Community Promotional Fund Application
APPLICANT INFORMATION:
Robert Blomker
Name of applicant:
LifeStream Blood Bank
Name of organization or group represented:
384 W. Orange Show Rd
Mailing address:
Contact phone number(s): Email Address:
909-522-0366 blomkero@|stream.org
Non-Profit?V Yes•No If no, are you partnering with a non-profit:
PROJECT DESCRIPTION:
Monthly - Barstow Bloodline Blood Drives
Name of Event:
Amount requested: $ 6000
What will the funds be used for and/or what are the waiver of fees for? Waiver for the fees for Rental for non-profit
blood drive
Second Tuesday of every month
When will the activity take place?
Harvey House
Where will the activity take place?
Why are the funds/waiver of fees/in-kind services needed? Non-profit blood drive for community blood bank
How many Barstow area residents are involved with this organization? 50-100+ 0 How many spectators will watch this activity?
Please describe how this activity will benefit Barstow. If additional space is necessary, please attach additional sheets:
Barstow saves 1000s of lives a year with these blood drives.
Rev. April 2020 Community Promotional Fund Application Page 1 Community Promotional Fund Application
With this application, please attach the following:
1. A detailed budget stating the total cost of the activity or event, all sources and amounts of funding, and all expenses;
2. A description of the organization's or group's purpose or objective.
3. A copy of the organization's non-profit determination.
By signing below, I declare that I have read the City's Community Promotional Fund Policy and agree to all its terms and conditions. I agree that there is a formal process in place to conduct background checks on all employees and volunteers who work with persons under the age of 18 years and senior citizens.
I understand that an incomplete application will not be accepted and that the organization or applicant will not be considered for funding. (If the application is being submitted on behalf of an organization or school, an additional signature is equired.)
Rolls Robert Blomker 9/2/25
Signature of Applicant Applicant Name (printed) & Date
School Principal or Organization
President/Director Signature
(if applicable)
**Please note that the fiscal year 2020-2021 budget will likely be impacted by the COVID-19 crisis. While the City recognizes the value of the Community Promotional Fund, awards will be contingent on the availability of funds.** Rev. April 2020 Community Promotional Fund Application Page 2 • 2.
Internal Revenue. Service
EP/EO Disclosuze Desk
P 0. Box 2350 Los Angeles, CA 90033
Person to Contact:
•F.. Barragan
/ BLOOD BANK OF BAN BERNARDINO Telephone Number
AND RIVERSIDE COUNTIES INC (213)894-4232
P 0: BOX 5729 Refer Reply to:
SAN BERNARDINO, CA:. 92412 91-783
Dete: OCT 3 0 1990
BE! 95-1708743
BLOOD BANK OF SAN BERNARDINO
AND RIVERSIDE COUNTIES INC
Gertlemen:.
This is in response to your request for a determination letter of the above-named organization.
A reviewiót our zecords indicates that the above-hamed
recognised to be exempt trom federal ino ome
organstation. was
An APBIL::. 1952, as an organization described in
Internal Revenue Code section 501/c)(3). "It' is further classified as an organization that is nota private
foundation as defined in section 509(ä) of the code, because. it is an: organization described in section 509(A)(2)
This letter is to verify your exempt status
and the faot that the determination letter
issued on APRIL, 1952 contirues to be in eli*ot:
in need of further assistance, please feel tree to
contact me át the above address.
we appreciate your cooperation in this regard.
2%
Sincerely;
Y, Bany
Disclosure Assistant