne Stark I itle. Chairman of the Board (Please print) Signature: ' L Date 413/16 Date Received: Application Packet Complete (original plus eight copies) Application Form (signed& dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements �I Yes No Reasons Application f orm. Page Two of Two �`� � APPIUCATION FOR FISCAL YEAR 2016-2017 . f :SIT" OF EHCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM 7Ri AIN 7-A i 10N N ANIE- `3iIver Ache Y c,qa C01T1ITIL.r1iiV GUtrEaC'II PRO.Ir;i,T TITLE. Silvei-Age Yoga for Encinitas Seniars�T_� �� �� ---- PROGRAM BUDGET Before you begin, ple-ise refer to the Instruction Sheet for cnmplete details on what is requirnW. INCOME: s 1j-' .r.,^., ".Uil�irlr�^� ni-r y.���n� , to IrOpide M_t rnt lirpli-d tc rirnnts, ntnte'ano' .un:-,, In-Nn.—Al of -1c.-d.- -ind ser (ices. tick4t revenue, rt,emhcr:yhIp f".Jduc.,,, V1.1n l a'.l otl%r;,, ��: of 0-ren0,-.. !3�:,4 Sheet for additional information.1 TYPE SOURCE STATUS AMOUNT f�l It ' . " "fIIII" f- it Jr " t r'Littf, $3,500 In-kind Community Room donated by Encinitas Senior Center $1.000 In-kind Community Room donated by Encinitas Library $3,000 In-kind 3 Instructors @$30/hr x 40 weeks/year $3,600 Donations Students $400 INCOME TOTAL*: 1011,500 F'".PENSF. tint all twojec'.ee cxnend::uryr- If Vou claims-d In-kinu ►ncw%�, that Item should also be in:I±i-.e�' �^ 't or �d1!'.:: 1,tion slle!pt forwjeiw-,nnl infoi*m--ti jn-1 ITEM DESCRIPTION 1COST Instructor Fees In-kind service donated by 3 Instructors @$30 1hr x 40 weeks/year $3,600 Instructor Fees Substitutes for 3 instructors @ 301hr x 10 weeks/year $900 Instructor Fees Instructor for new class @301hr x 50 weeks/year $1,500 Room Rental Room Rental at Encinitas Library $3,000 Room Rental Rcam Rental at Encinitas Senior Center $1;000 Program Administration Entering student data/waivers,processing instructor invokes,locating substitutes $1,000 General Administration General administration including website support,BOOK keeping,grant writing,fundraising. $500 EXPENSE !'OTiAt-*• $11,500 ow, tot i louc r,.:?ami Torot r vpew er >nnuld oc `,cur k li + tr( "" Knvxbnwa ---I-- 1.. 0. SOX 2508 CIN C7MTI, OK 45201 $mployer Identification Number! te: FEB 4 7 1045 64-1642673 DLL: 1.7053181082024 6IIjVBR AGE YOGA 1T'y a UMMCH Contact person: IDA 95183 C! FRANK 18Z7►1C MARY ASHL,INE Contact T 1844 ChMIm nRL MAR STS 19 Telephone Number: Dfii, I#AR, CA 92014-2246 (971) 829-5500 Accounting period Ending: Deceewber 31 Public Charity Status: 509(a) (ZI porm 990 Required- Y%25 Stfective Date of Exe9Gpticn: 04&rch 4, 2004 Contribution Deductibility: Yes Advance Ruling Endirig Date: Decmwber 31, 2008 D*ar Applicant: We are pleased to inform you that upon review of your application for tax mcmmpt status we have determined that you are exempt from Federal income taut under section 501(c) (3) of the Intesrnal Revenue Code. Contributions to you are deductible under section 170 of the Code. Tau are also qualified to receive AM deductible bequests, devises, transfers or gifts under section 2055, 2106 _xZ 2522 of the Code. Because this letter could help resolve any questiaaes regarding your eammpt status, you should keep it in your peramnaat retards. Organ£sutia0s exiespt under section 501(c) (3) of the Coda are further clanaifieed ass either public charities or private foundation. During your advance ruling period, you will be treated as a public charity. Your advance ruling period begins with tha effective date of your exmption and end s with advance ruling sanding date shown in the ]treading of the letter. Shortly before tha end of your adv,wce ruling period, tie will send you Form 8734, Support Seh *ules for Advance Ruling period. You will have 90 days alter t ate end of your advance ruling periIOd to return the cveaplete d form. We will then notify you, in writing, about your public charity status. Please see enclosed Inforoatiou for Byeupt Organizations Under section 501(c) (3) For some Aelptul information about your responsibilities as an exempt organization. Letter 1045 (DO/CG) I u4uu AGie YQC.A Ct1KKWTTY GUMRAC I sincerelti . • �� Lots G. Lerner Director, Rxempt Organizations Rulings and Agreements Enclosures: Information for Organisations Exempt Under section 501(c) (3) Form B72-C Letter 1045 (DO/CG) ATTACHMENT B RESOLUTION FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF SILVER AGE YOGA COMMUNITY OUTREACH WHEREAS, the Silver Age Yoga Community Outreach is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Silver Age Yoga Community Outreach hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 29th day of March, 2016 Barbara Chenault-Miller Secretary, Board of Directors Silver Age Yoga Community Outreach APPLICATION FOR FISCAL YEAR., 2016-2017 � ��- CITY OF ENCINITAS AND 1611ZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATIOit! NAME.Silver Age Yoga Community Outreach TITLE OF GRANT PROGRAM: Silver Age Yoga for Encinitas Seniors UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person. Joanne Stark Title: Chairman of the Board Signature Date- 4/3/16 EVALUATION FORM - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION F COMMUNITY GRANT PROGRAM FY2014/15 Date June 13, 2015 Organization: Silver Age Yoga Community Outreach Address: P.O. Box 160 City: Del Mar State CA Zip 92014 Phone: 858-693-3110 Fax N/A Email: JoanneS @SilverAgeYoga.org State the goals and objectives of your project and whether they have been met. The goal of the Silver Age Yoga for Seniors project was to offer yoga classes, free of charge, to the senior residents of Encinitas. Silver Age Yoga Community Outreach held approximately 140 classes at the Encinitas Library and Encinitas Senior Center. This objective was met. How were the goals and objectives of your project measured? Classes were held at: The Encinitas Senior Center on Mondays at 2:00 PM The Encinitas Libraray on Tuesdays at 1:00 PM The Encinitas Library on Wednesdays at 1:30 PM Average class size for the Senior Center was 22 Average class size for the Library was 25 These averages remained consistent when comparing the first 6 months to the last 6 months. We had 36 new students attend during the year,with over 100 different students taking our classes. Who participated in the evaluation process? The evaluation was done based on SAYCO's review of student waivers. How was the City's funding for this project utilized? SAYCO understands the grant was awarded in large part to provide compensation for our teachers; our teachers began donating their time as of July 1,when this grant cycle began. For that reason,we did not spend the majority of the funds granted to us. We spent more than $800 administering the program but request$800 because that was the amount indicated on our grant application. T:\CGP\Ol CGPTemplates+Forms\Agreement Return Letter with forms.doc t = _ APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts program. Choose only one option. IV Civic ❑Arts Grant Request Amount: $5,000. Free of Charge: I Yes ❑ No (Not to exceed$5,000) Program Title: "Breaking Up With Styrofoam" ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 33-0009949 ■ IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Solana Center for Environmental Innovation (Must match name filed under the Tax/Employer Identification Number) Street Address: 137 N. El Camino Real, Encinitas, CA 92024 Mailing Address. N. El Camino Real, Encinitas, CA 92024 Doing Business as (dba) Name: Solana Center Please list the names and titles of the organization's Board of Directors: Joel Rabasco President Mary Ann Stone Treasurer Lindsey Sheehan Secretary ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Solana Center will facilitate a community workshops to kick-start the adoption of environmentally-friendly food containers, as an alternative