Agenda — Temecula City Council, November 15, 2022 (part 3 of 6)

FISCAL YEAR (FY) 021-2022 COMP41ANCE REPORT
If your organization is awarded a Community Service Funding Grant In FY 2021r2022 by the City of Temecula, then this Information Is not due until Mdnday, September 12, 2022 If your organization Is awarded a Community Service Funding Grant in Fiscal Year 2021-2022 by the City of Temecula, --all-grant-funds reoelved-must-be-expended-anytkne-on-or-between-July-1 2021-and-Jung-30,-2022- In addition, - all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any future funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up Information to substantiate how funds reoetved from the City were spent. t% If the funds are not spent in accordance with the approved purpose staled on the Application, the organization will be required to refund the amount of funds. To substantiate that Fiscal Year 2021-2022 funds received from the City were spent appropriately, proper back-up documentation including the table below with accompanying recelpts/invoices, must be submitted to the City on or before due date: Monday, September 12, 2022.

EXPENDITURE REPORT due on or before Monday, September 12, 2022 1 1. Provide the number of beneficiaries living in 92590, 92591 and 92592 that directly, benefitted from this program (approximate number of beneficiaries if you don't have a precise number): IQLOO

2. Fill out this table (include additional copies if needed to explain all expenditures)

3. Attach Receiptslinm voices (in the sae order as listed in this table)

4. Send to: City of Temecula, 41000 Main St, Temecula, CA 92590, Attn: City Managers Office - CSF Organization: Cultivating InCIUSIOn Inc. Name of ProjecWrogram:L,f1;Lh&.t3:7ulCIUS! Amount of Grant Fund Awarded: $ Month + Year Grant Received from City.() � -- Data (Mo/DayNt)
Name of Company on Recelpt/lnvolcs
on Recelptllnvolce Must be dated on or
$ between July 1. 2021 -
June 30, 2022
"IN
7 .0401H 3-1S-;
Describe...

Explain ...

Amount
Of
Expenditure
(1) what the expenditure was
(2) purpose of the expenditure
MUST
MUST support Project Program
description on Application + Award Lettet
how the expenditure
specifically benefitted
residents
M namecfaddnasas of Temecula
beneAdarlss art available.
$ -- ��
3 •
Ham, cfo�i Frr
drs ^40.n "P -, -I" kw
�_
,.rc- ni A
naw a*
fdr
wivt Prro-
EXPENDITURE TOTAL ` �O. (�
Note, Ex nditure roiai must be equal$ 4 to
(or greater than) the-AarlqurIf of Grant Fund I
Awarded' (above) provided by the City
r
W CJfr.-0tls
ait"ndC tbwd
tom-
l) le, .

City of Temecula Community Service Funding Grant APPLICATION Page 6 of 7

FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
If your organization is awarded a Community Service Funding Grant in FY 2021-2022 by the City of Temecula, then this information is not due until Monday, September 12, 2022 If your organization is awarded a Community Service Funding Grant in Fiscal Year 2021-2022 by the City of Temecula, all grant funds received must be expended anytime on or between July 1, 2021, and June 30, 2022. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may -jeopardize -any -future -funding.. City -of Temecula -reserves-the-right to -conduct an -aud it -and/or require -additional back-up information to substantiate how funds received from the City were spent.

If the funds are not spent in accordance with the approved purpose stated on the Application4he organization will be required to refund the amount of funds. To substantiate that Fiscal Year 2021-2022 funds received from the City were spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City on or before due date: Monday, September 12, 2022.

EXPENDITURE REPORT due on or before Monday, September 12, 2022

1. Provide the number of benefioieries living in 92590, 92591 and 92592 that directly benefitted 1200 from this program (approximate number of beneficiaries if you don't have a precise number):

2. Fill out this table (include additional copies if needed to explain all expenditures)

3. Attach Receipts/Invoices (in the same order as listed in this table)

4. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Office - CSF Organization: Cultivating Inclusion Inc.

Amount of Grant Fund Awarded: $ 5,000.00
Name of Company
E on Receipt/lnvoice
t�
u E
az'
1 Orozco Gen Maint
Date (Mo/DayNr)
on Receiptlinvoice
Amount
Must be dated on or
between July 1, 2021 -
of
Expenditure
June 30, 2022
03/01 /2022
$ 385.00
r[uUUI rr rCSL- TlujI
AZ
- 3 Rodent Pest Tech 0911 gI2021 1� $ 230.00
4 Rodent Pest Tech 11 /19/2021 $ 230.00
5 Rodent Pest Tech f 12/20/2091 $ 230.00
6 Rodent Pest Tech 102/19/2022 $ 230.00
7 Rodent Pest Tech 1 03/22/2022* $ 230.00
Name of Project/Program: Cultivating Inclusion Inc.

Month + Year Grant Received from City: 01 /2022
Describe...
(1) what the expenditure was
(2) purpose of the expenditure
MUST support Project/Program
description on Appilcation + Award Let
Keeping our farm free of weeds
so thal it has a neat accessible appearance.

Rid the farm of vermin and pests
to ensure a safe environment,
Rid the faun of vermin and pests
to ensure a safe environment.

Rid the farm of vermin and pests
to ensure a safe environment.

Rid the farm of vermin and pests
_ to ensure a safe environment.

Rid the farm of vermin and pests
to ensure a safe environment.

EXPENDITURE TOTAL 'pd on 3/1112022
Note: Expenditure Total must be equal to $ 111,8109 3 of 3 (or greater than) the "Amount of Grant Fund Total $54t4rW for 3 pgs Awarded" (above) provided by the City
a 19
City of Temecula Community Service Funding Grant APPLICATION Explain ...
how the expenditure
specifically benefitted
Temecula residents
If namesladdresses or Temecula
beneficiaries are available,
please attach.

Helps keep our farm safe for
visitors and more food for food banks,
clients and more food for food hanks.

Helps keep our farm safe for
clients and more food for food banks.

Helps keep our farm safe for
4*ntn oral morn rood for frxxl banks,
Helps keep our farm safe for
clients end more food for food banks.

Helps keep our farm safe for
clients end more food for food bunks,

Page 6 of 7 ends

FISCAL YEAR (FY) 2022-2023 COMPLIANCE REPORT
If your organization is awarded a Community Service Funding - REINVESTMENT IN TEMECULA Grant in FY2022-2023 by the City of Temecula, follow these instructions.

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the Funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said amount of funds to the City. To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

I. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance Of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Organization:- Cultivating Inclusion Inc. Name of Project/Program: Cultivating Inclusion Inc.

TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: 5_ was received from City: _

1. Is this Expenditure Report is to provide documentation for first $5,004 awarded and racelved? Yes or No (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the City

3. Is this Expenditure Report is submitted to request reimbursement of funds? No or Yes If yes, Amount of Request $ Number of beneficiaries living in 92590, 92591, 92592 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) m l Date on Expenditure
E t Name of Company Receipt/invoice MUST SUPPORT PROJECT/PROGRAM IN APPLICATION &AWARD LETTER o E on Receipt or Invoice MUST BE ON OR BETWEEN
a z' 1 Merch 20, 2020-JUNE 30, Amount Description Purpose 2024
2 $
3 $
EXPENDITURE TOTAL $ EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:
• Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. • Awards will be given to organizations and activities that directly benefit the residents of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement.

If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Cultivating Inclusion Inc.

MAILING ADDRESS:

Cultivating Inclusion c/o Mary Ann Tams 951 296-7756
31430 Loma Linda Rd.,
PHONE: (_)
Temecula, CA 92592-1604 [email protected] EMAIL:

M
PRESIDENT /AUTHORIZED OFFICER: Mary Ann Tams, Garden Director A �� ,1 �� ,� PRINF NAIME 11`LE
I Y I l�t�i' y t �I f. v T-� August 2, 2022
SIGNATURE: DATE:

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:

PRINT NAME
MONTH, DAY. VIA!
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: [email protected] (951) 694-6413
[email protected] (951) 693-3959
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

INTERNAL REVENUE SERVICE
P. O. BOX 2508
CINCINNATI, OH 45201
Date- J U 2 6 2018

CULTIVATING INCLUSION INC
39901 ALPINE UNION DR UNIT C
__MURRIETA,CA 92563-0000
Dear Applicant:

DEPARTMENT OF THE TREASURY
Employer Identification Number:
82-4809510
DLN:
26053569009448
Contact Person:

CUSTOMER SERVICE ID# 31954
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:

March 9, 2018
Contribution Deductibility:

Yes
Addendum Applies:

No
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 947

-z-

CULTIVATING INCLUSION INC
Sincerely,
Director, Exempt Organizations
Rulings and Agreements
Letter 947

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
F T B t PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 7/31 /2022
ESL ID: 3166835146
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 4127453
Entity Name: CULTIVATING INCLUSION INC.

1. The entity is in good standing with the Franchise Tax Board.

2. The entity is not in good standing with the Franchise Tax Board.

X❑ 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d.

4. We do not have current information about the entity.

5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Important Information
This information does not necessarily reflect the entity's current legal or administrative status with any other agency of the state of California or other governmental agency or body. • If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).
• The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Connect With Us
Web: ftb.ca.gov
Phone: 800-852-5711 from 7 a.m. to 5 p.m, weekdays, except state holidays 916-845-6500 from outside the United States
California
Relay Service: 711 or 800-735-2929 (For persons with hearing or speech impairments) FTB 4263A WEB (REV 12-2019)

Q HELPS] MENU
Home > Tax Exempt( rganixation Search > Cultivating Inclusion Inc. < Back to 5earcUesults
Cultivating Inclusion Inc.

EIN: 82-4809510 1 Temecula, CA, United States
Other Names
Determination Letter e
A favorable determination letter is issued by the IRS if an organization meets the requirements for tax-exempt status under the Code section the organization applied.

Final Letters
Publication 78 Data o
Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in determining deductibility of their contributions.

On Publication 78 Data List: Yes
Deductibility Code: PC
Form 990-N (e-Postcard) a
Organizations who have filed a 990-N (e-Postcard) annual electronic notice. Most small organizations that receive less than $50,000 fall into this category.

Tax Year 2021 Form 990-N (e-Postcard)

Tax Period:
2021 (01/01/2021 - 12/31/2021)
EIN:
82-4809510
Legal Name (Doing Business as):

Cultivating Inclusion Inc
Mailing Address:
31430 Loma Linda Road
Temecula, CA 92592
United States
Principal Officer's Name and Address:

Mary A Tams
31430 Loma Linda Road
Temecula, CA 92592
United States
Gross receipts not greater than:
$50,000
Organization has terminated:

No
Website URL:
http://www.cultivatinginclusionfarm.com
Tax Year 2020 Form 990-N (e-Postcard)
Tax Year 2019 Form 990-N (e-Postcard)
Tax Year 2018 Form 990-N (e-Postcard)
Po Lost Reviewed or Updated: 20-November-2020 r* Share Print

L. 0'e C � i.-i! 4. . zif
Organization Name;
CUr1:11VATING INCLUSION INC., IRS FEIN:
824809510
Entity Type:

Public F3ci,etit
SOS/FTB Corporate/Organization Number:
4127453
Registry Status:

Current
Renewal Due/Exp. Date:
5/ 15/2023
RCT Registration Number:

CT026-1665
Issue Date:
10/14/20t9
R"ortl Iype:

Charily Re-isuation
Effective Date:
10/14/2019
Date of Last Renewal:
6/6/2022
DBA:

Mailing Address
'Street; 31430 LOMA LINDA RD
Street Line 2:

City, State zip: ITNIECULA CA 92592
("f--47Q Confirm ltljon LiLjjggi tt' tl n Click on Document I')�pe at the Icft to open PDF 1' un g D� 117] Cl1lS —� ��-�-- Click on Documcnl Type ai the left lu open I't)1- � - Form CT-TR-i 2021
CT-550 Fornl f IBC' _1,_.1ticoIllplete 2018
Form RRf-1 2019-An1INI I
"")I -Ill CT-TR-1 2020
I prat RRf I 2020
wjLR Fit - L 2021
Renewal Fill 1L 2020 _� ~
it
Status of Filing: ;accepted
Accounting Period Begin Dale: Ut/201 n
Accounting Period End Date: i2 1/2018
Filing Received Dale: 10,29/2o19
Form R11117-1 Reject/Incomplete Reason:

Form CT-TR-1 Reject/Incomplete Reason:

IRS Form 991) Reject/Incomplete Reason:

Hates From Registry Staff:

Status of Filing:

E-•Accepted
Accounting Period Begin Date:
1/1/20[9
Accounling Period End Date:
12;:31/2019
Filing Received Date:
1 /2T2020
Form RRF-1 Reject/Incomplete Reason:

Form C F-TR-1 Reject/Incomplete Reason;
IFUR Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accepted

Accounting Period Begin Date:
7,11/2019
Accounting Period End Date:
7/1/2020
Filing Received Date.
7/27,2020
Form RRF-I Reject/Incomplete Reason:

Form CT-TR-1 Reject/[ncomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accepted
Accounting Period Begin Date:
1/1/2020
Accounting Period End Date:
12/3 P2020
Filing Received Date:

I I.M12021
Form RRF-I Reject/Incomplete Reason:

Resubmission/Correction Accepted
Form CT-TRA RejectAncomplete Reason:

Resubmission/Correction Accepted
IRS Form 990 Reject/[ncomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accounting Period Begin hate:

Accounting Period land Dale:

Filing Received Date:

Form RRF-1 Reject/incomplete Reason:

Form CT-TR-I Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Accepted
1 /1 /2021
12/ 3 1 /2021
5/27/2022
Res ubinission/Correction Accepted
ReSUbmissiwL/CwTectlon Accepted
No Related Records

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
14 DORLAND MOUNTAIN ARTS
COLONY INC.

CITY OF TEMECUI.A
FISCAL YEAR 2022 - 2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

I PROJECT/PROGRAM INFORMATION
Amount Requested: $
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Project/Program Title: Art for Temecula Start Date: 1/1/2023 End Date: 12/31/2023 Physical Address of Project/Program: Dorland Mountain Arts 36701 Highway 79 Temecula CA 92592 INCLUDE IF DIFFERENT THAN ORGANIZATION's MAILING ADDRESS If Grant is Awarded, Make Check Payable Dorland Mountain Arts to: Mailing Address: PO Box 6 Temecula CA 92593

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant
Organization: Dorland Mountain Arts Year Founded: 1979_ Website: m Social Media:

Number of Paid Staff: 2 Number of Volunteers: 95
Geographic Area(s) the Organization Serves: Temecula valley Geographic Area(s) the Project/Program Serves: Temecula Valley NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Janice Cipriani- Willis Title/Position: Executive Director Contact Person's Direct Telephone: 951-302-3837 Contact Person's Email: [email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes ® Date of Incorporation as a Nonprofit: 1984 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 95-3786125 State Identification Number:

PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this.link: http://ar)os.irs.clovlapo%osl

2. ❑ Attach State Entity Status Letter using this link:
htt s:!/ www.ftb.ca , ov/online/self serve entity status letter/index-as

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: httta:Ilrct.doi.ca.govNerification/Web/Search.apx?facih'fy=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No x❑ Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES. voflana s mission Is io provloe a unique, Inclusive WorKing retreat Tor visual artists, Writers, and musicians inspiring creativity in a secluded natural setting. Dorland serves the regional community with arts events, educational and healing workshops and projects for children and adults. In conjunction with The Nature Conservancy, Dorland is mandated to protect the ecology of the undeveloped portion of its 300 acres. As such, Dorland staff and volunteers maintain trails and a small lake on the property, and make every effort to identify and preserve indigenous flora and fauna, and remove non -indigenous species.

On May 3, 2004, the Eagle Mountain fire destroyed every single one of Dorland's structures. Convening immediately after the fire, the Board of Directors, devoted past resident artists, and individual supporters moved forward to rebuild. A licensed arborist guided the project, delicately removing fire -damaged trees to preserve the remaining indigenous oaks and surrounding native plants. Importantly, the Board of Directors used this loss as an opportunity to begin more sustainable building and construction practices.

