APPLICATION FOR
CITY COUNCIL DISCRETIONARY FUNDS
Di
strict: __________________________
Councilmember: __________________
Name of Party requesting Council Discretionary Funds:_____________________________________ Contact Name: _________________________
Contact Phone: _________________________
Contact Email: _________________________
Does your organization have non-profit status? _____________________________________________ Requested Amount: ___________________________________________________________________ If awarded, who will the amount be payable to? ___________________________________________ Date of the Event: __________________________ Location: __________________________________ Describe the event, program, or project for which you are requesting funds: ____________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Describe the Community Benefit: ________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please include the following attachments:
W-
9 Chapter 5.10 Acknowledgement Form
I
certify that the information and materials submitted are true to the best of my knowledge and belief. I acknowledge that it is the sole responsibility of the recipient to comply with all federal, state, and local laws, regulations, ordinances, and policies as may be applicable in connection with Discretionary Funds received. I understand that if the Discretionary Funds are used in violation of federal, state, and local laws, regulations, ordinances, and policies, the City may seek to recover all awarded funds.
Appl
icant Name: _________________________________________________________ Applicant Signature: ______________________________________________________
ATTACHMENT C