to styrofoam. According to the US EPA, over 75%of the 3 million tons of Styrofoam produced in the U.S.annually ends up in landfills. Much of it finds its way into our waterways.With Encinitas' reputation for having pristine beaches and being environmentally-minded, it would be fitting to encourage local food establishments to reduce their use of Styrofoam containers. The target audience for the workshop will be Encinitas restaurant owners/managers. Some suggested locations include:La Paloma Theater or Patagonia.There,they will learn from a respected guest speaker(ie. Rob Machado), view a short film on waste(part animated and yet very insightful), hear a panel discussion(members of the Encinitas Chambers of Commerce, Restaurant Owners and Residents), and compare alternative product samples. The outcome will be a bulk buying program in which environmentally-preferable containers can be sold at competitive pricing in the future to the Encinitas merchants. The Program will sustain itself by putting a team in place during the workshops. Organizational History: For over 30 years, Solana Center for Environmental Innovation has been teaching the San Diego community about caring for our earth, air, and water. We have won the highest environmental honor for our work as well as several local awards. Solana Center operates at the nexus where vision meets reality. Application Form, Page One of Two -M APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: 137 N. El Camino Real, Encinitas, CA 92024 Total Est. Cost: $5.000. Time Frame: One evening Number of Encinitas Residents Served: 61,588 Fundraising Activity: ❑ No K Yes If yes, please explain: To raise money for Premiere Cooperative Bulk Buying for Alternative Take Out Supplies CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Jacqueline Prairie Mailing Address: 137 N. El Camino Real, Encinitas, CA 92024 Telephone Number: 760.814.7528 Email Address: Jacqueline @solanacenter.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Jacqueline Prairie Title: Director, Programs & Development (Please print) Signature: Date: Y`,��L /Vf '' THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed & dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Solana Center for Environmental Innovation PROJECT TITLE: PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 In-kind Service donated by Guest Speaker Secured $100 In-kind Movie rental fee Secured $250 Ticket Revenue Estimated ticket revenue(100 participants X$5.) Pending $500 INCOME TOTAL*: $5,850 EXPENSE: List all projected expenditures. If you claimed In-kind Income,that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Marketing Promotion and Advertisement local publications and social media. $1,200 Volunteer Coordinator Service provide to oversee volunteers(55 hours X$15./hour) $975 Purchase Supplies Refreshments,products and supplies $600 Planning&Product Search Service provided as Event Coordination(50 hours X$20./hour X 2 staff) $2,000 Location Fee Cost to host event with screening capability $725 Guest Speaker Fee In-kind service provided by Guest Speaker $100 Rental Movie Fee In-kind donation of movie rental $250 EXPE1±1SE TOTAL*: $5,850 Budget Form *Your Total Income and Total Expenses should be equal. i Internal Revenue Service Department of the Treasury P. O. Box 2508 Date: August 9, 2007 Cincinnati, OH 45201 Person to Contact: SOLANA CENTER FOR ENVIRONMENTAL Ms. Lumpkins 17-57099 INNOVATION Customer Service Representative 137 N EL CAMINO REAL Toll Free Telephone Number: ENCINITAS CA 92024-2802 877-829-5500 Federal Identification Number: 33-0009949 Dear Sir or Madam: This is in response to your request of August 9, 2007, regarding your organization's tax- exempt status. In September 1984 we issued a determination letter that recognized your organization as exempt from federal income tax. Our records indicate that your organization is currently exempt under section 501(c)(3)of the Internal Revenue Code. Our records indicate that your organization is also classified as a public charity under section 509(a)(2) of the Internal Revenue Code. Our records indicate that contributions to your organization are.deductible under section 170 of the Code, and that you are qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Internal Revenue Code. If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely, Michele M. Sullivan, Oper. Mgr. Accounts Management Operations 1 RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF DIRECTORS OF Solana Center for Environmental Innovation WHEREAS, the Solana Center for Environmental Innovation is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the Solana Center for Environmental Innovation hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 6h day of March, 2016 �b Lauren Lindner Secretary, Board of Directors Solana Center for Environmental Innovation ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 AML CITY OF ENCINITI AS AND MIZEL FAMILY FOUNDATION --- COMMUNITY GRANT PROGRAM ORGANIZATION NAME:Solana Center for Environmental Innovation TITLE OF GRANT PROGRAM: Breaking up with Styrofoam UNDERSTANDING OF INSURANCE REQUIREMENTS ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one milrion dollars{$1;000,000)for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both_ A)CITY OF ENCINITAS B)MIZEL FAMILY FOUNDATION as the "Certificate Holder' and as an "Additional Insured' by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn_City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about:this process, please call(760)633-2610. 3)The aforementioned insurance policies shall not be canceled,terminated, or allowed to expire without thirty days prior written notice to the CITY. 4)Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle- 1 hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application_ Contact Person: Jacqueline Prairie Tide_ Director, Programs&Develle St nature: �' Gate_ April 94,2x16 � �l EVALUATION FORM - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015-16 Date 4/12/2016 Organization: Solana Center for Environmental Innovation Address: 137 N El Camino Real City: Encinitas State CA Zip 92024 Phone: 760-436-7986 x 226 Fax Email: lisa @solanacenter.org State the goals and objectives of your project and whether they have been met. -The goal of the rain barrel program is to support the research, initial design and development of a rain barrel sales program to serve to the residents of Encinitas. The year 2015-16 is expected to be an El Nino year, Each of the rain barrels holds 50 gallons of roof run from rain or morning condensation. The water saved it the rain barrels will have a significant impact in reducing the imported and processed water needed. -These collection times will occur numerous times during a year, so the barrel has the ability to reduce the number of gallons o water drawn from the water transported and processed by the local water district. -By the end of the February, a provider for the rain barrels had been identified, the system for selling rain barrels was in place which included a link to the rebate program offered by Metropolitan Water District and 224 rain barrels were sold through the program funded by Encinitas/Mizel. How were the goals and objectives of your project measured? -The goals were to research, qualify a supplier for rain barrels, and create a system for the residents of Encinitas to purchase rain barrel in a cost effective and user friendly manner. Solana Center was able to research the available rain barrel providers and partnered with Rain Water Solutions. The rain barrels were then drop shipped to Solana Center's facility and picked up b� the resident at the "store". The "store"was designed and built which provided a central point for the administering the