Since 2014, Dorland has added four more cottages, a Community Arts Center, ADA compliance (including two ADA parking spaces) and a pavilion and deck for community events. The now -thriving Associate Artists Program benefits Dorland's local and regional artists by providing artists, writers, musicians and supporters of the arts with essential space to meet, discuss: create, plan and impiement activities that support Dorland

FINANCIAL STATEMENTS

I
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No Z Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH +YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANTOR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECTIPROGRAM IN THIS APPLICATION? No Q Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW
AMOUNT MONTH + YEAR

RECEIVED NAME OF ENITY

FUNDING RECEIVED
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT - RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT. the Associate Artist Program serves our local area of Temecula Valley. The program is run soley by volunteers. 550 local members participate in the program by organizing public activities that support Dorland, the regional arts community, and each other Dorland.'s cultural events in the Temecula Valjey attract an. average of 1615 attendees/ year, promoting the arts in our region. In conjunction with the City of Temecula, Dorland supports local artists with exhibits at the Merc Gallery, the Temecula Valley Museum, an online gallery and other local venues. The recent addition of Dorland's Community Arts Studio building with its outdoor Pavilion further gives Dorland the opportunity to provide expanded public arts events, exhibits, and educational and healing workshops for community children, youth, and adults.

Programs that directly serve Temecula Valley residents:

ASSOCIATE ARTISTS PROGRAM: Coffee on the Deck - Discussions about art, sharing, demos and critiques. 2 x per month COMMUNITY ARTS CENTER. 6 Art Exhibits per year open for public viewing and receptions WORKSHOPS: Sunday Scribblers - Free. This is a writing workshop and critique focusing on poetry and prose every Sunday. It includes guest speakers.

Table Manners Theater - Free. Open to the public to participate in reading original and new plays and screenplays 6x per year 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

Funding will support the operation of the Community Art where Dorland runs its community programs.

Grant support would enhance the amenities by funding the installation of a utility sink and new flooring.

New Flooring Art in the Community Studio/Gallery -$1500 Utility Sink Art in Studio/Gallery -$500
Facilities/Rent/Insurance for Community Studio/Gallery - $1,839 Supplies - $430
Marketing - $289
TOTAL- $4558
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

Dorland hosts many events open to Temecula residents in The Community Arts Center located on our beautiful mountain campus. This three room building, deck and pavilion area allows us a space to invite local residents to participate in programs, workshops and special projects.

The main room of this building provides a gathering place for workshops, programs and meetings. In addition, there is a library room and studio used for programs and available for special projects. Tge deck and covered pavilion provide outdoor space for community meetings, workshops and programs.

Dorland Mountain Arts strives to provide a safe and welcoming space for the community to come together, learn about new ideas and skills and meet other creative folks. By offering free and very low cost programs to Temecula residents we are providing an opportunity for creative exchange, learning and sharing. Having a quality space with varied amenities enhances the experience for Temecula residents and allows for more programs in the future.
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 800-1000 FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 1 10 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS.

Dorland Mountain Arts is committed to providing quality programs and experiences to the Temecula community. —Upgrading our program space will -help us continue to provide creative sharing and learning opportunities. The Community Art Center is vital to our mission and indispensable in offering a quality experience to the residents of Temecula Valley. 5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

I_
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM-
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $
Community Services Grant (Not to exceed $50,000) 4,558
Amount contributed to the Project/Program by the Applicant $ Organization 5,500
Other grants or funding already awarded for Project/Program, if any $ In -Kind match amount or volunteer credit hours estimated amount $ 7,704 TOTAL REVENUE $ 17,762

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment $
Facilities/Rent/Insurance $ 1,839
Supplies $
430
Marketing $
289
Services $ 2,000
Food
Other flooring and sink $ 2,000
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT, - HOWEVER PLEASE INCLUDE. $ 3,500
TOTALEXPENSES $
TOTAL BUDGET J $ 17,762 1 $ 10,058
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS* FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

If your organization was awarded a Community Service Funding Grant in Fiscal Year 2021-2022 by the City of Temecula, all grant funds received must have been expended anytime on or between July 1, 2021, and June 30, 2022. In addition, ail grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any future funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent If the funds were not spent in accordance with the approved/awarded application, the organization will be required to return the amount of funds to the City. To substantiate that Fiscal Year 2021-2022 funds received from the City were spent appropriately, proper back-up documentation including the completed table below with accompanying receipts/invoices, must be submitted to the City on or before due date: September 12, 2022. 1 _ Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization: Name of Project/Program:

FY 2021-2022 Amount of $
CSF Grant Fund Awarded:

Month & Year CSF Grant Received from City:

Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):

Date on
Expenditure
E Name of Company
2 Receipt/Invoice
M on Receipt or Invoice

MUST BE ON OR BETWEEN
Amount
Description
Purpose
a3
JULY 1, 2021 - JUNE 30, 2022

DESCRIBE THE EXPENDITURE

PURPOSE OF EXPENDITURE
1 $
2 3
4 5
$
6 $
EXPENDITURE TOTAL $ EXPENDITURE TOTAL MUST BE EQUAL TO
(OR GREATER) THAN TOTAL AWARD AMOUNT
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said -amount-of-funds-to-the-City To -substantiate -that -grant -funds -from -the -City -are -spent -appropriately, proper -.pro documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Organization: Name of Project/Program:

TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: $ was received from City:

1. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the City

3. Is this Expenditure Report is submitted to request reimbursement of funds? No or Yes If yes, Amount of Request $ Number of beneficiaries living in 92590, 92591, 92692 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number)_ E Name of Company
E on Receipt or Invoice
Q Z
1 2
3 Date on Expenditure
Receipt/Invoice MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER

MUST BE ON OR BETWEEN
March 20, 2020 - JUNE 30, Amount Description Purpose
2024 Q
W
R
EXPENDITURE TOTAL $ EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.

The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. ■ If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Dorland Main Arts
MAILING ADDRESS: PO Box 6
Temecula CA 92593
PHONE:( 951 ) 302-3837
EMAIL: infoRDorlandArts.org
PRESIDENT / AUTHORIZED OFFICER: 4 Nawsha Narrisnin _
SIGNATURE: r�U - r DATE: 9/10/2022

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:

SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: Stacey. [email protected] (951) 694-6413
Betsy. [email protected] (951) 693-3959
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

!nternal Revenue Service
District Director
DORLAND 4OUNTAIN ARTS COLONY, INC.

Da te:

NOV 0 1 1984
Dorland N,cuntain Colony, Inc.
36701 Highway 79
Temecula, CA 92390
Dear Applicant:

DepartrnehL Jr the TreasL,,, y
Our Letter Dated:

December 29, 1982
Person to Contact
M. Tomback
Contact Telephone Number.
t 213 ) 688-488 5
This modifies our letter of the above date in which we stated that you would be treated as an organization which is not a private foundation until the expiration of your advance ruling period.

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 Internal Revenue Code, because you are an`organization of the type described in section Sn�(all1�* Your exempt status under section 501(c)(3) of the code is still in effect.

Grantors and contributors may rely on this determination until the Internal Revenue Service publishes notice to the contrary. However, a grantor or a 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 that resulted in your loss of section 504!T1f�,L* _ status, or acquired knowledge that the Internal Revenue Service had given potice that you would be removed from classification as a section 509laR W organization.

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 iotlrn.

District Directar
'axed 170(b)(1)(A)(vi)
P.O. Sox 2350, Los Angeles, Calif. 90053 Letter 1o50 (00) (7-771

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
F T B PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 9/12/2022
ESL ID: 7857079728
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 1104809
Entity Name: DORLAND MOUNTAIN ARTS COLONY INC

1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board. 0 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d, ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Connect With Us
Web: ftb.ca.gov
Phone: 800-852-5711 from 7 a.m. to 5 p.m. weekdays, except state holidays 916-845-6500 from outside the United States

s�!i
�• California Secretary of State
Electronic Certified Copy
I, SHIRLEY N. WEBER, Ph.D., Secretary of State of the State of California, hereby certify that the attached transcript of 2 pages is a full, true and correct copy of the original record in the custody of the California Secretary of State's office.

IN WITNESS WHEREOF, I execute
this certificate and affix the Great
Seal of the State of California on
this day of January 15, 2022
SHIRLEY N. WEBER, Ph.D.

Secretary of State
Verification Number: P82RJ34
Entity (File) Number: C1104809
To verify the issuance of this Certificate, use the Verification Number above with the Secretary of State Electronic Verification Search available at bizfile. sos. ca. gov

rn'
California Secretary of State MINN
Electronic Filing Secretary of State
r State of California
Corporation - Statement of Information
Entity Name: DORLAND MOUNTAIN ARTS COLONY,
INC.

Entity (File) Number:

File Date:

Entity Type:

Jurisdiction:

Document ID:

Detailed Filing Information

1. Entity Name:

2. Business Addresses:
a. Street Address of Principal
Office in California:
b. Mailing Address:

3. Officers:
a. Chief Executive Officer:

C1104809
01 /13/2022
Corporation

CALIFORNIA
H110480

DORLAND MOUNTAIN ARTS COLONY,
INC.
36701 Highway 79 South
Temecula, California 92592
United States of America
PO Box 6
Temecula, California 92593
United States of America
Curtis Horton
1869 Pasadena Glen Rd
Pasadena, California 91107
United States of America
b. Secretary: Noreen Ring
1935 Vista Del Norte
Fallbrook, California 92028
United States of America
Use bizMe.sos.ca.gov for online filings, searches, business records, and resources. v
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Electronic Filing
Officers (Cont'd):

C. Chief Financial Officer:

4. Agent for Service of Process:

Natasha HdIIISUn
24 Almy St
Newport, Rhode Island 02840
United States of America
Curtis Horton
1869 Pasadena Glen Rd
Pasadena, California 91107
United States of America
By signing this document, I certify that the information is true and correct and that I am authorized by California law to sign.

Electronic Signature: Janice Cipriani
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Form 990 OMn No, 1545-0047
Return of Organization Exempt From Income Tax 2020
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) DapfuImool of Iho Tnlin ry ► Do not enter social security numbers on this form as it may be made public. Open to Public Intmnat Revenue Service ► Go to wwwJrs. ov1Form990for instructions and the latest information. Inspection A For the 2020 calendar year, or tax year beginning .2020. and ending 20 B Check if applicable: C Employer identification number ,Address change DORLAND MOUNTAIN ARTS COLONY 95-3786125 Name change P.O. BOX 6 E Telephone number
Inliiai�e ;rn TEMECULA, CA 92593-0006 - 951 : 302-3 337 Final returNtermir'aled bb
Amended return, G Cross recmials Y
Appheation pendiny F Name and address of principal off,cer: WO'Is�Mis a group return for subordinate Tax-exempt status:

J Website: ► W
K Form of organization:

SAME AS C ABOVE
501(cy3) 501(c) ( )� (Insertno.)
)ORLANDARTSCOLONY,ORG
Corporation I I Trust I I Ass or: ialion Other
H(b) Are all subordinates mcruded?
If ' No, , attach a list_ Sea. insuuctions
Grcup exemption number
142 830.

Yet: No
Y<F No
I Year or formation: 1982 I M Slate of legal domicile: CA Part l
I 5ummaill
1 Briefly describe the organization's mission or most significant actnrilies:THE MISSION OF DORLAND MOUNTAIN ARTS_
COL_ONY__IS TO PROVIAE A jQVETWORK_ING AN_D_PE_RFORMANCE_R_E_TR_EAT�FOSTERING --_'_---_ _
r
A COMMUNITY CONNECTION TO_THE_CREATIVE
PROCESS IN A SECLUDED_
_CR_E_ATI_V_ITY_, _All]
_
_ __-
0 2
_NA_T_U_RA_L__SE_T_TING_._____-_-_--__________-_-_-_-__--__--_-_--_--____--_-__--_----_ Check this box ► f if the organization discontinued its operations or disposed of more than 25% of its net assets. —
_ ---
ta
3 Number of voting members of the governing body (Part VI, line la). ..... 3 7
°a
N
4 Number of independent voting members of the governing body (Part VI, line lb) - - - q
5 Total number of individuals employed in calendar year 2020 (Part V. line 2a). -. 5 2
6 Total number of volunteers (estimate if necessary). - 3 a
7a
Total unrelated business revenue from Part VIII, column (C), line 12 7a
a.
b Net unrelated business taxable income from Form 990-T, Part I, line 11 ..... 7b
0,
Prior Year
Current
Year
8 Contributions and grants (Part VIII, line lh)......... .... 174 803.
57,364.
9 Program service revenue (Part VIII, line 2g) ..
79,267.
74,586.
10 Investment income (Part VIII, column (A), lines 3, 4, and M) 1,450.
642.
cc
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9C. I0f:..an _dilie] 13,066.
10,238.
12 Total revenue -- add Imes 8 through 11 (must equal Part Vlll- co mn (A), line 12) 268, 586.
142, 830.
13 Grants and similar amounts paid (Part IX, column (A), lines 1-3).. - - . 14 Benefits paid to or for members (Part IX, column (A), line 4) .... .. . w
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 21, 669,
25,993.
16a
Professional fundraising fees (Part IX, column (A), line Ile) wb
Total Fundraising expenses (Part IX, column i line 25) ► 1,662. 17 Other expenses (Part IX, column (A), lines IIa-lid, 11f-24e)-- .. ..- ... 18 Total expenses. Add lines 13-17 (must equal Part )X, column (A), line 25) 19 Revenue less expenses. Subtract line 18 from line 12 86 561.
105 170.
108 230.
131 163.
160 356.
11 667.
88 4"
0p
1LL
20 Total assets (Part X, line 16).-
21 Total liabilities (Part X, line 26)
22 Net assets or fund balances. Subtract line 21 from line 20 Beginning of Current Year
End of Year
903, 212.
920 211.
11,158.1
16,490.
892,054.1
903 721.

Part If Signature Bloc
urvfw penalties of poqury, I drrefare that I have eaamufed the return, mcludufy all:4v"anying scheduies and sialemerC, and to Bee best of my knnwledge and belief, it is free, cerrect, and complete. Declaration of preparl (other than officer) is based on all Womil W whMil prepare, has any knuMedge. t�
Sign - arrgrwreraa11.oreCer vase
Here CURTIS HORTON PRESIDENT.

Yt7u or print narne and hl e
Printilype preparers came Nreparcr's signature Dale Checx Lj If PT•N Paid LESLIE A. DOHERTY CPA LESLIE A. DOHERTY CPA self-employed P00449291 Preparer Firm snarne ► LESLIE A DOHERTY CPA APC
Use Only nm'saddress ► 41880 KALMIA ST STE 115 FinnsEIN► 20-2082661 MURRIETA, CA 92562 Phoncno. (951) 698-2260
May the IRS discuss this return with the preparer shown above? See instructions JXYes No I For Paperwork Reduction Act Notice, see the separate instructions. rF=ALlo1L o!nnra' Form 990 (2020)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
1!5

FINE ARTS THEATER NETWORK

CPI`Y OF TEM.IOCULA.

FISCAL. YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVEST'MENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEF"ORE:-MONDAY-, SEPT-EMBER 12, 2022---

PROJECT/PROGRAM INFORMATION
)
Amount Requested: $ 50,000.00 _ MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Pump up the Volume
Project/Program Title. _ Start Date: 12/1122 End Date: 5/31 /23 Physical Address of Project/Program: 42051 Main Street, Temecula CA 92590

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Fine Arts Network Mailing Address: 41391 Kalmia St #200
Murrieta, CA 92562

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant Fine Arts Network Theater
Organization: _ Company Year Founded: 1994
Website: www.fantheater.com
Number of Paid Staff: 3 (part time)
Social Media: FB, Instagram
Number of Volunteers: 100's annually
Geographic Area(s) the Organization Serves: SW Riverside County, Temecula Valley Geographic Area(s) the Project/Program Serves: Old Town Temecula Community Theater NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name- Beverly Stephenson Title/Position: founder/director Contact Person's Direct Telephone:951-314-2401
Contact Person's Email: faerietalewriter@gmail,

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes E Date of Incorporation as a Nonprofit: 10/7/94 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 33-0624570 State Identification Number: 1872912 PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. N Attach IRS Deductibility Status using this link: httpJ/al)ps.irs.gov/apeleros/

2. K Attach State Entity Status Letter using this link:
https://www.ftb,ca.g-Q-v/online/self serve enfty status letter/index.as

3. N Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: littn�//rct.do'.ca. ❑v/VerificatiordWeb/`Search.as x?facilll =Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

APPLICATION AUTHORIZATION
Has the organization or any members of the Board of Directors of the organization been involved with any personal business transactions valued over $500 including any business transactions, negotiations, investments, or interests in real property with a Temecula City Council Member during the past 12 months? No Q_Yes -❑_IF_YES,-BRIEFLY_ DESCRIBE: —
Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No pj Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organizations:

Executive Committee ❑ Board of Directors M
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

To build the self-esteem of all individuals through broad based, hands-on exposure in the performing arts. To channel the creativity of young and old in a positive and artistic direction.

