CITY OF FONTANA
COMMUNITY SERVICES DEPARTMENT
DONATION ACCEPTANCE
(For All Donations)
Name of Donor/Organization
Kaiser Permanente
Address
75 N. Fair Oaks Avenue, 4th Fl Pasadena, CA 91103
Contact Person, Title Phone No.
Martha Valencia, Community Health Manger (909) 427-5268 Type of Donation: (Check boxes)
Monetary Amount'$ 14,000 (Receipt No.
Invoice No. 80348
(Attach copy of Receipt)
Goods/Services Estimated Value $ Description
Intended use of Donation:
Specific → Description
Community Health Contributions Program "The Awareness Project" grant General
Thank you/acknowledgement letter sent to Donor? (Required for ALL donations) Attach copy of acknowledgement letter to this form.
G.E.T. Online Donation Tracking Form Has Been Completed. (Required for ALL donations with a value equal to or greater than $500.00) Received By Date
Jasmine Sarsadias 11/22/2021
Copy of this form sent to Supervisor/Manager
- = - FOR ADMINISTRATION USE ONLY - --
City Council Agenda Date
Entered in Novus by: Date
This form must be filled out for all donations received regardless of value amount. This donation must be approved by City Council prior to any spending or use of the donation.
Ilcity-fileservertshared|Forms|CSD\Intranet|Donation Acceptance Record.xls|10/15/201913:58 PM FONTANA November 22, 2021
CALIFORNIA
Kaiser Permanente
Martha Valencia, MPH, Community Health Manger
City Council
9961 Sierra Avenue
Acquanetta Warren Fontana, CA 92335
Mayor
Phillip W. Cothran
Mayor Pro Tem Dear Martha,
John B. Roberts
Council Member
On behalf of Healthy Fontana and the City's Community Services Department, thank you for Jesus "Jesse" Sandova
Council Member choosing our proposal of 'The Awareness Project' as one of the funded Community Health Contributions Program grants for next year. We are so excited to work on this project to Peter A. Garcia bring awareness and reduce stigma associated with mental health and mental illness. This Council Member
much needed funding will help to bring education and activities to the most vulnerable populations including the youth of our community.
It is with deep gratitude that Healthy Fontana accepts this funding to bring much needed resources for all in the City of Fontana and we look forward to continuing to partner with Kaiser Permanente in the future.
Sincerely,
Jasmine Sarsadias
Jasmine Sarsadias, Community Services Coordinator
Healthy Fontana
CITY of FontanA Community Services DEPARTMENT
16860 VALENCIA AVENUE, FONTANA, CALIFORNIA 92335
WWW.FONTANA.ORG
FONTANA
Community Services Departmen
16860 Valencia Ave
Fontana
United Slates, 92336
Tel: 909-349-6900
1 QTY Healthy Fontana-
Donation
$14,000.00
SUBTOTAL
$14,000.00
TOTAL COPY
$14,000.00
INITIAL PAYMENT
$14,000.00
CHECK TEND
$14,000.00
STATUS Success
Payment# PYMT-435800
Payment Date 11/22/21 12:16:02
Customer Kaiser Permanente
Telephone (626) 381-2200
Type Sale
Transaction# 403919
Transaction Date 11/22/21 12:16:03
Clerk JCastellon Solares
See Refund Policy at:,
http://www.fontana.org/index.as
px?NID=159, No Camp Refunds
403919
CSD Administration Office
CAISER PERMANENTE
KAISER FOUNDATION HEALTH PLAN INC
ACCOUNTS PAYABLE DEPARTMENT
75N. Fair Oaks Avenue, 4th Fl
asadena, CA 9110:
626) 381-2201
AND KARMANENTED
0121953 01 RE 0.458 "AUTO T6 0 6219 92335-359853 - P21974 CO7 11/12/2021
CITY OF FONTANA
8353 SIERRA AVE COPY
FONTANA CA 92335-3598 PAGE 1 OF 1
VENDOR 100021809
INVOICE NO. INVOICE DATE GROSS AMOUNT DISCOUNT NET AMOUNT 80348 11/05/2021 $14,000.00 $14,000.00
Preferred payment is ACH. Email [email protected].
TOTALS $14,000.00 $0.00 $14,000.00
DETACH AND RETAIN THIS STUB FOR YOUR RECORDS CHECK # 0020634350 ATTACHED BELOW KAISER PERMANENTE No. 0020634350
I KAISER KAISER FOUNDATION HEALTH PLAN INC
I PERMANENTE• ACCOUNTS PAYABLE DEPARTMENT 62-20
75N. Fair Oaks Avenue, 4th Fl 311
Pasadena, CA 91103
(626) 381-2200 11/12/2021
PAY TO THE CITY OF FONTANA $$$$$$$$$$14,000.00
ORDER OF 8353 SIERRA AVE NOT VALID AFTER ONE YEAR
FONTANA CA 92335 VENDOR 100021809
KAISER FOGENERAL ACCOUM PLAN, INC
Fourteen Thousand and 00/100 Dollars
ONE PENS WAY, NEW CASTLE, DE 19720
100 20634350 1031100209 38781009