progran and signs were designed and printed to direct the customers to the "store". - Marketing materials, including the demonstration rain barrel, flyers, emails and the Solana Center quarterly newsletter, were developed for the rain barrel sales program. -The residents frequently commented that the on-line pre-purchase system was easy to use. -The residents found Solana Center's "store"an easy, effective and efficient location for the rain barrel pick-up. The residents were pleased with the process where they were processed and their barrel was loaded in less than 5 minutes. Who participated in the evaluation process? -Staff agreed that the rain barrels chosen were attractive and the on-line system provided easy directions for installation via videos. Rain Water Solutions was a wonderful partner in providing rain barrels to Encinitas residents. -Residents who picked up the rain barrels were excited to have the rain barrel and found the experience to be smooth and ea,, How was the City's funding for this project utilized? -The City's funding was used for the demonstration rain barrel, flyers about the event, stickers for the rain barrels, and hardware for building the roof of the store. The store provided an important central point for providing service to the Encinitas residents. FYI 5-16 CGP REIMBURSEMENT& EVALUATION FORMS APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY:Grant requests are classified into two categories:Civic or Arts program. Choose oniv one option. ❑Civic Arts Grant Request Amount: $5000 Free of Charge: 0 Yes ❑ No (Not to exceed$5,000) Program Title: Effective Oral Presentation Skills Through Storytelling for Encinitas Youth ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 45-5050462 0 IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION. Organization Name: Storytellers of San Diego (Must match name filed under the Tax/Employer Identification Number) Street Address: 13142 Sundance Ave, San Diego, CA 92129 Mailing Address: 13142 Sundance Ave, San Diego, CA 92129 Doing Business as(dba) Name: Storytellers of San Diego Please list the names and titles of the organization's Board of Directors: Jim Dieckmann, President, Board of Directors Sheila Crosby Li-Anne Rowswell-Mufson, Secretary Dave Watters Marilyn McPhie Lindsay Hanlon V■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Research shows that businesses acknowledge a need for students to have 21 st skills, including oral communication, public speaking&presentation skills, civic and social justice literacy. Storytelling programs address these needs directly, and previous programs with Encinitas schools have received 100%positive feedback from administrators, teachers&students. To give important models of effective public speaking&presentation skills, professional storytellers will provide interactive assemblies to EUSD elementary schools,with priority to those with most English Language Learners.Also,storytellers will conduct a small-group workshop at each school to provide an in-depth experience in selecting and adapting stories, using techniques of voice expression,characterization,movement and related skills.At the request of the branch manager,we will establish a kids'storytelling club at the library, free on a sign-up basis for ages 8-12,to develop essential skills in storytelling, research,and public speaking in both individual and group presentations. Continuing the tradition, all students will have the opportunity to tell their stories on the main stage at the 7th annual storytelling festival at the Encinitas Library for an audience of several hundred family members,peers,and the public in a real-life performance experience. Awards,feedback,evaluation and follow-up will be provided to all student storytellers. Organizational History: Storytellers of San Diego has a 28-year history of teaching &performing,first as an informal group of professional and semi-professional storytellers in concerts,workshops, and instruction at all levels,and since 2010 as a California non-profit with expanded goals and programs. Storytellers of San Diego received federal 501c3 status in 2013. Application Form, Page One of Two -. - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Encinitas Unified School District elementary schools, Encinitas Library Total Est. Cost: $12,500 Time Frame: January-April 2017 Number of Encinitas Residents Served: 6980 Fundraising Activity: It No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Marilyn McPhie, President, Storytellers of San Diego Mailing Address: 13142 Sundance Ave, San Diego, CA 92129 Telephone Number: 858-484-1325 Email Address: mmcphie @gmail.com ❑■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Marilyn McPhie Title: President, Storytellers of San Diego (Please print) Signature: Date: 4-7-16 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed &dated) Program Budget Attachment A(IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: Yes ❑ No Reasons: Application Fonn, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Storytellers of San Diego PROJECT TITLE: Effective Oral Presentation Skills through Storytelling for Encinitas Youth PROGRAM BUDGET Before you begin,please refer to the Instruction Sheet for complete details on what is required INCOME: List all types and its source of Income, confirmed or pending,to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $5,000 Matching Funds La Jolla Kiwanis Club Confirmed $1,700 Matching Funds USAA Insurance Pending $1,000 Matching Funds Point Loma Credit Union Pending $200 Matching Funds Anonymous Donor Confirmed $2,000 In-Kind Storytellers of San Diego-project coordination,invoices,billing Confirmed $200 In-Kind Storytellers of San Diego-program materials Confirmed $200 In-Kind Storytellers of San Diego-student festival texts,props,costumes,supplies Confirmed $200 In-Kind Encinitas USD-9rms @4 hrs.each(assemblies),9 rrns @l hr each(workshops);3 rrns @5 hrs.each(residency) Confirmed $1,600 In-kind Encinitas Library-facility for student festival Confirmed $50 In-kind Encinitas Library-facility for student storytelling club Confirmed $300 In-kind Friends of the Encinitas Library-awards for student festival Confirmed $50 INCOME TOTAL*: $12,500 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Performers'Fees 2 assemblies each @ 9 schools;1 workshop each @ 9 schools $6,300 Workshop Fees Artist-in-Residence-15 workshops,3 sessions performance coaching $1,500 Project Coordination Fees School contacts,coordination,invoices,contracts,billing $200 Teaching Artist Fees Student Storytelling Club-5 meetings+performance $660 Teacher Materials Pre-and post-performance guides,workshop guides-donated by Storytellers of San Diego $200 Student Materials Family storytelling handouts-donated by Storytellers of San Diego $200 School Liaison Scheduling,booking,liaison with schools&library 12 hrs @$10/hr-donated by Storytellers of San Diego $90 Facility Use Use of school multipurpose room-4 hrs.each @ 9 schools-donated by EUSD $900 Facility Use Use of classroom for workshops-1 hr.each @ 9 schools-donated by EUSD $450 Facility Use Use of classroom for residency-15 hrs @ 1 school-donated by EUSD $250 Facility Use Use of community room for student festival-donated by Encinitas Library $50 Facility Use Use of study room for student storytelling club-5 sessions-donated by Encinitas Library $300 Awards Awards for student storytellers at festival-donated by Friends of Encinitas Library $50 Insurance Liability Insurance $500 School Materials Production,design,duplication of storytelling recordings for classroom use $850 EXPENSE TOTAL*:1$12,500 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. 