To utilize the sucess and self-esteem attained through participation as a preventative measure against negative peer pressure and anti -social behaviors. To involve the community, from youths to seniors in the sharing of their talents both on stage and off as leaders and mentors. To provide instruction in all genres of performing arts and stagecraft. To produce and perform quality local productions for the benefit of the participants and the spectators.

FINANCIAL STATEMENTS
UPON REQUEST, COPIES OF THE ORGANIZATION's CURRENT BUDGET/FINANCIAL STATEMENTS (BALANCE STATEMENT AND INCOME STATEMENT), AND IF AVAILABLE CPA'S AUDIT, MAYBE NEEDED UPON REQUEST TO DEMONSTRATE SOUND FINANCIAL MANAGEMENT. DO NOT SUBMIT NOW.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes M IF YES, PROVIDE BELOW
NAME OF PROGRAM/PROJECT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP Theater LIVE after Covid $2500 October 2020 Community Servic $
$
$
$
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? No ■ Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW
AMOUNT MONTH + YEAR

NAME OF ENITY
RECEIVED _ _ FUNDING RECEIVED
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECTIPROGRAM DESCRIPTION

IMPORTANT - RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

When the Old Town Theater _opened, The —Theater _Foundation -provided 36 wireless mic units. We, (Theater -foundation, Fine Arts Network, TVP) the resident companies have refurbished these mics multiple times over the past 17 years.

We, now, only have 10 working units. We, Fine Arts Network, proposes to purchase an additional 24 units so we once again have enough mics to stage full musicals, concerts and plays. The program specifically is to keep the OTTCT at the cutting edge of performance venues by providing a quality visual and sound experience. The program would free us from the burden of renting mics from amide-aaencies.-at_a_heftv price while maintainina a auality sound experience. 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

The grant will provide for the purchase of 24 body mic kits which includes the elements, battery pack, transmitter and case to house all 24 units. (see attached) 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS, The Old Town Temecula Community Theater (OTTCT) has been praised as a "jewel box" of a theater. From its inception we have provided great sound. That element is in danger of disappearing due to the 17 year old and nearly obsolete equipment we have refurbished on several occasions. Local residents comprise over 50% of our audience. Temecula residents are proud to boast of the fine theater we have. If the sound quality is poor, the entire experience of live theater is undermined and becomes a negative experience for all. When first conceived, great attention was paid to the acoustics of the theater. After all the time and money spent on building and creating a fine reputation, we desire to maintain the 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 1 O,000+ annua FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: I200+ City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION
CON71NUED
4 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS. -Pump up the Volume will maintain quality sound and quality theatrical experience at the OTTCT by purchasing new state of the art equipment. 5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

The pandemic stripped us of our reserves and any ability we might have had to purchase this equipment directly. At the most recent board meeting we were earmarking funds to purchase new mic units over the next 3 years. We hoped to purchase 5-10 units (based on costs) immediately. Based on the estimate we just received, we would be hard pressed to afford 5 units currently ourselves. It would then take us 5 years in order to build to a full rack of 24 mics, hoping that we would not lose all of the older 10 units before we could replace them. The pandemic has created a situation, where we feel we are at ground zero, starting all over again building audiences, networking with performers and training our young theatrical enthusiasts.
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

The above mentioned funds will complement and ultimately replace seriously dated equipment that verges on being obsolete. It will allow new and existing programs/productions to maintain the high caliber of sound come to be expected of performances at OTTCT.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from -this City of Temecula $ 50,000 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ 17,000 I Organization
Other grants or funding already awarded for Project/Program, if any In -Kind match amount or volunteer credit hours estimated amount $ TOTAL REVENUE $ 67,000

LIST OF EXPENSES FOR PROJECT/PROGRAM
24 body mics with elements, casing,
Tools/Equipment transmitters etc. see attached $ 67,000 Facilities/Rent/Insurance $
Supplies $
Marketing $
Services $
Food $
Other $
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; $ HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES $
TOTAL BUDGET $67,000 $67,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

FISCAL YEAR (FY) 2020-2021 COMPLIANCE REPORT
If your organization is awarded a Community Service Funding Grant in FY 2020-2021 by the City of Temecula, then this information is not due until September 13, 2021 If your organization is awarded a Community Service Funding Grant in Fiscal Year 2020-2021 by the City of Temecula, all grant funds received must be expended anytime on or between July 1, 2020, and June 30, 2021. In addition,
—all=grant=funds=must=be=substantiated-Mth-proper-back=up=dseumentation: Failure-to=provid"roper=docum-e-ntatl6n may jeopardize any future funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent.

If the funds are not spent in accordance with the approved purpose stated on the Application, the organization will be required to refund the amount of funds. To substantiate that Fiscal Year 2020-2021 funds received from the City were spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City on or before due date: September 13, 2021.

EXPENDITURE REPORT due on or before September 13, 2021

1. Provide the number of beneficiaries living in 92590, 92591 and 92592 that directly benefitted 4,000 locals from this program (approximate number of beneficiaries if you don't have a precise number): annually

2. Fill out this table (include additional copies if needed to explain all expenditures)

3. Attach Receipts/Invoices (in the same order as listed in this table)

4. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Office - CSF Organization: Fine Arts Network Theater Co.

Amount of Grant Fund Awarded: $ 2500.00
Theater LIVE
Name of Project/Program: after Covid
Month + Year Grant Received from City: DEC 2020
Date (Mo/Day/Yr)
Describe...

Explain ...

Name of Company
on Receipt/invoice
Amount
(1) what the expenditure was
how the expenditure
E -
on Receipt/Invoice
of
(2) purpose of the expenditure
specifically benefitted
E
Must be dated on or
between July 1, 2020 -
Expenditure
MUST support Project/Prcgram
description on Application + Award Letter
Temecula residents
Q z
June 30, 2021
1 It benefitted residents
Collection
Made By City:
/1/2020 - 9/30/2020
$ 300.00

1. Social Media
by keeping them
10/1/2020-12/31/20
0 S �00.90

2. To keep FAN alive and
formed of social
informed
opportunities that were
Brittany
relevant during closure. To
safe and available. It
_
Campbell
promote Go Fund Me and
provided and outlet for
fundraising efforts during
safe gathering and
1/1/2021- 3/31/2021
UU
$ 300.
closure on Social Media
provided hope andcomfort through artistic
4/1/2024 - 6/30/2021
$ 300.0o
presentations
2 Got
Print.com
January 13,
2021

1. Season program
$2,427.94 2. To provide advertising
and promotion materials
EXPENDITURE TOTAL 3627.94
Note: Expenditure Total must be equal to (or greater than) the "Amount of Grant Fund Awarded" (above) provided by the City.

City of Temecula
Community Service Funding Grant
In anticipation of
opening we prepared a
advertising style
magazine piece to
provide information
about the City, the
Theater and upcoming
shows and what to
FY 2021/2022

PREVIOUS* FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

If the funds were not spent in accordance with the approved/awarded application, the organization will be required to return the amount of funds to the City. To substantiate that Fiscal Year 2021-2022 funds received from the City were spent appropriately, proper back-up documentation including the completed table below with accompanying receipts/invoices, must be submitted to the City on or before due date: September 12, 2022.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office— CSF JEXPENDITURE REPORT due on or before September 12, 2022 Fine Arts Network Theater Pump up the Volume
Organization: Name of Project/Program:

Omvanv 91
FY 2021-2022 Amount of $
CSF Grant Fund Awarded: '�' Month & Year CSF Grant Received from City: October 2020 I
Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):

Date on
E Name of Company Receipt/invoice
E on Receipt or Invoice MUST BE ON OR BETWEEN
QZ JULY 1, 2021 - JUNE 30, 2022
2 3
4 5
6 —.I-- I

EXPENDITURE TOTAL
_ Expenditure
Amount Description Purpose

DESCRIBE THE EXPENDITURE I PURPOSE OF EXPENDITURE

EXPENDITURE TOTAL MUST BE EQUAL TO
(OR GREATER) THAN TOTAL AWARD AMOUNT
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in - - accordance with the approved/awarded applicaticn, thee organization may not -receive and/or will -be -required -to -return -said amount -of -funds -to -the -City. To- substantiate--that-grant-funds from-the-City--are-spent--appropriately, proper -back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1,A above first, B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Organization: Fine Arts Network Theater Name of Project/Program: Pump up the Volume Company p
TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: _ _ was received from City: .

1. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the City

MUST BE ON OR BETWEEN
March 20. 2020 - JUNE 30,
2024
Expenditure

MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER Amount Description Purpose
I
3 EXPENDITURE TOTAL $ EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:

Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. ■ Awards will be given to organizations an__d activities that__directly_benefit the reWents_of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

C The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Fine Arts Network Theater Company
MAILING ADDRESS: 41391 Kalmia St.#200
Murrieta, CA 92562
PRESIDENT/ AUTHORIZED OFFICER: Joe Arreola
PHONE: (951 )314-2401
EMAIL: [email protected]
President
SIGNATURE: LJrG _ _ DATE: "/9/22
MONIT'H, DAY. YEAR
IFDIFFERENT THAN AB ",Beverly Stephenson founder/director APPICATION PREPARED BY:

I T ; . "'.

SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions. Stacey. [email protected] (951) 694-6413
Betsy. Lowrey@TemeculaCA,gov (951) 693-3959
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

STATE OF CALIFORNIA
�jj FRANCHISE TAX BOARD
FTB PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 9/12/2022
ESL ID: 5629859781
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 1872912
Entity Name: FINE ARTS NETWORK
0 1.

The entity is in good standing with the Franchise Tax Board.

2. The entity is not in good standing with the Franchise Tax Board.

3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d.

4. We do not have current information about the entity.

5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Connect With Us
Web: ftb.ca.gov
Phone: 800-852-5711 from 7 a.m. to 5 p.m. weekdays, except state holidays 916-845-6500 from outside the United States
California
Relay Service: 711 or 800-735-2929 (For persons with hearing or speech impairments)

Q HELPB MENU
Home > Tax Exempt Organization Search > Fine Arts Network < Back to Search Results
Fine -Arts- Network
EIN: 33-0624570 1 Murrieta, CA, United States
Publication 78 Data o
Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in determining deductibility of their contributions.

On Publication 78 Data List: Yes
Deductibility Code: PC
Copies of Returns (990, 990-EZ, 990-PF, 990-T) o
Electronic copies (images) of Forms 990, 990-EZ, 990-PF or 990-T returns filed with the IRS by charities and non- profits.

Tax Year 2019 Form 990
Tax Year 2018 Form 990
Tax Year 2017 Form 990
Tax Year 2016 Form 990EZ
Tax Year 2015 Form 990EZ

INTERNAL REVENUE SERVICE

DISTRICT DIRECTOR
2 CUPANIA CIRCLE
MONTEREY PARK, CA 91755-7406
Date: OCT

FINE ARTS NETWORK
C/O-VIRGINIA K. COSTILQYT
28410 FRONT STREET, SUITE 104
TEMECULA, CA 92590
Dear Applicant:

DEPARTMENT OF THE TREASURY
Employer Identification Number:
33-0624570
Case Number:
954230016
Contact Person:

TERRY IZUMI
Contact Telephone Number:
(714) 826-1448
Accounting Period Ending:

December 31
Foundation Status Classification:
509 (a) (2)
Advance Ruling Period Begins:

July 27, 1994
Advance Ruling Period Ends:

Dec. 31, 1998
Addendum Applies:

No
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).

Because you are a newly created organization, we are not now making a final determination of your foundation status under section 509(a) of the Code.

However, we have determined that you can reasonably expect to be a publicly supported organization described in section 509(a)(2).

Accordingly, during an advance ruling period you will be treated as a publicly supported organization, and not as a private foundation. This advance ruling period begins and ends on the dates shown above, Within 90 days after the end of your advance ruling period, you must send us the information needed to determine whether you have met the require- ments of the applicable support test during the advance ruling period. If you establish that you have been a publicly supported organization, we will classi- fy you as a section 509(a)(1) or $09(a)(2) argani.zation as long as you continue to meet the requirements of the applicable support test. If you do not meet the public support requirements during the advance ruling period, we will classify you as a private foundation for future periods. Also, if we classify you as a private foundation, we will treat you as a private foundation from your beginning date for purposes of section 507(d) and 4940, Grantors and contributors may rely on our determination that you are not a private foundation until 90 days after the end of your advance ruling period.

If you send us the required information within the 90 days, grantors and contributors may continue to rely on the advance determination until we make a final determination of your foundation status.

If we publish a notice in the Internal Revenue Bulletin stating that we Letter 1045 (DO/CG)

2020�-
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MURRIETA, CA-925 5 2_
951-314-2401

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tJnuer section 501(c). 521, or 4941(a)(1) 04 J-e Internal Fit,'Me Cade (e.lcept pr;.ate f�,, ptjjI! ) 1, Do nCt ante ioc!a€ security numbefs on this form as .I D,A-/ be made pubirc svw.

Go to w,1.rs-gossForm990 for Instructions and the latest Information, r, ur tax year
To a; ass,>ts
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Star Way Systems Corporation
Quote
P. 0. Box 1357
Murrieta, CA 92564
9/8/2022
Phone # 951-678-5680
• ' " '
&0) '
Fax # 951-678-8052
19592
Fine Arts Network
Beverly Stephenson
41391 Kalmia St Ste 200
Murrieta, CA 92562
Omnidirectional Condenser Miniature-Lavalier Mic-Black
Shure WL93
30 95.00

80.00 2,400.00
Quad Digital Wireless Receiver with internal power
Shure
6 9,034.
5,646.2
33,877.50
supply, 1 /2 Wave Antenna and Rack Mounting hardware
ULXD4Q=-G50
Digital Wireless Bodypack Transmitter with Miniature 4-pin Shure ULXD1=-G5
1 24
794.
496.25
11,910.00
Connector
Five -way active antenna and power distribution system.

Shure UA845UWB
2 1,474.
921.25
1,842.50
Switchable frequency ranges: 147-216 MHz, 470-960 MHz,
1240-1260 MHz, 1492-1525 MHz, 1785-1805 MHz
Passive Directional Antenna (470-952 MHz)
Shure PA805SWB
2 373.0
261.25
522.50
includes 10' BNC/BNC Cable
Rechargeable Battery
Shure SB900B
48 126.00
100.0c
4,800.00
Rack Battery Charger
Shure SBRC-US
4 835.00
621.25
2,485.00
Black Label 16-space Amp Rack with Wheels
Odyssey
2 799.95
592.19
1,184.38
FZAR16WBL
Utility Rack Drawer 3RU 5.25in
Middle Atlantic
4 242.00
153.12-
612.50
UD3 3RU
Snake Cable 12-channel XLR male to XLR female, 19
Sescom
2 189.4S
173.69
347.38
12XLM-12XLF-10
Labor - Rack Build
1,500.0
1,500.00
Estimated shipping
600.00
600.00
OPTIONAL UPGRADE:
(30) Omnidirectional Earset Headworn Microphone, cocoa - Shure MX153C/0-TQG
$226.25 each x 30 = $6,787.50 plus tax, if applicable
NOTE: Prices are valid for 15 days from date of quote.

Deposit of 50% is required to bind this quote. Once order is placed (ie. deposit is received), estimated delivery is 6 months due to supply chain issues.