0. BOX 2508 CINCINNATI, OH 45201 nn�rt' Employer Identification Number: Date: (�"' Z9 `2_1 45-5050462 DLN: 17053064318013 STORYTELLERS OF SAN DIEGO Contact Person: C/O MARILYN MCPHIE GARY MUTHERT ID# 31518 13142 SUNDANCE AVE Contact Telephone Number: SAN DIEGO, CA 92129-2411 (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: _ 170(b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: November 19, 2012 Contribution Deductibility: Yes Addendum Applies: No Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. Please see enclosed Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. Letter 947 (DO/CG) STORYTELLERS OF SAN DIEGO Sincerely, PI Holly O. Paz Director, Exempt Organizations Rulings and Agreements Enclosure: Publication 4221-PC Letter 947 (DO/CG) Minutes 2-16-2016 Storytellers of San Diego, Annual Meeting February 16th, 6:OOpm Encinitas Library, 540 Cornish Dr., Encinitas, 92024 1. Call to Order- 6:16 2. Directors and Officers Present- Chairperson/Treasurer Jim Dieckmann President-Marilyn McPhie,Vice President-Linda Whiteside, Secretary-Li-Anne Rowswell Mufson, Board Member-Sheila Crosby, Board Member-Dave Wafters Also present Kathleen Warren of Friends of the Encinitas Library. 3. Approval of the Agenda-Unanimous 4. Approval of the Minutes-Unanimous 5. New Business: Action a. Nominating Committee conducts election of Board Members for 2016 i. Present slate of recommended Board members- Sheila proposes we accept the below slate, Li-Anne seconds Passed unanimously: Chairperson/Treasurer Jim Dieckmann President-Marilyn McPhie Secretary-Li-Anne Rowswell Mufson Board Member-Sheila Crosby Board Member-Dave Watters Board Member- Carla McMullen ii. Ask for additional nominations from the floor-none iii. New Board candidate's oral statement of qualifications and interest-accepted iv. Voice vote by all present to accept slate of Board members- unanimous b. Board elects Chairperson- Dave proposes we accept Jim for the coming year Chairperson, Marilyn seconds, unanimously approved. c. Board approves Corporate Officers- Linda proposes we accept the following slate, <Marilyn seconds, unanimously accepted: President-Marilyn McPhie Vice- President-Linda Whiteside Treasurer-Jim Dieckmann Secretary-Li-Anne Rowswell Mufson d. Board members sign conflict of interest statement for 2016 6. Treasurer's Report a. Present balance sheet, including approved grants—Sheila Motions, Li- Anne Seconds, unanimously accepted b. Board approves 2015-year end balance sheet-- Marilyn motions, Sheila 2nds, unanimously accepted. c. Board authorizes filing of necessary documents with Franchise Tax Board, CA Secretary of State and the IRS for 2015-Jim motions, Sheila 2nds. d. Board considers requests for disbursements, including grant funds- Sheila moves, Linda seconds. i. Festival stipends, include outreach- Jim moves we pay Li-Anne $750.00 for workshops in Encinitas., Marilyn seconds. Unanimously passed. Also at Festival Workshop leaders will be paid $100.00 per workshop, Storytellers will be paid $70.00 for first appearance, $30.00 for subsequent Guest Chef will be paid$75.00 plus expenses, ii. Rebecca's stipend-remains at$20.00 per member storyteller. Per time slot. e. Report on current fund raising efforts-La Jolla Kiwanis, Point Loma Credit Union and NCC-tT are all contributirng-monetarily. As well as anonymous Membership donations. f. '«eport of prospective grant opportunities, approval of proposals- Jim I motioned we approve Storytellers to apply for the City of Encinitas {s'rant, ' Sheila Seconded, unanimously approved. 7. P resident's Report `��.. 2015 progress toward SSD goals-Marilyn will send attached butplease note. Marilyn will be moving up to NSN Regional Director as our Current director moves to the National Board and Li-Anne will become or Regional NSN Representative. Also we have a new Instagram account with over 500 followers. b. 2016 Festival update and planning- "Strong Women" is the theme and we coincide with National Storytelling Day. The library is trying new things with publicity. Kudos to Sheila and the Friends of the library. Kathleen is working hard on the Opportunity drawings, we have donations of items from Chinaberry, Barnes and Noble, Coast Traders, The Friends of the library, and many more. Lindsey and Kathleen will coordinate about volunteers. All the Concerts look great as do the workshops and Community Tellers. Marilyn is working on getting us a Food Truck 8. Information/Discussion a. Priorities for 2016 i. Tellabration- The performances were very strong attendance somewhat disappointing. All present feel strongly it should continue and we can continue to experiment. ii. South/East County Festival- no movement iii. 2017 San Diego Storytelling Festival- Sheila gave us a go ahead. iv. Rebecca's- April will be the completion of our second calendar year. v. Fund raising to support activities- Ongoing/open to new ideas 9. Announcements- Mariposa has Donald Davis this year- Festival is March 11-13th 10. Next Meeting-WEDNESDAY (note day change)MARCH 16,2016 6:OOPM ENCINITAS LIBRARY 11. Adjournment 7:50 PM ATTACHMENT C �a APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Storytellers of San Diego TITLE OF GRANT PROGRAM: Effective Oral Presentation Skills through Storytelling for Encinitas Youth UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Marilyn MCPhie Title: President, Storytellers of Sari Signature: `{-'� �� s. Date' AP-- APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classified into two categories: Civic or Arts proqram. Choose only one option. i Civic ❑Arts Grant Request Amount: $5,000 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Surfing Madonna Oceans Project-2016 Surf Camp for Special Needs Youth and Wonded Warriors ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 45-3042628 * IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Surfing Madonna Oceans Project (Must match name filed under the Tax/Employer Identification Number) Street Address: 1106 2nd Street, Suite#301, Encinitas, CA. 92024 Mailing Address: 1106 2nd Street, Suite#301, Encinitas, CA. 92024 Doing Business as (dba) Name: Surfing Madonna Oceans Project (SMOP) Please list the names and titles of the organization's Board of Directors: Bob Nichols -Chairman Mira Kanter- Secretary Mark Patterson -Vice Chairman Dave Tanner, John Gjata, Diana Walls- Directors Megan McCarthy -Treasurer Jim Wang, Teresa Barth -Advisors ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): Consistent with our mission to build community awareness and responsibility for our oceans and coastline, SMOP offers free surf camps to special needs youth,and wounded warriors throughout North County San Diego. By giving this unique experience to hundreds of children and selected wounded warriors each year,we're fostering oceans awareness and creating new stewards for our oceans. The enrichment that over a hundred local volunteers receive has them returning to support the surfers year after year. For the second year in a row,this annual surf camp will be held at Moonlight Beach. In addition to bringing hundreds of families into our community over the course of summer, our local residents can watch the excitement and healing powers of the ocean take hold on these individuals, most of whom would not otherwise have an opportunity to experience the ocean in a safe and supported way. The camps take place on 11 seperate days from Memorial Day through Labor Day,with a special camp on Veterans Day for the wounded warriors. Professional instruction is provided by Surfin' Fire, a local surf school capable of offering one-to-one instruction to these individuals. Registration for this year's camp filled up within hours,with a long waiting list growing daily, reflecting the importance of this camp. Additionally,there are over a hundred local residents who have each already committed many hours of their time to this year's surf camp. Organizational History: Formed in May 2011, SMOP is a secular organization created to improve the quality of our ocean, coastline and foster an ocean-conscious community. Since December of 2013,we have donated over$160,000 to local Encinitas organizations, the City, individuals and projects which support ocean conservation, education, and increase our community's responsibility to our oceans. Application Form, Page One of Two - APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: Moonlight Beach, Encinitas Total Est. Cost: $29,900 Time Frame: May 2015 - November 2015 Number of Encinitas Residents Served: 300+ Fundraising Activity: X No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Robert Nichols, Chairman and President, Surfing Madonna Oceans Project Mailing Address: 1106 2nd Street, Suite 301, Encinitas CA. 92024 Telephone Number: 760-846-5721 Email Address: bob @surfingmadonna.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Robert Nichols Title: Chairman and President (Please print) Signature: . "�` Date: 3/31/2016 THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed & dated) Program Budget Attachment A (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 6. ... 'i CITY OF ENCINITAS AND MIZEL FAMILY 1. FOUNDATION COMMUNITY GRANT PROGRAM URGANIZATION NAME: Surfing Madonna Oceans Project PROJECT TITLE: 2016 Surf Camp for Special Needs Youth and Wounded Warriors at Moonlight Beach PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas & Mizel Family Foundation Grant Program Pending $5,000 SMOP Funds Proceeds from the 2015 Surfing Madonna Beach Run to cover part of instruction Secured $6,000 In Kind Portion of surf instruction costs donated by Surfin'Fire Secured $5,500 Private Grant Designated donation to SMOP for Special Needs Surf Camp Secured $4,000 SMOP Funds Proceeds from the 2015 Beach Run to cover City of Encinitas Permits Secured $1,100 SMOP Funds Proceeds from the 2015 Beach Run to cover Insurance(est.) Secured $1,200 In Kind Breakfast and/or lunch for participants to be donated by Fish 101 &Bull Taco Pending $2,000 In Kind Participant gifts to be donated by Dr. Bronner's Soaps and Billabong Pending $3,000 SMOP Funds Proceeds from the 2015 Beach Run to cover participant shirts and medals Secured $1,000 SMOP Funds Proceeds from the 2015 Beach Run to cover sunscreen and film editing for families Secured $800 ind Promotion donated by Autism Society,Down Syndrome Association,Camp Pendleton Secured $300 INCOME TOTAL*: 1$29,900 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Surf Instruction/Surfn'Fire Sun'Fire Instruction from May-September $16,500 Permit Fees City of Encinitas Permit Fee($5 per person/per day) $1,100 Insurance Liability Insurance $3,000 Sun Protection/Shelter Tents and sunscreen for participants $1,500 Food-Snacks Snacks and water for participants $ 1,500 Food-Lunch Breakfast and/or lunch for participants $2,000 Gifts Participant gifts mementos Billabong, Dr.Bronner's Soaps $3,000 Printing,banner Printing cost for waiver and certificates $300 Rash Guards Rash guards to identify participants and volunteers while out in the water and on the sand $500 Marketing&Promotion Website and digital promotion donated by the Autism Society,Down Syndrome Association,Camp Pendleton $300 Gifts Photos of participants and film editing for families $200 EXPENSE TOTAL*: $29,900 Budget Form *Your Total Income and Total Expenses should be equal. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASURY P. O. BOX 2508 CINCINNATI, OH 45201 Employer Identification Number: Date: JM. 2 4 W4 45-3042628 DLN: 17053093369023 SURFING MADONNA OCEANS PROJECT Contact Person: C/O DAVID VAN NESS TERRY IZUMI ID# 95048 914-A NORTH COAST HWY 101 Contact Telephone Number: ENCINITAS, CA 92024 (877) 829-5500 Accounting Period Ending: December 31 Public Charity Status: 509(a) (2) Form 990 Required: _ Yes Effective Date of Exemption: May 15, 2014 _ Contribution Deductibility: Yes Addendum Applies: Yes Dear Applicant: We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of the Code. You are also qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep it in your permanent records. Organizations exempt under section 501(c) (3) of the Code are further classified as either public charities or private foundations. We determined that you are a public charity under the Code section(s) listed in the heading of this letter. For important information about your responsibilities as a tax-exempt organization, go to www.irs.gov/charities. Enter "4221-PC" in the search bar to view Publication 4221-PC, Compliance Guide for 501(c) (3) Public Charities, which describes your recordkeeping, reporting, and disclosure requirements. Letter 947 =-,W_-State of California WF_ranchise Tax Board PO BOX 1286 Rancho Cordova CA 957411286 SURFING MADONNA OCEANS PROJECT Date: 08.13.14 1106 2ND ST#301 Case: 26560551776797233 ENCINITAS CA 92024 Case Unit: 26560551776797236 In reply refer to:760ARE:F120 Regarding :Tax-Exempt Status Organization's Name :Surfing Madonna Oceans Project — CCN :3394953 Purpose :Charitable R&TC§ :23701d Form of Organization :Incorporated Accounting Period Ending :12/31 Tax-Exempt Status Effective :07/01/2011 Exempt Determination Letter We have determined the organization is tax-exempt from California franchise or income tax as stated in the above Revenue and Taxation Code(R&TC)section (§). To retain tax-exempt status,the organization must be organized and operating for nonprofit purposes within the provisions of the above R&TC section.An inactive organization is not entitled to tax-exempt status. We have based our decision on the information submitted and the assumption that the organization's present operations will continue unchanged or conform to those proposed in the organization's application.In order for us to determine any affect on the tax-exempt status,the organization must immediately report to us any change in: • Operation • Character • Purpose • Name • Address Our determination may no longer be applicable, if these changes occur: • Material facts or circumstances relating to the organization application. Relevant statutory,administrative,or judicial case law. • Federal interpretation of federal law in cases where our decision was based on such interpretation. It is the organization's responsibility to be aware of these changes should they occur.This paragraph constitutes written advice,other than a chief counsel ruling, within the meaning of FTB 9941 PASS(REV 03-2013) Exempt Application\Correspondence\ LTR 002-EDL Attachment B RESOLUTION OF THE BOARD OF DIRECTORS of SURFING MADONNA OCEANS PROJECT AUTHORIZING GRANT APPLICATION WHEREAS,the Surfing Madonna Oceans Project is a legally constituted corporation, under the laws of the State of California, and is in complete control of its affairs through its own officers and board members, NOW THEREFORE BE IT RESOLVED,that the Board of Directors of Surfing Madonna Oceans Project hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 25t' day of March, 2016 Mira Kanter Secretary, Board of Directors ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 — - CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: Surfing Madonna Oceans Project TITLE OF GRANT PROGRAM: Surfing Madonna Oceans Project-2016 Surf Camp for Special Needs Youth and Wounded Warriors UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT-Q 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Robert Nichols Title. Chairman and President f 3/31/2016 Signature: Date- EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM FY2015-16 Date Organization: Surfing Madonna Oceans Project Address: ✓ket, "511 I-e #/3f/ City: State C Zip 0262 y Phone: Fax Email: State the goals and objectives of your project and whether they have been met. / r Our G vo( Wr-5 4o in�lOUQC>` f�L v'4�'On f o G4Kr 5pecjo1r)eeA Unc1 iA./r ,de-� Vail+'d- C�;r,M,�n OV. ot�zcA✓-e. h/oS -0 creo dM�aSSa�c' S�rOcr ©LL'an Qnr�S�vf� C�nmrn��t i�y �N S f' ��c✓ i M pO=��.,�0� ' �G c'�n i S G'n d�1.