Sales Tax

8.75%
5,248.40
Total $67,330.16
To accept this quote, please sign, date and return:

Prepared by CS

Full Compass Systems, Ltd
9770 Silicon Prairie Parkway
MADISON, WI 53593
608-831-7330
Fax:608-831-6330
Bill to:

Fine Arts Network
41391 Kalmia St
Ste 200
MURRIETA HOT Si'RINGS, CA 92562
Ship to:

Fine Arts Network
41391 Kalmia St
Ste 200
MURRIETA HOT SPRINGS, CA 92562
Quotation
Confirmation #
Page
Date
Sales order
Purchase order #
Ordered by
_Salesperson
Payment
Customer account
FOB
Expiration date
a
SOC4836238-3
1of2
9/12/2022
SOC4836238
Dave Cradler
Credit Card
CUC2601395
FOBO
10/27/2022
Qty
Extended
Mfg
Item number
Description ordered Unit
Ship via
Unit jerice
price Fin
SHU
MX153T/0-TQG
Mic, Headworn Omni Cond. Tan
30 EA
Bestway
$224.12
$6723.60
https://www.fullcompass.com/prod/205081
SHU
ULXD4Q-G50
Quad Digital Receiver
6 EA
Bestway
$5088.45
$30530.70
https://www.fullcompass.com/prod/215817
SHU
ULXD1-G50
Transmitter, Bodypack
24 EA
Bestway
$491.58
$11797.92
https://www.fullcompass.com/prod/205101
SHU
UA845UW-B
Antenna/PowerDistSy
2 EA
Bestway
$917.28
$1834.56
https://www.fullcompass.com/prod/518501
SHU
PA805SWB
Antenna Wide Band
2 EA
Bestway
$272.42
$544.84
https-:// www.fullcompass.com/prod/125440
SHU
SB900B
Lithium -Ion Rechargeable Battery 48 EA
Bestway
$101.92
$4892.16
https://www.fullcompass.com/prod/602392
SHU
SBRCUS
Axient Digital Rackmount 8-Bay
4 EA
Bestway
$613.72
$2454.88
Charging Station
https://www.fullCOMpa5S.com/prod/530000
ODY
FZAR16WBL
Case,16sp w/Wheels,BlackLabel
2 EA
Bestway
$533.49
$1066.98
https-// www.fullcompass.com/prod/230379
MID
UD3
3 Space Rack Drawer
4 EA
Bestway
$142.56
$570.24
https://www.fullcompass.com/prod/020422
PRO
MT12XFXM-10
Snake 12chl XLRF-XLRM loft
2 EA
Bestway
$114.66
$229.32
Sales subtotal amount: $60645.20
Promotional discount:
$0.00
Shipping & handling:
$375.24
Net amount:
$61020.44
Sales tax:
$5306.46
Total:
$66326.90

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
16 FIRST TEE INLAND EMPIRE

AKA BRIGHTON HILL ACADEMY

SPORTS AND LEARNING CENTER

CITY OF TEMECUTA
FISCAL YEAR 2022 - 2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

I PROJECT/PROGRAM INFORMATION I
Amount Requested: $ 50,000
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Project/Program Title: First Tee IE Life Skills Experience ClassesStart Date: 9/1/2022 End Date: Ongoing Physical Address of Project/Program:

INCLUDE IF DIFFERENT THAN ORGANIZATION's MAILING ADDRESS If Grant is Awarded, Make Check Payable to: First Tee — Inland Empire Mailing Address:
215 N. D Street, Suite 304
San Bernardino, CA 92401

I ORGANIZATION AND GEOGRAPHIC AREA SERVED I
Name of Applicant Brighton Hill Academy SLC dba First Tee — Inland Empire Organization:

Year Founded: g014
I Irs esln aTr�rre
Website: %vww.firstteeiniandempir_e_,org Social Media: FB—firsttee-inlande►r+pire Number of Paid Staff: 4 Number of Volunteers: 35
Geographic Area(s) the Organization Serves: Raypyside and San Be[Dard no county Geographic Area(s) the Proiect/Program Serves Temecula Valley NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Pamela Tyler
Title/Position: Executive Director
Contact Person's Direct Telephone: 909,297.6262 _ Contact Person's Email:
[email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes ® Date of Incorporation as a Nonprofit: 2014 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 46-4933764 State Identification Number: 3671608 PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ® Attach IRS Deductibility Status using this link: http-://aPI)s.irs.gov/app/eos/

2. ® Attach State Entity Status Letter using this link:
https://www.ftb.ca.gov/online/self serve entity status letter/index.as

3. ® Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: httr):/Iret.doi.ca..govNerification/Web/Search.asnx?faciiity=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No ® Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee [N Board of Directors ❑ Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

To impact the lives of young people by providing educational programs that build character, instill live -enhancing values and promote healthy choices through the game of golf.

Create a safe introduction to golf for Temecula Youth via three delivery channels: Green golf courses, Community Programs partnering with other Youth Organizations, and School Programs introducing the program via PE Classes in the Temecula Unified School District teaching youth CORE Values, life skills, and how to succeed in their communities. Participants ages 5-18 progress through the program, deepening their understanding of life skills and golf development.

The integrated approach helps youth build confidence and resilience while on the course, at home and in school. The goal is to Build Game Changers who are committed to: Pursuing Goals, Growing through Challenge, Collaborating with others, Building Positive Self -Identity and Using Good Judgment.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes ® IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP I
First Tee Inland Empire Jr Golf Program $ 2000 -May 2021 CMO-MR First Tee Inland Empire Jr Golf Program $ 1000 May 2021 CMO-J Stewart First Tee Inland Empire Jr Golf Program $ 1000 May 2021 CMO- ME First Tee Inland Empire Jr Golf Program $ 2500 July 2021 CMO- Schwank $
$
$ I I
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? No ❑ Yes DKI IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT

RECEIVED

NAME OF ENITY
J Michael or J Kathleen Smith (Quarterly)
Tom Pernice, Jr. Charities, Inc. 20,000.00
MONTH + YEAR

FUNDING RECEIVED
$
$ 75,000
$ 20,000
$ 10,000
$ 99,910
67, 848
$ 5,826
$ 25,000
2020
12-2020
2020
Toyota -Corporate
Corporate Contributions
Government Grants
Business Contributions
Charles Schwab Matching Funds Grant
2021
2021
2021
2022
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT. 1 First Tee — Inland Empire (FTIE) is a youth character development educational program teaching youth NINE CORE Values and NINE Healthy habits while learning to play golf. Youth learn life skills on how to better -communicate -with -family, —in school--and-how-to succeed -in tlTeir-future endeavors: -Supporting children ages 5-18 in the City of Temecula in the First Tee IE Junior Golf Program. The goal is to reach youth through After -School Program opportunities on local Golf Courses, School PE Programs and Community Programs through the City of Temecula Parks.
2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

The grant funding will be utilized to expand FTIE programs in City of Temecula. This funding will allow FTIE to purchase curriculum, supplies for programs, hats, shirts, and other items needed to run the programs. It will help offset insurance, service costs and snacks. Additional Coaches will be needed which require Background Checks, training, and additional Program Expenses. 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

FTIE exists to enable kids to build strength of character that empowers them through a lifetime of new challenges. Temecula's youth in our programs are: more confident in school, and active community members. A progressive curriculum that focuses on social and emotional learning objectives through activities that are developmentally appropriate, designed to meet kids where they are. FTIE is building Game Changers who can change and enrich a community. The outcome of being in First Tee programs are good citizens, better people, more confident youth with a higher self-esteem that helps heal their generation and community. This helps reduce juvenile delinquency, gang affiliation, and crime for the community. Stats show 98% graduate High School and 84% go onto College. FTIE is focused on diversity, equity and inclusion of all youth no matter their ethnicity or socioeconomic status. It provides an equal playing field for under -served kids who normally would not be able to afford playing golf.

Scholarships are offered. No child is turned away.
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 650 FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM 35 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS.

By seamlessly integrating the game of golf with a life skills curriculum, FTIE creates learning --experiences that -build -inner strength, self=confidence,and resilience that -kids -carry to- — everything they do. FTIE offers after school programs at Golf Courses, Parks and Schools for eight weeks, four times a year and summer camps. We could not expand our program access to these youth programs without generous contributions from the City of Temecula! 5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

FTIE lost 60% of committed funds during Covid-19 Pandemic. This resulted in reduced staff and reduced programming to the community.

Increased costs during this inflationary period has driven up the cost for employees, program supplies, vendor and transportation costs, higher golf course fees, all materials affecting each area of the operation have increased.

In an effort to help First Tee Chapters rebound from Covid and inflationary concerns, Charles Schwab is offering Matching Grant funds if the Chapter receives 50% more donations than the year before, FTIE will receive $32,500 in 2023.

IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM-
If approved, funds will expand and continue existing programming in more Temecula Parks, Schools, Golf Courses, Charter Schools and other Youth Organizations .

OBJECTIVES:
• Growing Participant base by 50%, increasing Girls participation by 15%, and BIPOC by 25% • Growing Coach base by 50% to reach 650 more participants while increasing diversity of staff/coach/volunteers to six more under -served, underrepresented program locations • Increasing after -school programming locations by 35% to help students reach their full potential as productive, caring, and responsible citizens
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)
LINE ITEMS FOR PROJECT/PROGRAM REVENUES i EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula ' $ 50,000
� Community Services Grant -(Not to exceed-$50;000) � — Amount contributed to the Project/Program by the Applicant $ 105,000 I Organization
Other grants or funding already awarded for Project/Program, if any $ 35,000
in-Kinci maTrn Amount nr vniiintppr rrpriit hmirc pctimntpri mmniint TOTAL REVENUE 1 $ 215,000

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
Facilities/Rent/Insurance
Supplies
Marketing
Services
I _ _
Food
Other
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET j $ 215,000
$ 2000
$ 2000
$ 1500
$ 10,000
1,500
$ 33,000
$ 165,000
$ I
$ 215,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS` FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21/22 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office —CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization:

FY 2021-2022 Amount of $
CSF Grant Fund Awarded:

Name of Project/Program:

Month & Year CSF Grant Received from City:

Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):

EName of Company
Eon Receipt or Invoice
4Z'
2 3
4 5
6 Date on
Receipt/Invoice

MUST BE ON OR BETWEEN
JULY 1, 2021 - JUNE 30, 2022

EXPENDITURE TOTAL
Amount
Expenditure
Description

DESCRIBE THE EXPENDITURE
EAh-LNUI I UKt I U I AL IVIUJ I bt tUUAL I U
(OR GREATER) THAN TOTAL AWARD AMOUNT
Purpose

PURPOSE OF EXPENDITURE
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said amount of funds to the City To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount )
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Organization:

I
TOTAL FY 2022-2023
Amount of Grant Fund Awarded: $
Name of Project/Program:

Month & Year FIRST $5,000 check
was received from City:

1. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the City

3. Is this Expenditure Report is submitted to request reimbursement of funds? No or Yes If yes, Amount of Request $ Number of beneficiaries living in 92590, 92591, 92592 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) V Date on Expenditure
0 Name of Company Receipt/Invoice MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER u E on Receipt or Invoice' MUST BE ON OR BETWEEN
Z _ March 20, 2020 - JUNE 30, Amount Description Purpose E-1
EXPENDITURE TOTAL $

EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:
• Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. ■ Awards will be given to organizations and activities that directly benefit the residents of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

Please -allow -time -for -checks -to -be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.

The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Brighton Hill Academy SLC dba First Tee —Inland Empire MAILING ADDRESS: 215 N. D Sreet
San Bernardino, CA 92401
PRESIDENT / AUTHORIZED OFFICER: Pamela Tyler
aRINJ Nnrnr
SIGNATURE:

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:

PHONE: (909 ) 297-6262
EMAIL: [email protected]
Co -Founder, Executive Director
DATE: 8-18-2022
rA0N 1 1. —AV (-AP
TrFi-F_
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: [email protected] (951) 694-6413
Betsy. [email protected] (951) 693-3959
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

INTERNAL REVENUE SERVICE
P. 0. BOX 2508
CINCINNATI, OH 45201
Date: 1 A N 28 2015

BRIGHTON HILL ACADEMY SPORTS AND

LEARNING CENTER

C/O MELODY FISCHETTI
3560 RAWLEY 5T
CORONA, CA- 92882
Dear Applicant:

DEPARTMENT OF THE TREASURY
Employer Identification Number:
46-4933764
DLN:
17053301366004
Contact Person:

FAITH E CUMMINS ID# 31534
Contact Telephone Number:
(877) 829-5500
Accounting Period Ending:

December 31
Public Charity Status:
170(b)(1)(A)(vi)
Ford"990-Requ1red:J�"-�"
Yes
Effective Date of Exemption:

April 30, 2014
Contribution Deductibility:

Yes
Addendum Applies:

No
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 wow.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.

Sincerely,
Director, Exempt Organizations
Letter 947

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
FTB PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 8/25/2022
ESL ID: 8861241572
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter Entity ID: 3671608
Entity Name: BRIGHTON HILL ACADEMY SPORTS AND LEARNING CENTER ❑X 1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board. ❑X 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d. ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

990 -Return-oUOrganization-Exempt From -Income Tax OM13,NQ._1545.0047— .,- Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) 2021 =.r—mot of the Treasury No Do not enter social security numbers on this form as it may be made public, a AFV_a� P.-venue Service ► Go to www.irs.gov/Form990 for instructions and the latest information. x. =or the 2021 calendar year, or tax year beginning , 2021, and ending, 20 e it applicable: o Name of organization BRIGHTON HILL ACADEMY, SPORTS AND LEARNING CENTER D Employer identification number .-esschange DW22 business as THE FIRST TEE OF INLAND EMPIRE 46-4933764 .A.,re change Number and street (or P.O. box if mail is not delivered to street address) Room/suite E Telephone number s alraturn 215 NORTH D STREET 309 909) 297-62G2
=: ar rewrWtorminated City or town, state or province, country, and ZIP or foreign postal code k. b-,dadr©Sum SAN BERNARDINO, CA 92401 1 G Gross receipts $ _335r 669. _ AM. Mllon par4rig F Name and address of principal officer: H(a) Is this a group return for subordinates? [3 Yes © No JT VISBAL 215 NORTH D STREET ST. 304 SAN BERNARDINO CA 92401 H(b) Are all subordinates Included? ❑ Yes ❑ No --. exempt status: X❑ 501(c)(3) [] 501(e) ( ) -4 (Inien no.) ❑ 4947(a)(1) or ❑ 527 If "No," attach a list. See instructions.

H(c] Group exemption number ►
► www. firstteein1andem ire. o rig
A. of otganizalion: ©corporation ❑ Trust ❑ Association ❑ Other ► L Year of formation:
2 014 1 M State of legal domicile: CA
Surnmaq
,
1 -
Briefly describe the organization's mission or most significant activities: EMPOWER YOUTH WITH TUTORIAL, ED_U_CATI.ONAL_ S SPORTS PROGRAMS WHICH INSTILL PERSONAL G QWT.l�1__PROVIDE LIFE PRINCIPLES - - - ----------------------------------------
_ ,a 2
C 3
4 AND STFZENGHTHEN CHARACTER VIA THE FIRST TEE LIFE SKILLS Check this box ► ❑ if the organization discontinued its operations or disposed of Number of voting members of the governing body (Part VI, line 1 a) .

Number of independent voting members of the governing body (Part VI, line 1 b) . _w w_ _ __----------------------------
more than 25% of Its net assets.
3 . . . 4
-
15 15
5 Total number of individuals employed in calendar year 2021 (Part V, line 2a) 5 9
' 6
Total number of volunteers (estimate if necessary) , . . . . . . , , . . . . . 6
25 7a
Total unrelated business revenue from Part VIII column C line 12 b
Net unrelated business taxable income from Form 990-T, Part I, line 11 7b

0. Prior Year
Current Your
_
Contributions and grants (Part VIII, line 1h) , . . . . . , . . . . . 116 665.
286
355.
= G
Program service revenue (Part VIII, line 2g) . . , . . , , , - • 30 810.
49 314.

Investment income (Part VIII, column (A), lines 3, 4, and 7d) . . . . . . 3 •
U,
- 1
Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11 e) . ':2
Total revenue —add lines 8 through 11 must equal Part VIII, column , Iine 12 14' 4 7 8 .
335,669.
13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) , , . , , 14 Benefits paid to or for members (Part IX, column (A), line 4) . . . , . . :5
Salarles, other compensation, employee benefits (Part IX, column (A), lines 5-10) 202 810 .
134
798.
299.
'6a Professional fundraising fees (Part IX, column (A), line 11e) . . . , . , r b
Total fundraising expenses (Part IX, column (D), line 25) ► __25 _691. 105 414.
131,
128.

Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e) . , . . . 'o
Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 308 224 .
266
225,
19 Revenue less expenses, Subtract line 18 from line 12 -160 7 4 6.
69 4 4 4 .
" =
Beginning
of Current Year
Fnd of Year
-_ 1 20
1_ 21
' 22
Total assets (Part X, line 16) • , , , , , , , , , , , , , , , Total liabilities (Part X, line 26) , . . . . , . . , . . . .

Net assets or fund balances. Subtract line 21 from line 20 63,022.
67 105.
225 391.
201
092 -
-162 369.
-133.
987.