�6���tS i f'C[��.�1 rU�1 c'��, How were the goals and objectives of your project measured? `/ Ovr1D�l5 D,4o�jec�'✓cs kler-P— M.CaSe,r-e iy ��cl, aek W&' reee,,''ed1fa, , 0,7 r 1j a 4u` a a n{ 110/Nn j�°E'!5 Who participated in the evaluation process? ` G'1da 6s 417©n�/OCISs How was the City's funding for this project utilized? e-c( 40 /e Y�a✓J ®c�. con de r�. r %� tee. FY15-16 CGP REIMBURSEMENT & EVALUATION FORMS - -- APPLICATION FOR FISCAL YEAR 2016-2017 -- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM CATEGORY: Grant requests are classed into two categories: Civic or Arts program. Choose only one option. ❑Civic Arts Grant Request Amount: $5,000 Free of Charge: 0 Yes ❑ No (Not to exceed$5,000) Program Title: La Jolla Playhouse's 2017 Performance Outreach Program (POP)Tour ELIGIBILITY DETERMINATION:Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: 0 Non-profit ❑Tax-exempt Tax/Employer Identification Number(TIN/EIN): 95-1941117 ■ IRS Letter. A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Theater and Arts Foundation of San Diego County (Must match name filed under the Tax/Employer Identification Number) Street Address: 2910 La Jolla Village Drive, La Jolla, CA 92037 Mailing Address: P.O. Box 12039, La Jolla, CA 92039 Doing Business as (dba) Name: La Jolla Playhouse Please list the names and titles of the organization's Board of Directors: Margret McBride, Chair Michael Yeatts, Treasurer Kay Gurtin, First Vice-Chair Mary Walshok, Ph.D., Secretary Michael Flaster, Second Vice-Chair Attached:Full Board List(note:Resolution approved/signed by 15/16 Board) ■ Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAM SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): The POP Tour is La Jolla Playhouse's signature education program that has impacted thousands of elementary&middle school children at schools throughout San Diego County since its inception in 1986.The program's goals are to help fill the void in arts education in the school system and expose youths&underserved students to quality arts programming. The POP Tour brings a world-premiere play,commissioned each year by the Playhouse and created by world-class artists,to schools,libraries and community centers across the County.Each play is 45 minutes,addresses issues relevant to students today and has creatively-designed set/costume/prop pieces to ensure a mobile production that can be loaded and unloaded by the cast and crew of 6 and fit into a variety of spaces to accommodate different school spaces.Teachers receive pre-show Resource Guides with STEAM-based activities and exercises related to the play and are offered free in-class workshops to allow for proper integration into existing curriculum.Post-show Q&As are also held. Pre-and post-show experiences draw on the play,the Guide and related themes,with the intention of inspiring creativity and supplying students with an alternative learning approach.The 2017 play will be written by Wesley Middleton,known for her groundbreaking Theatre for Young Audiences work.The Playhouse hopes to again bring the POP Tour to 5 Encinitas schools in winter 2017 for a total of 10 performances. Organizational History: Founded in 1947 by Gregory Peck, Dorothy McGuire and Mel Ferrer, La Jolla Playhouse's mission is to advance theatre as an art form and as a vital social,moral and political platform.A nonprofit,professional theatre on the UCSD campus, it is currently led by Artistic Director Christopher Ashley and Managing Director Michael Rosenberg.The Playhouse reaches 140,000+annually. Application Form,Page One of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM PROGRAM INFORMATION: Location: 5 Encinitas elementary schools:Ada Harris, Capri, Cardiff, Flora Vista, Ocean Knoll, Park Dale and/or Paul Ecke Central Total Est. Cost: $22,496 Time Frame: February -April 2017 Number of Encinitas Residents Served: 2,250 Fundraising Activity: N No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Alexandra Kritchevsky, Grants Manager Mailing Address: P.O. Box 12039, La Jolla, CA 92039 Telephone Number: (858) 228-3086 Email Address: akritchevsky @ljp.org ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct, to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Alexandra Kritchevsky Title: Grants Manager (Please print) ' I I 1l l Signature: �; I_• �:1 `1_ .� , Date: THIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete (original plus eight copies) Application Form (signed &dated) Program Budget Attachment (IRS Letter) Attachment B (Board Resolution or Minutes) Attachment C (Statement of Understanding) Meets Eligibility Requirements: F-1 Yes I1 No Reasons: Application Form, Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: La Jolla Playhouse PROJECT TITLE: La Jolla Playhouse's 2017 Performance Outreach Program (POP) Tour PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is rewired. INCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending Earned Support from Schools*(*amounts reflect 1/9 of funding for the nine-week tour) pending $ 1,111 Donations Support from Individuals* pending $1,667 Grant US Bank* pending $3,333 Grant San Diego Scottish Rite Foundation* pending $2,222 Grant Ellen Browning Scripps Foundation* pending $ 1,667 Grant Wells Fargo Foundation* pending $ 1,667 Grant Union Bank* pending $1,667 Grant ResMed Foundation&Farrell Family Foundation* secured $2,778 Grant Nordson Corporation Foundation* pending $556 —rant Macy's Foundation* pending $556 -rant Seth Sprague Charitable and Educational Foundation* pending $556 Grants Grants<$5,000(Employees Fund of Boeing,Pratt Memorial Fund,LJ Kiwanis,etc.)* pending $4,716 INCOME TOTAL*: $22,496 EXPENSE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Personnel Salaries/benefits&taxes/worker's comp/creative fees $ 14,797 Designer Expenses Sets/props/etc. $ 1,576 Events Catering $33 Housing Housing rental/trash disposal $67 Guest Artists Shipping/transportation $356 Production Crew Meals/company relations $ 167 Auditions $222 Commission $667 Travel Expenses Lodging/food/gas/mileage/parking/rental $ 1,033 Office Costs/Admin Costs Educational&instructional materials/copying/postage/printing/administrative costs $3,578 EXPENSE TOTAL*: $22,496 Budget form *Your Total Income and Total Expenses should be equal. La Jolla Playhouse Board of Trustees 2016/2017 Margret McBride Chair Kay Gurtin First Vice-Chair Michael Flaster Second Vice-Chair Michael Yeatts Treasurer Mary Walshok, Ph.D. Secretary Trustees Michael Bartell Clark Guy Dave Bialis John Ippolito Gregg Brandalise Joan Jacobs Ralph Bryan* Sheri Jamieson Robert Caplan Jeanne Jones Lisa S. Casey Pradeep K. Khosla, Ph.D. Linda Chester Lynelle Lynch* Randall L. Clark Kay Matherly Doug Dawson Mark J. Munoz Edward A. Dennis, Ph.D. Bennett Peji Brian Dovey Jeffrey Ressler* Daniel Einhorn David Smotrich Mick Farrell Amy Spielman William Georgis Steven M. Strauss* Noel Gillespie Sharon Weremiuk Wendy Gillespie Charlayne Woodard Jeffrey Goldman Hanaa Zahran Lynn E. Gorguze Barbara ZoBell Honorary Trustees Emeritus Trustees Richard Atkinson, Ph.D. David Copley(1952-2012) Ivan Gayler Ted Cranston (1940-2012) John Goodman Milton Fredman (1920-2005) Ewart W. Goodwin, Jr.* Hughes Potiker(1925-2005) Joel Holliday* Roger Revelle(1909-1991) Julie Potiker Willard P.VanderLaan, M.D.*(1917-2012) Geri Ann Warnke* Arthur Wagner, Ph.D. (1923-2015) Gary Wollberg* Mandell Weiss (1891-1993) Robert Wright, Esq. Emerita Trustees Rita Bronowski (1917-2010) Marian Jones Longstreth (1906-1997) Sheila Potiker(1930-2011) *Past Chair of,the Board Ellen Revelle(1910-2009) lntarnai Sevenua Service Decartnent or the Treasury District � $�P.O.Box 391.Los Angaies.Calf.90053 Director RECEIVED t I- �9 Person to Contact: Jim app Telephone Number: (213) 688-5727 Theatre and Arts Foundation of San Diego County Reier Reply to: Bog 12039 La Jolla, Ca 92037 Date: February 6, 1985 Fed. ID# 95-1941117 Mr. Alan Levey, This is to acknowledge receipt of your letter dated December 17, 1984 regarding the determination letter for the above organization. We do not up-date determination letters, however, our records do show that on August 19, 1958, the Theatre and Arts Foundation of San Diego County was held to be exempt from Federal Income Tag as an organization which is described in section 501(c) (3) of the Internal Revenue,Code and classified as an organization that is act a private foundation as defined in section 509(x) of the Code because it is an organization described in section*509(a) (2). The determination letter issued to you on August 19, 1958 continues to be in effect. SincerWRapp es Internal Revenue Agent RESOLUTION OR MEETING MINUTES FROM BOARD OF DIRECTORS AUTHORIZING GRANT APPLICATION RESOLUTION OF THE BOARD OF TRUSTEES OF LA JOLLA PLAYHOUSE WHEREAS,the La Jolla Playhouse is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED, that the Board of Directors of the La Jolla Playhouse hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this_22_day of February, 2016 M. Walshok Secret- ,Board of Trustees La Jolla Playhouse ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 --- CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION COMMUNITY GRANT PROGRAM ORGANIZATION NAME: La Jolla Playhouse TITLE OF GRANT PROGRAM: La Jolla Playhouse's 2017 Performance Outreach Program (POP)Tour UNDERSTANDING OF INSURANCE REQUIREMENTS - ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000) for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Alexandra Kritchevsky Title: Grants Manager Signature j _` ,y _ Date: H ItA EVALUATION FORM CITY OF ENCINITAS AND MIZEL FAMILY FOUNDATION ,r COMMUNITY GRANT PROGRAM FY2014/15 Date June 16,2015 Organization: Theater and Arts Foundation of San Diego County dba La Jolla Playhouse Address: 2910 La Jolla Village Drive City: La Jolla State CA Zip 92037 Phone: (858)550-1070 Fax (858)550-1075 Email: ala�itchevsky0aT or State the goals and objectives of your project and whether they have been met. The goal of the Performance Outreach Program(POP)Tour is to fill the arts education gap in San Diego schools.2015 objectives: • Create a 45-minute,dynamic, engaging production: Yes • Address one of the seven pillars of character through a socially conscious theatre piece: Yes,"respect," "responsibility" • Enhance academic curricula by providing arts education experiences to at least 17,000 students: Yes, reached 18,009 • Present nine weeks of performances,reaching over 45 schools in the San Diego area: Yes, reached 48 schools • Tour 5 Encinitas schools: Yes (6)—Ada Harris,Capri,Cardiff,Flora Vista,Ocean Knoll, Paul Ecke Central • Include a minimum of 25 Title I schools in the POP Tour circuit: Yes, reached 27 Title 1 schools • Provide engagement packets and pre-and post-performance supplemental materials to enhance education in the classroom: Yes, please see attached Engagement Guide • Lead in-school,pre-performance workshops to prepare students for the show: Yes,led 88 workshops How were the goals and objectives of your project measured? The goal and objectives of the 2015 POP Tour were measured by assessing the total number of students reached and the quality of the educational experience they received. The following methods ensure the POP Tour's proper evaluation: • The Stage Manager submitted a daily report including an audience headcount and highlights from each show. • Post-performance Q&As with the students and teachers assessed retention of themes, comprehension, engagement and emphatic response(based on VAPA standards). • Administrators and teachers whose students participated were encouraged to fill out online evaluations about the play and preparation process. • Students were asked to write a letter and/or create a piece of visual art about what they learned and/or about their favorite part of the POP Tour experience.These were sent to the Playhouse by teachers and school administrators. • Partnerships in San Diego County school systems monitored the progress of the program. Who participated in the evaluation process? La Jolla Playhouse takes program evaluation very seriously. The POP Tour evaluation process involves responses from a wide range of individuals(teachers, school administrators, students, actors and members of the Playhouse's artistic and production staff). Evaluation enables us to ensure the POP Tour remains an important and relevant program that positively impacts thousands of students and teachers across the County. How was the City's funding for this project utilized? The 2015 POP Tour reached 19,000 people across San Diego County, including over 18,000 students at 48 schools during its nine-week run. The play was also performed at Casa Familiar in San Ysidro and on site at La Jolla Playhouse for a total of 80 performances. The cost to present each production is more than $2,000. A generous grant from the City of Encinitas helped to underwrite a portion of this expense so the play could visit elementary schools in Encinitas. Specifically, the Playhouse used the$4,500 to hire stellar artists and designers to turn the creative team's vision into reality. T:\CGP\O 1 CGPTemplates+Forms\Agreement Return Letter with forms.doc APPLICFn nl =0R F► C AL `.TAR 2016-2017 rlTY OF 141r9HT.,aS "AP D o417—EL FAIMILY -� F�'ili�i+��':�`u I�va �'41?R�����'i��-"�`�`' ���'��,I��T '.�f�'�t�a/�I►�I CATEGORY: Grant requests are classified into two cateqories:Civic or Arts program. Choose only one option. ❑Civic Arts Grant Request Amount: 3,600 Free of Charge: Yes ❑ No (Not to exceed$5,000) Program Title: Stories for Seniors ELIGIBILITY DETERMINATION: Only non-profit and/or tax-exempt organizations may apply. Identify the legal status of your organization: W Non-profit Tax-exempt Tax/Employer Identification Number(TIN/EIN): 23-7257065 • IRS Letter.A copy of your organization's letter from the IRS showing status must be enclosed as Attachment A. ORGANIZATION INFORMATION: Organization Name: Write Out Loud (Must match name filed under the Tax/Employer Identification Number) Street Address: 3640 Alabama Street,San Diego, CA 92104 Mailing Address: 2358 University Avenue#179, San Diego, CA 92104 Doing Business as(dba)Name: Please list the names and titles of the organization's Board of Directors: Jack Van Sambeek- President Dr. Lynne Thrope Barbara Broderick-Secretary Linda Spuck Ross Porter-Treasurer Jennifer Montgomery a Board Approval. A copy of your organization's Resolution or Meeting Minutes reflecting Board approval of the project/program must be enclosed as Attachment B. PROGRAlri SUMMARY AND ORGANIZATIONAL HISTORY: Summary of Program (Limit to the space provided): A professional actor will read aloud and discuss stories,poetry,etc.at three or more Encinitas senior residences on a monthly or twice monthly basis. Storytelling connects generations and excites the imaginations of people of all ages. Many older people are partially sighted or experience eye strain that prohibits them from the joy of reading. A professional reader not only brings the literature to life off the page but also brings a human connection, the sound of a voice that is meant to be heard. The literature engages the imagination, triggering brain activity that is so important to healthy aging. It brings people together to listen, reflect, laugh - it brings enjoyment and helps fight a sense of