Signature Block
=anaties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. 09 2022
Signature of officer
Date
�rl
c'ere

JT VISSA& CHAIRMAN EMERITUS
Type or print name and title

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
17 FRED FINCH
YOUTH CENTER CARES INC.

CITY OF TEMECUI[A
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION I
Amount Requested: $ 3,960.00 MAXIMUM ALLOWABLE
Temecula BEST Program
Project/Program Title: Equipment and Materials Start Date:

Physical Address of Project/Program
$50,000 PER ORGANIZATION
End Date:
27555 Ynez Road, Suite 406 Temecula, CA 92591

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Fred Finch CARES, Inc.

Mailing Address: 8787 Complex Drive, Suite 300
San Diego, CA 92123

I ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant Fred Finch CARES, Inc.

Organization:

Website: fredfinch.rg/cares
Number of Paid Staff: 132
Year Founded: 2017
Number of Volunteers: 5
Geographic Area(s) the Organization Serves: southern California Geographic Area(s) the Project/Program Serves: Temecula NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Clay Myers -Bowman Title/Position: Development Officer Contact Person's Direct Telephone: (619) 972-1985 Contact Person's Email: claymyersbowman@fre

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes 0 Date of Incorporation as a Nonprofit:

No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 81-4243450
State Identification Number: _3956277
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this link: htt ://a s.irs. ov/a /eos/

2. ❑ Attach State Entity Status Letter using this link:
httos:/I www.ftb.ca.gov/online/self serve entity status letter/index.aslo

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: http://rct.doo.ca.g2v/Veri[ ic3tiDn/Web/Search.asQx?facility,=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No A Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee [] Board of Directors ❑
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

The purpose of Fred Finch CARES is to set the standard for thorough developmental assessment and supportive services to children and families impacted by developmental disabilities, mental health concerns, and significant trauma and loss, in San Diego County and across Southern California.

Our staff is diverse, compassionate, committed, and innovative. All our services respond to the needs of our local communities. At Fred Finch CARES, we are committed to having a workforce that is reflective of diversity as well as representative of the cultural and linguistic needs of those we serve. Children are empowered to foster self-reliance and independence, build, and improve healthy relationships, teach self-awareness, and increase their coping skills and self-esteem. Caregivers learn the skills to manage difficult situations, assess, and meet their child's needs. By providing an array of individualized, trauma -informed, and culturally responsive interventions that build upon each participant's strengths, we ensure strong positive outcomes.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA-SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No N Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT gMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECTIPROGRAM IN THIS APPLICATION? NO ■ Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH + YEAR

RECEIVED NAME OF ENITY FUNDING RECEIVED
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT Fred Finch CARES has developed the Behavior Education and Skills Training (BEST--)-program-in-order-to-bridge-the-behavioral-health- workforce -gap -while meeting the growing need for behavioral health workforce in communities of high need, including Temecula where we currently operate several social service and 'behavioral health programs for children, youth and families.

Fred Finch CARES seeks support to implement a Bilingual BEST program to help build a behavioral health workforce in Temecula.
2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

The BEST program will provide 10 participants with a paid training experience that will enhance their knowledge and skills in serving children, youth, and families with developmental disabilities; learn the basics of Applied Behavior Analysis, and medical and mental health terminology, while preparing them for job opportunities within our organization. Each successful graduate of the program who transitions into an entry-level position will be equipped to serve up to 10 bilingual (Spanish/English) and/or monolingual Spanish speaking children, youth, or families.

This arantfu.nd n.c wFll Su = material.-andeaaicment_Gosts for _the tra.in.ino. 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

The BEST program was developed out of the need for Registered Behavioral Technicians to work with children, youth and their families impacted by developmental disabilities. We are seeking to train qualified bilingual providers in the Temecula area who can deliver high quality services across a variety of sectors. By providing participants the training and skills that can be utilized across different treatment settings, we can ensure that the same quality of service is implemented to meet the growing needs of the community. 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT FROM THIS PROJECT/PROGRAM: 11 0
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 0 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS.

In response to a dire need for cultural and linguistic diversity in -mental health care, Fred Finch CARES seeks funding to support a bilingual Behavior Education and Skills Training program in order to meet the growing need for behavioral health workers in Temecula.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $ 3,960.00 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ Organization
Other grants or funding already awarded for Project/Program, if any $ In -Kind match amount or volunteer credit hours estimated amount $ TOTAL REVENUE $

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
Facilities/Rent/Insurance
Supplies
Marketing
Services
Food
(requested funding)
Other Participant Stipends; Contractors
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET $
I?
$2396.00
$3960.00
$5000.00
$6526.39
$17,882.39
$17,882.39
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS` FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 I (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization: Fred Finch CARES, Inc. Name of Project/Program: Temecula BEST Program Equipment and Materials
FY 2021-2022 Amount of $
CSF Grant Fund Awarded: Month & Year CSF Grant Received from City:

Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):

EName of Company
E on Receipt or Invoice
<Z
1 2
3 4
5 6
Date on
ReceiptlInvoice

MUST BE ON OR BETWEEN
JULY 1, 2021 - JUNE 30, 2022
Expend itu re
--
Amount Description Purpose

DESCRIBE THE EXPENDITURE PURPOSE OF EXPENDITURE

EXPENDITURE TOTAL EXPENDITURE TOTAL MUST BE EQUAL TO
(OR GREATER) THAN TOTAL AWARD AMOUNT
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said amuuld ur runds to the City. To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $1OK). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Organization: Fred Finch CARES, Inc.

Name of Project/Program: Temecula BEST Program
Equipment and Matertats
TOTAL FY 2022-2023 Month & Year FIRST $6,000 check
Amount of Grant Fund Awarded: $ was received from City: _ I. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes__ or No (already submitted).

2. My organization has already received $ of the total FY 2022.23 Grant Fund awarded by the City

3. Is this Expenditure Report is submitted to request reimbursement of funds? No or Yes If yes, Amount of Request $ Number of beneficiaries living in 92590, 92591, 92692 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) -Z-- --I- -
Date on
tm Name of Company Receiptllnvoice
u E on Receipt or Invoice MUST BE ON OR BETWEEN
A 2 March 20, 2020 - JUNE 30,
a z 2024
2 Expenditure

MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER Amount I Description
I EXPENDITURE TOTAL $ EXPENDITURE TOTAL
Purpose
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:
• Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. • Awards will be given to organizations and activities that directly benefit the residents of Temecula. —Funding-is-not immediately available_ to -the -recipient, and requires an -award letter signature upon -approval. -- Please allow time for checks to be processed.

The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula.

The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Fred Finch CARES, Inc.
8787 Complex Drive, Suite 300
MAILING ADDRESS: _ PHONE: ( )
San Diego, CA 92123 EMAIL:

PRESIDENT/ AUTHORIZED OFFICER: Julie Henderson, Director of Development SIGNATURE: DATE: 09/12/22
IF DIFFERENT THAN ABOVE, Alexander Grant Writer
APPICATION PREPARED BY:

SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

I��DCparhueut el'[he Trresury
1 IntFrnni Revrnue Srnlre
P.O. Box 2508 In reply refer to: 0248364843
Cincinnati OH 65201 Dec. 05, 2017 LTR 4168C 0
B1-4243450 090000 00
00005054
BODC: TE

FRED FINCH YOUTH CENTER CARTS INC
TOM AL.EXANDER
3800 COOLIDGE AVE
}` OAKLAND CA 94602
011299
Employer ID Number: 81-4243450
Form 990 required: Yes
Dear Taxpayer:

This is in response to your request dated Nov. 24, 2017, regarding Your tax-exempt status.

We issued you a determination letter in August 2017, recognizing you as tax-exempt under Internal Revenue Code CIRC) Section 501(c) (3).

Our records also indicate you're not a private foundation as defined under IRC Section 509(a) because you're described in IRC Sections 509(a)(1) and 170(b)(1)(A)(vi).

Donors can deduct contributions they make to you as provided in IRC Section 170. You're also qualified to receive tax deductible bequests, legacies, devises, transfers, or gifts under IRC Sections 2055, 2106, and 2522.

In the heading of this letter, we indicated whether you must file an annual information return. If a return is required, you must file Form 990, 990-EZ, 990-N, or 990-PF by the 15th day of the fifth month after the end of your annual accounting period. IRC Section 6033(j) provides that, if you don't file a required annual information return or notice for three consecutive years, your exempt status will be automatically revoked on the filing due date of the third required return or notice.

For tax forms, instructions, and publications, visit www.irs.gov or call 1-800-TAX-FORM (1-800-829-3676).

If you have questions, call 1-877-829-5500 between 8 a.m. and 5 p.m., local time, Monday through Friday (Alaska and Hawaii follow Pacific Time).

FRED FINCH YOUTH CENTER CARES INC

X TOM ALEXANDER
3800 COOLIDGE AVE
OAKLAND CA 94602
0248364843
Dec. 05, 2017 LTR 4168C 0
81-4243450 000000 00
0000505S
Sincerely yours,
Kim A. Billups, Operations Manager
Accounts Management Operations 1

STATE OF CALIFORNIA
p FRANCHISE TAX BOARD
F T W PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 9/12/2022
ESL ID: 6921971578
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter Entity ID: 3956277
Entity Name: FRED FINCH YOUTH CENTER CARES, INC.
❑X 1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board. ❑X 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d. ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

PUBLIC DISCLOSURE COPY

PLEASE FILE IN A SAFE PLACE
ARMAN I NO "P
12657 Alcosta Blvd., Suite 500
San Ramon, CA 94583
ph 925.790.2600
fx 925.790.2601

** PUBLIC DISCLOSURE COPY **
Return of Organization Exempt From Income Tax D'°I` NU,150-W`r Farm 990 Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) (Rev. January 2020)
Oepar[ment of the Treasury Do not enter social security numbers on this form as it may made public. Open to Public 2019
Inl,rnal geyenun Wr Lo Go to www,.irs.gov/Form99O for Instructions and the latest Information. Inspection A For the 2019 calendar year, or tax ar beginning JUL 1, 2019 and endinn JUN 30, 2020 B CN,.klt C Name of organization
.ppflr bta
=Atld%W1104 FRED FINCH YOUTH CENTER CARES INC.
n
Of4amn
dwloe Doing business as
Number and street (or P.O. box if mail Is not delivered to street address) 3800 COOLIDGE AVENUE
tarmm-
.tad City or town, state or province, country, and ZIP or foreign postal code =olwn1tle� tOAKLAND, CA 94602
ph
Di F Name and address of principal officer: ED HSU
prardfnn SAME AS C ABOVE
Tax exam t status. S 501 c 3 501 c insert rm. 4947 i
J Website: HTTPS://WWW.FREDFINCH.ORG/CARES/
K Farm of arpanizalion; .0 Corporation 0 Trust n Association F-1 Other D Employer identification number
81-4243450
Room/suite
E Telephone number
510-462-2244
G 0ormm"opl-s
2,891.868,
H(a) Is this a group return
for subordinates? „ ,-.
[Yes Q No
H(b) Are all subardlneles included?
[� Yes El No
lr 521
If "No," attach a list. (see instructions)
2016
CA
1 Briefly describe the organization's mission Or most significant activities: FRED FINCH YOUTH CENTER CARES INC. ("CARES") WAS FORMED IN NOVEMBER 2016 (CONTINUED ON SCHEDULE O) 2 Check this box if the organization discontinued its operations or disposed of more than 25% of its net assets. 0 3 Number of voting members of the governing body (Part VI, line 1 a) 3 4 0 4 Number of independent voting members of the governing body (Part VI, line 1 b) 4 3 Od
d
5 Total number of individuals employed in calendar year 2019 (Part V, line 2a) 5 132 M1
6 Total number of volunteers (estimate if necessary) 8 3 Q7
a Total unrelated business revenue from Part VIII, column (C), line 12 7a 0. b Net unrelated business taxable income from Form 9907line 39 7b 0.

Prior Year
Current Year

1.140.649.
1, 386 832.
ry
8 Contributions and grants (Part VIII, line 1h)
c
9 Program service revenue (Part VIII, line 2g)
959, 817.
1,505,036.
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) , , _

0. 0.
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 633.

G.
12 Total revenue - add lines 8 through 11 must equal Part VIII, column A fine 17 2,101.099,
2 891 868.
13 Grants and similar amounts paid (Part IX, column (A), lines 1.3)

0. 0.
14 Benefits paid to or for members (Part IX, column (A), line 4)

0. 0.
1,660,619.

2. 412 , 929.
w?
er
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) _ -

0. 0.
16a Professional fundraising fees (Part IX, column (A), line 11 e) -, - _ _ b Total fundraisingexpenses
p (Part IX, column (D), line 25) lop, 0.
739 327.
983, 296.
17 Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e) , 2,394,946.

3.396, 225.
18 Total expenses. Add lines 13.17 (must equal Part IX, column (A), line 25) -293 , 847.
-504 357.
19 Revenue less expenses. Subtract fine 18 from line 12 MC
Bapinifinn of Caffeat Year
End of Your
1 , 112 4D 2.
801 849.
20 TOtaI assets (Part X, line 16)
21 Total liabilities (Part X, line 26}
21972,233.
3,166,037.
2-
22 Net assets or fund balances. Sublract line 21 from line 20 .............. ........ . ....... -1, 859, 831.
-2. 364, 188.
r-Wr. n I Vrar,GLu,G UlVVd
Under penalties of perjury, I declare that I have examined this return, including accompanying schedulds and statements, and to the best of my knowledge and belief, it is if correct, and complete. Declaration of preparer Jolliet man officer) is based on all information of which orDvafer has any knowledgu.

Sign I Signaturc of officer Date
Here I ED HSU. CFO
Type or print name and title
Print/Type preparer's name Preparer's signature Date Chif e6 0 PTIN Paid IATTHEW PETROSKI TTHEW PETROSKI lo5113/21
sell-emplo eA �00853132
Preparer Firm'sname ill, ARMANINO LLP Flrm'SElN 94-6214841 Use Only Firm's address 12657 ALCOSTA BLVD, STE. 500
SAN RAMON, CA 94583-4600 Pitone no,925-790-2600
May the IRS discuss this return with the preparer shown above? tqeq instructions R Yas No 932001 01-20-20 LHA For Paperwork Reduction Act Notice, see the separate instructions. Form 990 (2019) SEE SCHEDULE 0 FOR ORGANIZATION MISSION STATEMENT CONTINUATION

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #

GOOD SAMARITAN

FOOD PANTRY

CI'I`Y OF'IWIVI ECULA
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ 50,000 MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Project/Program Title: Temecula Hunger Relief Program Start Date: 8/1/22 End Date: 8/1/23 Physical Address of Project/Program:

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Good Samaritan Community Food Pantry Mailing Address: 32127 Camino Rabago, Temecula CA 92592

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant
Organization: Good Samaritan Community Food Pantry Year Founded: 2019 Website: https://goodsamaritancommunity.oM Social Media: https://www.facebook.com/Good- Samaritan-Community-Food-Pantry-111174284381679 Number of Paid Staff: 0 Number of Volunteers: 12 Geographic Area(s) the Or action Serves: Temecula Residents Geographic Area(s) the Proiect/Program Serves: Exclusively used for Temecula residents NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Teri Sue Parker Title/Position: Founder
Contact Person's Direct Telephone: 951-415-5731,_Contact Person's Email: [email protected]_

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes X Date of Incorporation as a Nonprofit: 8/5/2020_ No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 85-3139441 State Identification Number: 4636074 PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this link: htt ://a s.irs. ov/a /eos/

2. ❑ Attach State Entity Status Letter using this link:
htti2s:// www.ftb.ca.gov/online/self serve entity status letter/index.asp

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: httt)://rct.doj.ca.gov/VerificationiWeb/Search.aspx?facility_=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? Nog] Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION_ This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

Our goal here at Good Samaritan is to provide and deliver healthy, fresh, food and essentials for Temecula residents, their families, and pets in a safe and courteous way.

Our goal is to lift up as many residents as possible who are in need and help them get back on their feet by taking some of the pressure of food insecurity. Delivering food and essentials they need gives them hope, strength, nourishment, and essential items for themselves, their families and their pets.

For the elderly and disabled we want to give them peace of mind they will not have to choose between food or medications or keeping their pets, and other essential living expenses they have.

We focus on Isolated seniors, veterans, cancer patients, disabled, foster families, and families at risk. Providing fresh and healthy nourishment can and will help these residents get back on their feet quicker and feel supported by their community.

FINANCIAL STATEMENTS

UPON REQUEST, COPIES OF THE ORGANIZATION'S CURRENT BUDGET/FINANCIAL STATEMENTS (BALANCE STATEMENT AND INCOME STATEMENT), AND IF AVAILABLE CPA'S AUDIT, MAY BE NEEDED UPON REQUEST TO DEMONSTRATE SOUND FINANCIAL MANAGEMENT. DO NOT SUBMIT NOW, City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ® Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH +YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP $ 1 f
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECTIPROGRAM IN THIS APPLICATION? NO ❑ Yes g] IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH + YEAR

NAME OF ENITY

RECEIVED FUNDING RECEIVED
$ 1 ,000 Morongo Casino 3/2020
$ Chick-fil-A — They are awarding grants if we get one 12/2022 $
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION '

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

This grant would support our Hunger Relief Program for Temecula. Temecula residents who are experiencing food insecurity.
2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

Healthy food to prepare breakfast, lunch, dinner, pet food, essential items and household goods, paper products and cleaning supplies for their homes.

This grant would allow us to purchase food that we currently do not get enough of from the community.

It is important that the weekly food bags have all of the essential items from all the major food groups and not just canned goods. We deliver meat, grains, dairy, fresh fruits, vegetables and per food that allows them to prepare their meals for their family and pets. 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

Good Samaritan Community Food Pantry is a local grassroots food pantry.

We drop off exclusively to Temecula residents in need directly to their doorstep weekly and biweekly.

This allows Temecula residents to stay in their homes. and keep their pets with them. We have found that many of the residents do not have reliable transportation, so delivering food and essentials directly to them has taken some of the burden from their shoulders. 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 1000 FROM THIS PROJECT/PROGRAM:
[3_c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 15+ City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINULI)
The funding from this grant will replenish the essential healthy food and essential items for the residents here in Temecula and their pets by providing Good Samaritan the resources to purchase the food locally and other essential items the homes need. By focusing on specific areas in Temecula we can provide residents with special dietary needs and restrictions for some, food prices have doubled and the food we drop off weekly or Bi-weekly has to be replenished and replaced. i
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

We depended 100% on donations of food and essentials from the residents locally, at the beginning we were able to keep adding residents in need due to the amount of food and essentials and pet food that was being dropped off to us. But now with food prices doubling and gas prices so high the donations of food and essentials and pet food has come to almost a complete halt. Inflation has devastated so many homes as well as food pantries since many people can only feed themselves and their families and can no longer afford to donate. We also deliver 99% of the food directly to the needy, so the gas prices for volunteers has become a big challenge for our drivers.

We were serving residents that could not leave their home, shut ins and residents with high risk factors we had to deliver safely and many have diet restrictions and health issues. The number of residents in need now is staggering. We serve so many with health issues that going out and buying healthy food to help keep them healthy is a luxury, some that we serve had not had fresh produce for months and some were afraid of who handled their food as to not get infected with the virus. Our number of shut-in's has increased and our number of family's has tripled over the last year as the cost of food has made it very hard to keep the fridges and freezers and shelves stocked. 6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

The funds from this grant would allow us to create new ways to add more residents in need and families with special needs. This grant would allow Good Samaritan to continue what we are doing daily - filling the food bags full of healthy foods, essentials, and pet food.

We can continue "Adopt A Family" "Adopt A Senior" programs during the Holiday's which has brought so much joy to those who need it. We can continue to provide fresh, healthy, safe food so those in need so they can prepare good meals for breakfast, lunch, and dinner. It will also help us to keep providing paper goods and cleaning supplies, so they can keep germs from spreading and their homes safe and clean. We will be able to continue providing those with special dietary needs.

It allows us to keep bringing pet foods and supplies, so they don't have to surrender their beloved pets to a shelter because they can no longer feed them.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $50,000 Community Services Grant (Not to exceed $50,000)

EXPENSES
Amount contributed to the Project/Program by the
$1500
Applicant Organization - Estimated donations through out donate button on website for project
Other grants or funding already awarded for Project/Program, if any $0
In -Kind match amount or volunteer credit hours estimated amount $85,000 as
**OUR IN -KIND donations come in as dropped off food and supplies by donated food
the community which has decreased substantially. Guesstimate for 2022 or essentials

NOT CASH

TOTAL REVENUE
$51,500

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
$
Facilities/Rent/Insurance — Electric/Gas
$6500.00
Supplies — Baggies/Wrapping/Bags/Flyers/Boxes
$2500.00
Marketing
$
Services $
Food and Essentials $41,000
Other $
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT, $0 HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES $
TOTAL BUDGET $50,000 $50,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS* FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21/22 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization:

FY 2021-2022 Amount of $
CSF Grant Fund Awarded:

Name of Project/Program:

Month & Year CSF Grant Received from City:

Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):
4 Name of Company RecDate on
eipt/Invoice
on Receipt or Invoice MUST BE ON OR BETWEEN Amount
JULY 1, 2021 - JUNE 30, 202-2
Z Q
2 3
4 5
6 EXPENDITURE TOTAL
Expenditure_
Description Purpose

DESCRIBE THE EXPENDITURE PURPOSE OF EXPENDITURE

EXPENDITURE TOTAL MUST BE EQUAL TO
(OR GREATER) THAN TOTAL AWARD AMOUNT.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

ACKNOWLEDGEMENT/SIGNATURE PAGE _ 1
The applicant acknowledges and agrees to the following:

Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.

Every Community Service Funding application is considered individually and on its own merit. • Awards will be given to organizations and activities that directly benefit the residents of Temecula.

Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

Please allow_time_ for checks -
to -be -processed.-. The awarding of Community Service Funding does not constitute an automatic annual allocation.

The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
■ The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. ® If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Good Samaritan Community Food Pantry MAILING ADDRESS: 21227 Camino Rabago Temecula CA 92592 PHONE: 951-415-5731 EMAIL: [email protected]
PRESIDENT / AUTHOOFF R. Teri S e Parker Founder
SIGNATURE: _ : =f ;� L OLI` l r�� Q
DATE:

All

IF DIFFERENTTHAN ABOVE,
APPICATION PREPARED BY: ` G� I Jul C3r1�
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

104 STATE OF CALIFORNIA

FRANCHISE TAX BOARD
PO BOX 94285757
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 8/7/2022
ESL ID:7074774595
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter Entity ID: 4636074
Entity Name: GOOD SAMARITAN COMMUNITY FOOD PANTRY INC
❑X 1. The entity is in good standing with the Franchise Tax Board.

2. The entity is not in good standing with the Franchise Tax Board,

3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 . 4, We do not have current information about the entity,

5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Important Information
• This information does not necessarily reflect the entity's current legal or administrative status with any other agency of the state of California or other governmental agency or body. • If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304,5, 23305a, 23305.1).
• The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
19 GREEN ACRES
INTERACTIVE THERAPY INC.

CITY OF TEMECUI[A
FISCAL YEAR 2022 - 2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

I PROJECT/PROGRAM INFORMATION
Amount Requested: $ 50,000
Project/Program Title:

Walk, Ride, Run for Gait
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Start Date: 5/1/23 End Date: 6/30/23
Physical Address of ProjectlProgram: 35750 De Portola Road Temecula. Ca. 92592

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make check Payable to: Green Acres Interactive Therapy Mailing Address: 35750 De Portola Road
Temecula. CA 92592

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant Green Acres Interactive
Organization: Therapy
Website: Gaitprogram.org
Number of Paid Staff., 9
Year Founded: 2014
Social Media: FT, Twitter
Number of Volunteers: 20
Geographic Area(s) the Organization Serves: Temeucla
Geographic Area(s) the Project/Program Serves: Temecula NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Margaret Rich Title/Position: Founder
Contact Person's Direct Telephone: 909-240-4500 Contact Person's Email: [email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes Date of Incorporation as a Nonprofit: 2014 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 46-4355227
State Identification Number: 3547698
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this link: http://aRps.irs.gov/aop/east

2. ❑ Attach State Entity Status Letter using this link:

Mps:// www.ftb.ca.gov/online/self serve entity status lefterlindexasip

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: http:lfrct.do}.ca.cLovlVerification/Web/Search.aspx?faci€ily=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No 41 Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors 0
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

To enrich lives by providing physical and emotional therapy through horse interaction.

FINANCIAL STATEMENTS

UPON REQUEST, COPIES OF THE ORGANIZATION'S CURRENT BUDGET/FINANCIAL STATEMENTS (BALANCE STATEMENT AND INCOME STATEMENT), AND IF AVAILABLE CPA'S AUDIT, MAY BE NEEDED UPON REQUEST TO DEMONSTRATE SOUND FINANCIAL MANAGEMENT. DO NOT SUBMIT NOW. 1 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT
MONTH + YEAR

NAME OF CITY GRANT
AMOUNT
-FUNDED_BY-THE-CITY-GRANT-OR-SPONSORSHIP--
-FUNDING-RECEIVED—
OR3PONSORSHIP--
E
i
$
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECTIPROGRAM IN THIS APPLICATION? No ❑ Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH + YEAR

RECEIVED NAME OF ENITY FUNDING RECEIVED
$ $5,000 Staples 8/22
$
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

To celebrate the growth of Gait and to keep t6he therapeutic riding accessible to the community of Temecula. We invite the community to join us for Walk, Ride, Run for Gait, a fun reason to get outdoors and raise awareness.

This was a virtual program because of Covid but now we would like it to be a City of Temecula event.
2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS

PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT Funds will be used to pay for the boarding, care and feeding of the horses inbolved in the program.

Funds ill be used to provide safety equipment (helmets, Gloves and any other tack) as needed to keep participants safe.

Funds will be used to clear the trail that will be used for the participants.

Funs will be used to provide water, snacks and T-shirts for the participants.

S
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

With the funding we can open up the ranch to the Temecula residents to get involved with the program that night not have the financial funds available to participate in the program.

There isn't another facility in Temecula that handles special needs, PTSD for Veterans and other public servants, and helping families that are in need of group therapy because of adoption or group home facilities.
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 50 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS.

This- program -is -to -raise -awareness -for -the -City -of Temecula-about-itis-therapeutic- program and provide a facility to help families in need of therapy that is interactive with animals and be outdoors.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

During Covid we had to shut down our facility and lay off employees and we could not secure volunteers even when we opened up the doors.

We have to use extensive funds to make the environment safe by purchasing products to clean helmets and reins and tack.

We have also had to deal with the rising costs of fuel, horse feed and vet care and food and have not raised our prices as to keep it affordable for the community.
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

The additional funds will help expand out program from virtual to a physical event that the city of Temecula can participate in.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill In shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES I EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money -requested -from -this -City of Temecula— - -$ 50,000 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ Organization
Other grants or funding already awarded for Project/Program, if any $ 5,000 In -Kind match amount or volunteer credit hours estimated amount $ TOTAL REVENUE $ 55,000

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
Facilities/Rent/Insurance
Supplies
Marketing
Services
Food
Other
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; HOWEVER PLEASE INCLUDE.
$10,000
f $15,000
$ 5,000
$ 2, 500
$4.200
S
$10,000
TOTAL EXPENSES $ 511700.

TOTAL BUDGET $ 1$50,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS* FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization: Green Acres Interactive Name of Project/Program: Walk, Ride, Run for Gait Therapy
FY 2021-2022 Amount of $
CSF Grant Fund Awarded: Month & Year CSF Grant Received from City:

Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):

El Name of Company
Eon Receipt or Invoice
aZ
Date on
Receipt/Invoice
MUST BE ON OR BETWEEN Amount
JULY 1, 2021 - JUNE 30, 2022
Expenditure
I
Description Purpose

DESCRIBE THE EXPENDITURE I PURPOSE OF EXPENDITURE
txF'tNUI 1 UKt I U I AL P (OR GREATER) THAN TOTAL AWARD AMOUNT City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit andror require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the _approved/awarded_application,_the_organization_may_not receive -and/or will be -required -to -return -said - amount of funds to the City. To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. (If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $51<4501K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula" EXPENDITURE REPORT DATED_
Organization: Green Acres Interactive
Name of Project/Program: Walk, Ride, Run for Gait
Therapy
TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: $ was received from City:

1. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the City

3. Is this Expenditure Report is submitted to request reimbursement of funds? No or Yes If yes, Amount of Request $ Number of beneficiaries living in 92690, 92691, 92692 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) Date on
rm Name of Company Receiptlinvoice
u E �on Receipt or Invoice MUST BE ON OR BETWEEN
US
March 20. 2020 - JUNE 30,
a z 1 2024
2 Expenditure

MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER Amount J Description I Purpose
EXPENDITURE TOTAL $ EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:
■ Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. • Awards will be given to organizations and activities that directly benefit the residents of Temecula. -• Funding -is -not immediately -available -to the -recipient,, and requires -an -award letter signature -upon approval. - Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Green Acres Interactive Therapy
MAILING ADDRESS: 35750 De Portola Rd
Temecula, CA 92592
PHONE: ( 90') 240-4500
EMAIL: [email protected]
PRESIDENT/AUTHORIZED OFFICER: Margaret Rich, Founder
DR, INT NAIV; tiT[ r
SIGNATURE: -btar aret Rich DATE: 9/12/2022

IF DIFFERENTTHAN ABOVE,
APPICATION PREPARED BY:

SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

GREEN ACRES INTERACTIVE THERAPY, INC. (3547698)-
Request Certificate
Initial Filing Date
02/01/2013
Status
Active
Standing - SOS
Good
Standing - FTB
Good
Standing - Agent
Good
Standing - VCFCF
Good
Formed In

CALIFORNIA
Entity Type
Nonprofit Corporation - CA - Public Benefit
Principal Address
35750 DE PORTOLA ROAD TEMECULA, CA 92592
Mailing Address
35750 DE PORTOLA ROAD TEMECULA, CA 92592
Statement of Info
02/28/2023
Due Date
Agent Individual 2810395 MARGARET RICH 35750 DE PORTOLA RD TEMECULA, CA 92592
Entity Information Initial Status Entity Type Formed In Agent Filing Date
GREEN ACRES Nonprofit
INTERACTIVE Corporation - MARGARET
THERAPY, INC, 02/O1/2013 Active CA - Public CALIFORNIA RICH (3547698) Benefit

INTERNAL REVENUE SERVICE
P. O. BOX 2508
CINCINNATI, OH 45201
Date : q U G 18 2014

GREEN ACRES INTERACTIVE THERAPY,
INC>

C/O SELINA STEELE
PO BOX 890339
TEMECULA, CA 92589-0339
Dear Applicant:

DEPARTMENT OF THE TREASURY
Employer Identification Number:
46-4355227
DLN:
17053167363024
Contact Person:

CUSTOMER SERVICE ID# 31954
Contact Telephone Number:
(877) 829-5500
Accounting Period Ending:

February' 28
Public Charity status:
170 (b) (1) (A) (vi)
Form 990 Required:

Yes
Effective Date of Exemption:

February 1, 2013
Contribution Deductibility:

Yes
Addendum Applies:

No
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 0£ 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 914221-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

Short Form OMB No. 154e-0047
Form 990-EI Return of Organization Exempt From Income Tax 2020 Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) ► Do not enter social security numbers on this form, as it may be made public. puparnnont of the treasury M
Internal nevonue Service 0-Go to www.irs.gov/Form990EZ for instructions and the latest information.

A For the 2020 calendar year, or tax year beginning Ma r 2020, and ending Feb 22 2021 B check it applicable: C Name of Organization D Employer identification number ❑ Address change GREEN ACRES INTERACTIVE 'THERAPY INC 46-4355227 ❑ Name change Number and street (or P.O. box if mail is not delivered to street address) oom swte E Talophone number ❑ initialren,rn 35-750 DE PORTOLA 9513022384
Find roturn/terminated
Amended return City or town, state or province, country, and ZIP or foreign postal code F Group Exemption Applicallan pending TEMECULA, CA 92592 Number ►
G Accounting Method: 0 Cash ❑ Accrual' Other (specify) ► H Check ► ❑X if the organization is not Website: ► N/A required to attach Schedule B
J TiLK-exempt status (check orgy one) -- ® 5olicje ❑Set a nsart no. ❑ 4947 1 or 11527 (Form 990, 990-EZ, or 990-PF).