isolation or loneliness. This program is in it's very successful third year and is sought after by facilites throughout the county. While the number of people it serves might seem small, the consistency of coming regularly to engage in intellectual stimulation has a big impact on one of our most fagile and underserved segments of society. Organizational History: Founded in 2007, WOL reads literature aloud for audiences of all ages. Six core programs include: Stories for Seniors, StoryBox Theatre for primary grades,TwainFest(a literary festival) Read Imagine Create to encourage teens to read, Poetry Out Loud for High School and Story Concerts for all. Application Form,Page One of Two rgas APPLIC,,OT10o' FOR FISCcvl 10'iO3-, 017 PROGRAM INFORMATION: Location: Encinitas Retirement Gardens, Atria Senior Living, Sea Crest Village, and possibly more Total Est.Cost: 7200 Time Frame: July 1, 2016 through June 1, 2017 Number of Encinitas Residents Served: 150 Fundraising Activity: W No ❑ Yes If yes, please explain: CONTACT INFORMATION AND STATEMENTS: Contact Person: (The individual who will sign the grant agreement and be responsible for the expenditure of any community grant funds allocated by the City of Encinitas to the organization) Name and Title: Veronica Murphy-Artistic Director Mailing Address: 3640 Alabama Street, San Diego, CA 929104 Telephone Number: 619-297-8953 Email Address: writeoutloudsd@gmail.com ■ Understanding of Insurance Requirements. A signed Statement of Understanding of Insurance Requirements must be enclosed as Attachment C. I hereby affirm that the information contained in this application is true and correct,to the best of my knowledge, and that I am authorized by the organization named herein to make such representations and statements in this application. Contact Person: Veronica Murphy Title: Artistic Director (Please print) Signature: { . 7 �'� Date: April 13, 2016 �„�, , �'�[.� _ HIS SECTION FOR OFFICIAL USE ONLY: Date Received: Application Packet Complete(original plus eight copies) Application Form (signed&dated) Program Budget Attachment A(IRS Letter) Attachment B(Board Resolution or Minutes) Attachment C(Statement of Understanding) Meets Eligibility Requirements: ❑ Yes ❑ No Reasons: Application Form,Page Two of Two APPLICATION FOR FISCAL YEAR 2016-2017 k CITY OF ENCINITAS AND MIZEL FAMILY } FOUNDATION COlnMUNIT",' GRANT PROGRAM t ORGAMIZATION i+".AME: Write Out Loud PROJECT TITLE: Stories for Seniors PROGRAM BUDGET Before you begin, please refer to the Instruction Sheet for complete details on what is required. .NCOME: List all types and its source of Income, confirmed or pending, to include but not limited to grants, matching funds, in-kind donations of goods and services, ticket revenue, membership fees/dues, and all other types of income. (See Instruction Sheet for additional information.) TYPE SOURCE STATUS AMOUNT Grant City of Encinitas& Mizel Family Foundation Grant Program Pending $3,600 Grant Dr.Seuss Foundation Confirmed $2,400 Government County of San Diego Community Enhancement Funds Pending $1,200 uNCOME TOTAL*: $7,200 E;*'PE01SE: List all projected expenditures. If you claimed In-kind Income, that item should also be included as an expense and identified as such. (See Instruction Sheet for additional information.) ITEM DESCRIPTION COST Professional Actor 72 Readings at Senior Facilities @$85 per event (includes mileage) $6,120 Artistic Coordination Selecting Material and Preparation for 72 readings $720 Administration Scheduling and associated administrative tasks for 72 readings $360 E :PENSE TOTAL*: $7,200 Zudgec Form Your Total Income and Total Expenses should be equal. r� T� Department of the Treasury 1 S Internal Revenue Service P.O. Box 2508 , Room 4010 In reply refer to : 4077552510 Cincinnati OH 45201 Jan. 14, 2010 LTR 4168C 0 23-7257065 000000 00 00020125 BODC: TE WRITE OUT LOUD AKA WOMENS RESPATORY THEATRE 3640 ALABAMA ST SAN DIEGO CA 92104-4006 4a�tL 005017 Employer Identification Number : 23-7257065 Person to Contact : Michelle Jones Toll Free Telephone Number : 1-877-829-5500 Dear Taxpayer : This is in response to your Dec . 17, 2009, request for information regarding your tax-exempt status . Our records indicate that your organization was recognized as exempt under section 501 (c) (3) of the Internal Revenue Code in a determination letter issued in February 1973. Our records also indicate that you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section 509(a) (2) . Donors may deduct contributions to you as provided in section 170 of the Code. Bequests , legacies, devises , transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code . Beginning with the organization's sixth taxable year and all succeeding years, it must meet one of the public support tests under section 170(b) ( 1) (A) (vi) or section 509(a) (2) as reported on Schedule A of the Form 990 . If your organization does not meet the public support test for two consecutive years, it is required to file Form 990-PF, Return of Private Foundation, for the second tax year that the organization failed to meet the support test and will be reclassified as a private foundation . If you have any questions , please call us at the telephone number shown in the heading of this letter . 4077552510 Jan . 14, 2010 LTR 4168C 0 23-7257065 000000 00 00020126 WRITE OUT LOUD AKA WOMENS RESPATORY THEATRE 3640 ALABAMA ST SAN DIEGO CA 92104-4006 Sincerely yours , Vpmall,' Cindy Thomas Manager, ED Determinations ATTACHMENT B CITY OF ENCINITAS PROPOSAL FOR FUNDING RESOLUTION OF THE BOARD OF DIRECTORS OF Write Out Loud WHEREAS, Write Out Loud is a legally constituted corporation or public/governmental entity, under the laws of the State of California, and is in complete control of its affairs through its own officers and members, NOW THEREFORE, BE IT RESOLVED,that the Board of Directors of Write Out Loud hereby approves the filing of an application for the City of Encinitas and Mizel Family Foundation Community Grant Program funding for the City's 2016-2017 Fiscal Year. Adopted on this 10th day of April, 2016 5 5 Barbara Broderick Secretary, Board of Directors WRITE OUT LOUD ATTACHMENT C APPLICATION FOR FISCAL YEAR 2016-2017 CITY OF ENCINITAS AMD M iZEL FAMILY FOUNDATION COM mUNITY GRANT PROGRAM ORGANIZATION NAME:Write Out Loud TITLE OF GRANT PROGRAM: Stories for Seniors UNDERSTANDING OF INSURANCE REQUIREMENTS -ATTACHMENT C 1) All grant recipients are required to obtain and, during the term of the grant cycle, maintain general liability and property damage insurance from an insurance company authorized to be in business in the State of California, in an insurable amount of not less than one million dollars ($1,000,000)for each occurrence. 2) The grantee's insurance company must provide a "Certificate of Insurance" naming both: A) CITY OF ENCINITAS B) MIZEL FAMILY FOUNDATION as the "Certificate Holder" and as an "Additional Insured" by endorsement on these policies and further, have the endorsement sent to the City of Encinitas, attn: City Manager, 505 S. Vulcan Avenue, Encinitas, CA 92024. If you have questions about this process, please call (760) 633-2610. 3) The aforementioned insurance policies shall not be canceled, terminated, or allowed to expire without thirty days prior written notice to the CITY. 4) Any person who drives an automobile in conjunction with the funded project or program shall have automobile liability insurance coverage on the vehicle. I hereby understand and will comply with insurance requirements 1 through 4 of the Community Grant Program and that I am authorized by the organization named below to make such representations in this application. Contact Person: Veronica Murphy Title: Artistic Director f, k - Date: April 13, 2016 Signature: w C s L