K Form of organization: © Corporation ❑ Trust Association ❑ Other L Add lines 5b, 5c, and 7b to line 9 to determine grass receipts, If gross receipts are $200,000 or more, or if total assets (Part II, column (B)) are $500,000 or more, file Form 990 instead of Form 990-EZ . . . . . . . . . . ► $ 13, , 1 r, .

Revenue, Expenses, and Changes in Net Assets or Fund Balances (see the instructions for Part 1) Check if the gr anixation used Schedule O to respond to anyguestion in this Part ! . IJ 1 Contributions, gifts, grants, and similar amounts received . . . . . . . . . . . . . 1 !2 993 2 Program service revenue including government fees and contracts . . . , . . . , . 2 3 Membership dues and assessments . . . . . . . . . . . . . . . . , 3 4 Investment income . . . . . . . . . . . . . . . . . . . , , , 4 5a Gross amount from sale of assets other than inventory . , , . IJR-1-- b Less: cost or other basis and sales expenses . , , . . . . . 5b c Gain or (loss) from sale of assets other than inventory (subtract line 5b from line 5a) 5c 6 Gaming and fundraising events:
a Gross income from gaming (attach Schedule G if greater than $15,000) . . . . . . . . . , . .
c 6a
b Gross income from fundralsing events (not including $ of contributions cc
from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributlons exceeds $15,000) . 6b 1 845. c Less: direct expenses from gaming and fundraising events . . , ec 5 854 . d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c) . . . . . . . . . . . . . . . . . . . . . . . . 6d —4, 009 7a Gross sales of inventory, less. returns and allowances 7a b Less: cost of goods sold . . . . . . . . . . . . . 70 c Gross profit or (loss) from sales of inventory (subtract line 7b from line 7a) . . . . 7c 8 Other revenue (describe in Schedule O) , . , . . . . . . . SP-E, Line 8 Stmt. . 8 1.8 _ 1 3 . 9 Total revenue. Add lines 1, 2, 3, 4, 5c, 6d'. 7c, and 8 . ► 9 12 8 312 . 10 Grants and similar amounts paid (fist in Schedule O) . . . . . . . . . . . . . . 10 11 Benefits paid to or for members; . . . . . . . . . . . . . . . . . . . 11 v 12 Salaries, other compensation, and employee benefits . . . . . . . . . . . . . . 12 f3 0 7 5 . c
13 Professional fees and other payments to Independent contractors . . . . . . . . . . 13 2 100.

X14 Occupancy, rent, utilities, and maintenance 14 42 703. w 15 Printing, publications, postage, and shipping , . . . . . . . . . . 15 2,071 . 16 Other expenses (describe in Schedule O) . . . . . . . . . see. Line 16. stmt 16 60 849. 17 Total expenses. Add lines 10 through 16 . ► 17 1 195, 798.. rn 18 Excess or (deficit) for the year (subtract line 17 from line 9) . . . . . . . . . . . . 18 —6, 7, 186. 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with 4 end -of -year figure reported on prior year's return) . . . . . . . . . . . . . . I19 6 f, 06 5.

Z20 Other changes in net assets or fund balances (explain in Schedule 0) . . . . . . . . . 20 21 Net assets or fund balances at end of year. Combine lines 18 through 20 . 1'-21 579 .

For Paperwork Reduction Act Notice, see the separate instructions. BAA REV 09/08/21 PRO Form 990-EZ (2020)

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Rancho California Arabian Horse Association Presents
at 61V.111 A['>'iIA RAH111
35750 De Portola Road
in Temecula
11 10rses
101
Apru -v_ _-
PDA
TRIO 16 A FREE EVENT THAT IS OPEN TO THE PUBLIC
Parking$5
clonjat.ionn* per car
inch-mles I FREE � a fle ticke—t,
*donation to benefit r,A1T Thnr,-4nn!rtl^ Rir4iri(s PI-ograirj and Temecula Valley Rural Lifestyles

CELEBRATING THE AMAZING WORLD
OF ALL THINGS MOR60
The beauty of the horse transcends all labels and preferences.

Behind every horse person lies the child that simply fell in love with a horse. # DEMONSTRATIONS # VENDORS 0 CLUBS FOOD
* RAFFLE PONY RIDES I& PETTING ZOO* HAY RIDES
Any questions contact Heather - [email protected] (951) 302-6045

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
20 HABITAT FOR HUMANITY
INLAND VALLEY INC.

CITY OF TEMECULA.

FISCAL YEAR 2022 - 2023

COMMUNITY SERVICE FUNDING M REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MOND", SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ 44,094
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Temecula Real Estate and
Project/Program Title: nf,,r Start Date: 10.1.22 End Date: 6.30.23 Physical Address of Project/Program: 41615 Winchester Rd Ste 214,Temecula CA 92590

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Habitat for Humanity Inland Valley Mailing Address: 27475 Ynez Road #390
Temecula, CA 92591

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant Habitat for Humanity Inland
Organization: Valley Year Founded: 1991
Website: habitativ.org
Number of Paid Staff. 42
Social Media: facebook.com/HabitatIV/
Number of Volunteers: 1,266
Geographic Area(s) the Organization Serves: Southwest Riverside County Geographic Area(s) the Project/Program Serves: Temecula NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Mary Stein Title/Position: Associate Director Contact Person's Direct Telephone: 951-296-3362 Contact Person's Email: mary!Rhabitativ.org

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes Date of Incorporation as a Nonprofit: 2/21/91 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 33-0461804
State Identification Number: C1681922
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ■❑ Attach IRS Deductibility Status using this link: http:/Iapl2s.irs.gov/ap.p/eosl

2. ❑■ Attach State Entity Status Letter using this link:
https://www.ftb.ca.gov/onfine/self serve entity_status lettertindex.as

3. >]■ Attach first page only of most recent IRS Form 990 or attach printout of detailed info about your charity found on this State Registry's Search Tool: hit ://rcLdo -ca. oy/Vedfication/WebiS t rch.as x?faciiit =Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No If Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ® Board of Directors ❑ Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

The mission of Habitat for Humanity Inland Valley, in partnership with God, is to facilitate the dream of homeownership as well as improve the living conditions for those in the community.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes E IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP Critical Home Repair Program $ 50,000 20/21 � CDBG
Critical Home Repair Program $ 52,662.71� 21/22
A Brush with Kindness $5,000 21/22
Critical Home Repair Program $49,724 122/23
CDBG
ICSF
CDBG
Temecula Home Repair Program $ 500,000 22/24 Covid19 Reinvest I$ -
I$
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? NO E Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW.
f----. r -- - -
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT - RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

The Temecula Real Estate and Education Center will provide resources, training and -home buyer counseling servicesto-help Temecula residents with affordable homeownership. Homebuyer orientations, resource fairs, financial literacy and Healthy Homes workshops will provide educational support to empower residents towards homeownership and preserving home affordability. 1:1 home buyer counseling will guide qualified clients through the complicated affordable home buying process with licensed real estate support and advocacy while also utilizing other available collaborative resources like downpayment assistance. 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS

PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT Habitat IV will spend the grant funding on launching and supporting the Temecula Real Estate and Education Center. Funds will be spent on facility costs to house the Center, including expenses related to securing space including rent, utilities, liability insurance, etc. Funds will also be spent on classroom supplies and materials for the workshops, including tables and chairs, minor improvements like shelving and partitions for the educational space, and marketing materials and signage for the Center and resource fairs.
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

This program will be provided to Temecula residents at the Real Estate and Education Center in Temecula and at community events or sites throughout the City. While any resident is welcome to attend and participate, we expect that most will be low -to -moderate income residents working towards affordable homeownership and struggling to navigate the complicated affordable home buying process, such as layering multiple sources of assistance towards their purchase. 3b
3c
ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 371 FROM THIS PROJECT/PROGRAM:

ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: cJ City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
14 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS.

The Temecula Real Estate and Education Center will provide home -buyer orientations, resource fairs, financial literacy and Healthy Homes workshops, and counseling to empower residents towards home affordability. 1:1 counseling will guide participants through the complicated affordable home buying process with licensed real-estate support while utilizing collaborative resources like down -payment assistance.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

COVID-19 impacted our ReStores, which provide a substantial source of revenue used to support and launch programs.

The pandemic and historic inflation also significantly impacted the rising cost of housing, driving affordable homeownership even farther away for many residents.

I
The launch of the Temecula Real Estate and Education Center is part of a broader affordable homeownership solution as we collaborate with other agencies and advocate for residents by combining resources, along with Habitat IV support, to impact the affordable homeownership crisis. 6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.
1) This funding would launch the Temecula Real Estate and Education Center by providing funds for facilities along with classroom materials, supplies, and marketing/signage.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $ 44,094 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ Organization
Other grants or funding already awarded for Project/Program, if any In -Kind match amount or volunteer credit hours estimated amount $ TOTAL REVENUE $ 44,094

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment $
Facilities/Rent/insurance Facility expenses: Rent, insurance, utilities, ! $ 28 944 landscaping, shelvin 1 arlitions, _POA dues, etc r
Supplies Classroom materials and supplies including $ 7 650 printed materials ,
Marketing Signage and marketing materials $ 7,500
Services I $
Food
Other
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT, HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET $44,094
$44,094
$44,094
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS* FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
xIF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3., Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization: Habitat for Humanity Name of Project/Program: A Brush with Kindness f ani d Vai ev
FY 2021-2022 Amount of $
CSF Grant Fund Awarded: 5000 Month & Year CSF Grant Received from City: 2021-2022 Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted 31 from this Program/Project (approximate number of beneficiaries If you do not have precise number):

E Name of Company
Eon Receipt or Invoice
Q Z
Seaeftached
1 spreadsheet
2 1
3 I
4 5
6 Date on
ReceiptlInvoice Amount MUST BE ON OR BETWEEN
JULY 1, 2021 - JUNE 30, 2022
FIN
Description I Purpose

DESCRIBE THE EXPENDITURE PURPOSE OF EXPENDITURE
EXPENDITURE TOTAL $S (Q 5 EXPENDITURE TOTAL MUST BE EQUAL TO (OR GREATER) THAN TOTAL AWARD AMOUNT.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

FISCAL YEAR (FY) 2022-2023 COMPLIANCE REPORT
If your organization is awarded a Community Service Funding - REINVESTMENT IN TEMECULA Grant in FY2022.2023 by the City of Temecula, follow these instructions.

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive andlor will be required to return said amount of fundc to the City. To substantiate that grant funds from thu City me, spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Organization: Habitat for Humanity Name of Project/Program: Temecula Real Estate and Inland Vallev Education Center
TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: $ was received from City:

1. Is this Expenditure Report Is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received $,_ of the total FY 2022-23 Grant Fund awarded by the City

3. Is this Expenditure Report Is submitted to request reimbursement of funds? No or Yes If yes, Amount of Request $ Number of beneficiaries living in 92590, 92591, 92592 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) Date on Expenditure
t MUST SUPPORT PROJECT/PROGRAM IN APPLICATION &AWARD LETTER Name of Company Receipt/invoice
a E on Receipt or Invoice MUST BE ON OR BETWEEN
a= March 20, 2020 - JUNE 30, Amount Description Purpose Z 2024
2 3
EXPENDITURE TOTAL $ EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. ■ Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Habitat for Humanity Inland Valley
MAILING ADDRESS: 27475 Ynez Rd #390
Temecula, CA 92591
PRESIDENT/ AUTHORIZED OFFICER: Tammy Marine,
SIGNATURE:

PHONE: ( 951 ) 296-3362
EMAIL: [email protected]
Executive Director
DATE: 9/9/22
RI'll ON11i2:, i 1's1,
IF DIFFERENT THAN ABOVE, Mary Stein, Associate Director APPICATION PREPARED BY:

P:�iN 111AT11_ I'i. 1
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

Habitat
for Humanity®
September 29, 2015
Inland Valley HFH
27475 Ynez Rd #390
Temecula, CA 92591-4612
RE: 501(c)(3) Letter for Inland Valley HFH, Partner ID# 1101-5322 Dear Affiliate Leader:

Help build it!
This letter will confirm that Inland Valley HFH, with employer identification number 33- 0461804, is considered a subordinate under the group tax exemption umbrella of Habitat for Humanity International, Inc. ("HFHI") under Section 501(c)(3) of the Internal Revenue Code.

The group exemption number assigned to HFHI by the IRS is 8545. This number may be provided to prospective donors, foundations and other grant organizations as they request it and is required on certain IRS forms.

Enclosed is a copy of the determination letter dated March 9, 2015, provided by the IRS as evidence of HFHI's tax exempt status as well as its group exemption. The determination letter, together with this letter, confirms Inland Valley HFH's subordinate status and provides evidence of its tax exempt status under Section 501(c)(3) of the Code.

In partnership,
Beverly Huffman
Director, US/Canadian Support Services Center
Habitat for Humanity International 877-434-4435
USSupp artCenter 1Tabitat.or • habitat.org !Habitat. We build - Enclosure
INTERNATIONAL HEADQUARTERS: 121 Habitat St., Americus, GA 31709-3498 USA www,habitat.org (229) 924-6935 toll free (800) 422-4828

h } jl i j(�� 3 POIF11 ineut of the I'FLniumy
� ��f jj lnfvirol Rovonue tirrvlce
In reply refer to: 4077550277
OGDEN UT 84201-0029 Mar. 09, 2015 LTR 4167C 0
91-1914868 000000 00
00040704
BODC: TE

HABITAT FOR HUMANITY INTERNATIONAL
INC

HABITAT FOR HUMANITY INTRNL PARENT
n V. EDWARD K QUIBELL - CFO/SR VP
121 HABITAT ST
AMERICUS GA 31709-3423
052913
Employer Identification Number: 91-1914868
Group Exemption Number: 8545
Person to Contact: Ms Benjamin
Toll Free Telephone Number: 1-877-829-5500
Dear Taxpayer:

This is in response to your Jan. 20, 2015, request for information about your tax-exempt status.

Our records indicate that you were issued a determination letter in January 1987, 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 incnme 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,
Tamera Ripperda
Director, Exempt Organizations

IRS GI-OLIp Exemption FAQs
The IRS refers to "central" or "parent" organizations, as well as "subordinate" organizations? What does these terms mean? An organization that has been granted a 501(c)(3) group exemptinn by the IRS is referred to as the central or parent organization. The central organization generally supervises many affiliates or chapters, called subordinate organizations. The subordinate organizations have similar structures, purposes, missions and activities. ❖ In Habitat's case, HFHI is the central organization and each Affiliate is a subordinate organization.

What is the reason for group exemptions vs individual exemptions? Group exemptions are an administrative convenience for both the IRS and organizations with many affiliated organizations. Subordinates in a group exemption do not have to file, and the IRS does not have to process, separate applications for exemption. Instead, the IRS allows the central organization to include its subordinate organizations under its tax exempt "umbrella."
❖ Group exemptions are more convenient because only one central organization (HFHI) needs to be checked for tax exempt status.

Who determines if a subordinate organization may be included under the central organizations' group exemption?
The central organization, not the IRS, determines who is exempt under its 501(c)(3) umbrella. The IRS does not approve or deny a subordinate's inclusion on HFHI's roster of exempt subordinates. It is solely at the discretion of the central organization holding the 501(c)(3) designation as long as the subordinate is similar in mission, purpose, structure and activities. The IRS leaves it up to the central organization to police its own list of subordinate entities and to report any changes. Failure to monitor the list in accordance with the rules set forth by the IRS may result in the central organization having its 501(c)(3) status revoked.
•D, HFHI is the final determiner of whether Affiliates are on its group exempt list. The IRS will not issue a letter with regard to an individual Affiliate.

How does a donor verify that an organization is included as a subordinate in a group exemption ruling?
The central organization which holds the group exemption (rather than the IRS) determines which organizations are included as subordinates under its grnilp exemption umbrella. Therefore, a donor should verify that an organization is a subordinate eligible to receive tax deductible donations by requesting a copy of a letter provided by the central organization to the subordinate confirming the subordinate entity's inclusion on its roster of exempt subordinates. This letter, coupled with a copy of the central organizations 501(c)(3) determination letter provides adequate proof of the entity's tax exempt status. ❖ Affiliate should provide donors a copy of the confirmation letter (with the HFHI IRS determination letter attached) that HFHI provides to each Affiliate on an annual basis.
❖ Donors should be told that the IRS determination letter will not reference the Affiliate by name.

How do donors verify that contributions are deductible with respect to a subordinate organization in a section 501(c)(3) group exemption ruling? Many donors are accustomed to consulting the IRS database known as EOS Select Check to confirm that donations to a specific organization are tax deductible. This works well for organizations that have an individual tax exemption; however, it creates a bit of confusion when it comes to organizations with a group tax exemption status.

The EOS Select Check database does NOT list all subordinate entities. It lists the central organization because the central organization is the entity that applied for, and was granted, a 501(c)(3) designation. Many times donors become alarmed when they do not see the individual Affiliate listed in the database. It is important to explain to your donor that providing HFHI's group exemption number (GEN) along with a confirmation letter from HFHI, as the central organization, is sufficient proof of the subordinate entity's tax exempt status. Donors may rely upon central organization verification with respect to deductibility of contributions to subordinates covered in a section 501(c)(3) group exemption ruling.
❖ Explain to your donors early the procedure so that they will not be surprised when the Affiliate is not referenced on the EOS database.

Employer Identification Number (EIN) vs Group Exemption Number (GEN) The Employer Identification Number (EIN) is a nine -digit number that is unique to each business and generally appears in the following format: XX-XXXXXXX. Its role for a business is similar to that of the Social Security number for an individual. The number includes information about which state the corporation is registered in. This unique identification number is assigned to a business entity so that they can easily be identified by the Internal Revenue Service. The EIN is also known as a Federal Identification Number (FIN) or Tax ID.

This number is apart and separate from a company's group exemption number (GEN). The EIN identifies the specific organization. The GEN identifies the entity's further designation as a tax exempt organization.

The GEN number is a number assigned by the IRS which identifies the central organization who was granted the group exemption. The GEN number is a 4 digit number that should be supplied to donors when they make a donation. This number allows the donor to make a tax deduction based on the donation to the tax exempt entity. • HFHI's GEN is 8545. This should be given to your donors. • Do not use HFHI's EIN in your Affiliate's tax return and other documents. This will cause the IRS to confuse your Affiliate with HFHI (including accidentally holding you responsible HFHI's payroll taxes, misreporting on Form 990, etc.) ❖ HFHI's GEN is 8545. This should be given to your donors. :• Do not use HFHI's EIN in your Affiliate's tax return and other documents. This will cause the IRS to confuse your Affiliate with HFHI (including accidentally holding you responsible HFHI's payroll taxes, misreporting on Form
990, etc.)

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
Fop� BOA 94257
SA
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 7/14/2022
ESL ID: 8461025921
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 1681922
Entity Name: HABITAT FOR HUMANITY INLAND VALLEY, INC.
0 1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board. 0 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d. ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Important Information
• This information does not necessarily reflect the entity's current legal or administrative status with any other agency of the state of California or other governmental agency or body. • If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).
• The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

State of California 06__�
Office of the
Department of Justice Attorney General

HOME ABOUT MEDIA CAREERS REGULATIONS RESOURCES PROGRAMS CONTACT Registrant
Details
Entity type: CorporaLe Class as registered �AiiLh the Secretary of State or based on 1`01-inding & registration do Organization Name: HABITAT FOR HUMANITY INLAND VALLEY, INC. IRS FEIN: 330461804 Entity Type: Public Benefit SOS/FTB Corporate/Organization Number: 1681922 Registry Status: Current Renewal Due/Exp. Date: 11/15/2022 RCT Registration Number: 081196 Issue Date: 6/30/2006
Record Type: Charity Registration Effective Date: 6/30/2006 Date of Last Renewal: DBA:
r • Address
Street: 41615 WINCHESTER RD #214
Street Line 2:

City, State Zip: TEMECULA CA 92590
Filings & Correspondence
S:_ 550 2010 CT-550 2010
BEL-LM
R R E -_ L 2011
RRF-1 2012
IRS Farm 920 2012
2010 RRF-I
2011 RRF-1
2012 RRF-I
2012 IRS Form 990
IRS Form 990 2010
F0A&gDoeuments
RRE-1 2009
�
2010 IRS Form 990
Founding Documents
2009 RRF-1
IRS -Form 22QM
BREA-
1RSFnrm 990 200$
�
M Form 920 2007
2009 IRS Form 990
2008 RRF-1
2008 IRS Form 990
2007 RRF-1
2007 IRS Form 990
RRF-1 2006
2006 RRF-1
IRS Form 990 2006
2006 IRS Form 990
ERE-1 20D5
2005 RRF-1
IRS Form 990 2005
2005 IRS Form 990
RRF-1 2004
2004 RRF-1
RRF-1 2003
2003 RRF-1
IRS Form 990 2003
2003 IRS Form 990
BELL=
2002 RRF-1
IRS Fonn 990 2002
2002 IRS Form 990
RRF- I�0
2000 RRF-I
t D uency Notice
1st Delinquency Notice

I;&OWgl Filing
2017
Renewal Filing
2020
RRF- 120 l 3
2013 RRF-1
IRS Form 990 20 l3
2013 IRS Form 990
ERE --I 20 l 1
2011 RRF-1 - —
IRS Form 990 2Q1.1
2011 IRS Form 990
RRE L2M
2014 RRF-i
IRS_ Form 99 2a i a
2014 IRS Form 990
20 ! 5 IZR A
2015 RRF-1
2015 lR,S, Egan 290
2015 IRS Form 990
-
2016 Form RRF-1
2016 IRS Eolm .990 Series
2016 IRS Fonn 990 Series
Renewal Filing
2018
Renewal Filing
2019
IRS Form 990 S r-LCS
2021
AnnualData
Status of Filing:

Accepted
Accounting Period Begin Date:
7/l/2009
Accounting Period End Date:
6/30/2010
Filing Received Date:
9/17/2012
Form RRF-1 Reject/Incomplete Reason:

Form CT TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notts From Registry Staff:

Status of Filing:

Accepted
Accounting Period Begin Date:
7/1/2010
Accounting Period End Date:
6/30/2011
Filing Received Date:
7/16/2012
Form RRF-1 Reject/incomplete Reason:

Form CT TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accepted
Accounting Period Begin Date:
7/1/2011
Accounting Period End Date:
6/30/2012
Filing Received Date:
11/19/2012
Form RRF-1 Reject/Incomplete Reason:

Form CT TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accepted
Accounting Period Begin Date:
7/1/2012
Accounting Period End Date:
6/30/2013
Filing Received Date:
2/20/2014
Form RRF-1 Reject/incomplete Reason:

Form CT-TR-I Rejectlincomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Statris of Filing:

Accepted
Accounting Period Begin Date:
7/1/2013
Accounting Period End Date:
6/30/2014
Filing Received Date:
12/23/2014

Form RRF-I Reject/Incomplete Reason:

Form CT-TR-I Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:
(Votes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-1 Reject/incomplete Reason:

Foi m CT-TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-i Reject/Incomplete Reason:

Form C'T-TR-I Reject/lncomplete Rcason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-1 Reject/Incomplete Reason:

Form CT-TR-I RejectAncomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accountine Period End Date:

Received Date:

Form RRF-1 Reject/Incomplete Reason:

Form CT-TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filln2 Received Date:
(Form RRF-1 Reject/Incomplete Reason:

Form CT-TR-I Reject/Incomplete Reason:

IRS Form 990 Reject/incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End,Date:

Filing Received Date:

Form RRF-1 Reject/Incomplete Reason:

Furor CT TR-I Reject/Incomplete Reason:

IRS Form 990 Rejectlincomplete Reason:

Notes From Registry Staff:
.Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-t Reject/Incomplete Reason:

Form CT-TR-I Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Prereq Type:

Registrant:

Registration No:

Date Established:

Prereq Type:

Registrant:

Registration No:

Date Established:

Proroquisito Relationship: Charily

BEYOND DIRECT MARKETING LLC
I;D01!]E93 Registration Type: Fundraising Event Registration Status: Complete 1/23/2014 Association Date: 1/1/2014 Expiration Date: 12/31/2014 Prerequisite Relationship: Charity

BEYOND DIRECT MARKETING LLC
F0022149 Registration Type: Fundraising Event Registration Status:
1/20/2015 Association Date: 1/1/2015 Expiration Date:

Complete
12/31/2015

Return of Organization Exempt From Income Tax ro-
A
Form990 Under section 501(c), 527, or 4947(aH1) of the Internal Revenue Code (except private foundations) Qnparlment of Ina iroeALey _Do _ not enter social security numbers on this form as itmay be made public.

For the 2020 Calendar year, or tax year baglnnIn 9 JUL 1 2020 and ending JN 30, 2021 B Check If C Name of organization D Employer identification number applicable: HABITAT FOR HUMANITY
Inge INLAND VALLEY INC.

Name
change Doing business as * * — * * * 18 0 4
Initial
return Number and street (or P.O. box if mail is not delivered to street address) Room/suite E Telephone number Final 41615 WINCHESTER RD #214 951-296-3362
return/
termin-
ated City or town, state or province, country, and ZIP or foreign postal code G Gross receipts $ 4Z572,741 retturnded TEME CULA CA 92590
H(a) Is this a group return
tb�eca F Name and address of officer. TAMARA MARINE
principal for subordinates? Yes [XI No
pending SAME
AS
`+ ABOVE H(b) Are an subordinates included? Yes NO
I Tax. exem Rit status: W 501 c 3 5o1 c ■ ]n5ert no. 4447 a 1 or 527 If "No," attach a list. See instructions J Web site: 10, WWW . HABITAT IV . ORG I H c Grou2 exemption number K Form of or anization; Corporation Trust Association Other ■ t_ Year of formation: 19 9 21 M Stain of leoal domicile, CA 1 1
Briefly describe the organization's mission or most significant activities: THE MISSION OF HAB I TAT FOR HUMANITY INLAND VALLEY INC. IN PARTNERSHIP WITH GOD IS
TO
c 2
Check this box if the organization discontinued its operations or disposed of more than 25% of its net assets.
'0 3
Number of voting members of the governing body (Part VI, line 1 a) ...--................................................. 3 15
0 4
Number of independent voting members of the governing body (Part VI, line 1 b) ...... a
15 5
5 4
5 Total number of individuals employed in calendar year 2020 (Part V, line 2a) .........................................• 6 7
Total number of volunteers (estimate if necessary) ....................... ....................................

Total
6 725
7a

0. a unrelated business revenue from Part VIII, column (C), line 12 ................ ...... ............................... b Net unrelated business taxable income from Form 9901Part I line 11 _ 7b

0. Prior Year
Current Year
y
6 Contributions and grants (Part VIII, line 1 h) „ „ --- ..-,-, . 331,397.
118,129.
v
9 Program service revenue Part Vlll, line 2 „„
( 9) ...........
1,074,355.
523,207.
d
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) 799.
778.
......„--,,,,-,-
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) --..... 2 71 b 698.
3 2 61 1 255 ,
12 Total revenue - add Imes 8 t h roug h 11 irrivst eq ual Part VI 11, column A fine 12 4,123,249.
13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) ...........................

0. 0.
14 Benefits paid to or for members (Part IX, column (A), line 4)

0. 0.
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 16a Professional fundraising fees (Part IX, column (A)line 11 e ..............
b Total fundraising expenses (Part IX, column (D), line 25) ► 85,418. 17 Other expenses (Part IX, column (A), lines 11s-11d, 11f-24e) ._ .................... 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) .,... ... ,- 19 Revenue less expenses, Subtract line 16 from line 12 ........ - ... o.
20 Total assets (Part X, line 16) ..................... 21 Total liabilities (Part X, line 26) ---, ............. 22 Not assels or fund balances. Subtract line 21
1 571,254. 1 6914 805.

Q a
2,521,583.
2,378,37z.
4,092,837.
4 073
176.
30 412.

Beginning of Currant Year
430 193.

End of Year
3,769,205.
3,491,798.
1,676,224-1
9681624
2,092,981.
2,523,174.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it Is true, correct, and complete. Declaration of preparor other than officer is based art all information of which preparer has an knowlod e.

Sign I Signature of officer CLIENTS COPY Date
Here TAMAR.A MARINE, EXECUTIVE DIRECTOR
Type or print name and title
Print/Type preparer's name Prepare Date Check PflN
Paid )ANIEL P. SCHREIBER 189202
Preparer Firm's name JGD & ASSOCIATES LLF Firm's EIN * * * * * 2551 Use Only Firm's addressila. 9191 TOWNE CENTRE DRIVE 0340 SAN DIEGO CA 92122-1274 Phonena.858-587-1000
May the IRS discuss this return with tho Rreparer shown above? See Instructions Yes No . ........................... ...
092001 12-23-20 LHA For Paperwork Reduction Act Notice, see the separate instructions. Form 990 (2020) SEE SCHEDULE 0 FOR ORGANIZATION MISSION STATEMENT CONTINUATION

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
21 HIS LITTLE FEET INC.

CITY OF TEMECULA
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ - 04 600 . MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Project/Program Title: Q� �1�C �� Start Date: End Date: (7 3 L 23 Physical Address of Project/Program: -�-«� �6-()et "C�M�� l C� 9 zsg2 INCLUDE IF DIFFERENT THAN ORGANIZATI`ON's MAILING ADDRESS If Grant is Awarded, Make Check Payable to: s t l )c -
Mailing Address: 344,5, r
chC I On

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant I j
Organization: l5 l 1 r�� Year Founded: 1 _
Website: V4 V��S L��[ Social Media: [r\C-4
Number of Paid Staff: S Number of Volunteers:

Geographic Area(s) the Organization Serves: V L a 1\ I}U�1�11°.S Geographic Area(s) the Project/Program Serves: %Q v;
do- co-�
NOTE: COMMUNITY SERVICE F�U`DI�G GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SE VE TEEMECULA.

Contact Name:� A� t jltin�j o\ Title/Position:XG(I •
Contact Person's Direct Telephone: V" (�ontact Person's Email: l5 mQi•`.�„

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? YesKDate of incorporation as a Nonprofit: 20 NO ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: l -3 1 611W State Identification Number:

PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this link: http://apps.irs.gov/apl /eos/

2. ❑ Attach State Entity Status Letter using this link:
htti)s:// www.ftb.ca,gov/online/self serve entity status letter/index.as

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool htip://rct.doi.ca.clovNerificationlWeblSearch.aspx?facility=Y

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No X Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES. rAP NCA ` e� a��.,
o v Vo f �� 4e -�.� sto
t It I��Qc`a , a��- aid��
c� C Q-[ s.
ll s ii W r7 5 S �.

Z
� j �'�� C � OU� of
SU �1es w VA qn� s oa �s /
A�° i ►n� and �s Q� , Soo
D W*ac D

FINANCIAL STATEMENTS

UPON REQUEST, COPIES OF THE ORGANIZATION'S CURRENT BUDGET/FINANCIAL STATEMENTS (BALANCE STATEMENT AND INCOME STATEMENT), AND IF AVAILABLE CPA'S AUDIT, MAYBE NEEDED 9MN§TKATt %@UNP FINAN9IAL M/ANAQlKMENT•. ID® NOT SUBMIT NOW-,

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No 2rY@5 ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? NO ❑ Yes IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH + YEAR

RECEIVED NAME OF ENITY FUNDING RECEIVED
$ , 000

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT - RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT. h
vm go bt ul
Cr\
c
+r r
2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF A

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT. elr
`` 5�� C
PS � �
Ok�s ��
ki
�0 � 1
" too �0i��iS/C�i��c �r Gns�S
- ow 3D0- -0g, a-�� , sa s �S - r G�► 1�,rec� .�
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING, EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS. ��,�•s �ar� S -��sQ o�� (e CGN � GoMMU
..�_�..1awl.i �s Ce�kloh� vt�dQr aae �-F i
�oU`�.•'o�i�r �8
\\NA 0
�U� r
%aA�Ms� M4 NIDe-/
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT FROM THIS PROJECT/PROGRAM: CJ
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 3r�

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS. cmss
Le„Wkt�� V� �A\
iO�f�Un �n 2D�3�
aliSl` S alno,- 1 h Q [,F to 4
EM L �1q 2?knce,
il Ins C`e ^ jh-�
�0 awl o of h s
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

Q
-A' �e
t1 Q ovr 0� o�
S p,� v
OW �G.`Q- o� s ha es
�v4
Q�h air �s
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $01000 Community Services Grant (Not to exceed <rn nn0)
Amount contributed to the Project/Program by the Applicant Organization
Other grants or funding already awarded for Project/Program, if any $ I—) I0b0
In -Kind match amount or volunteer credit hours estimated amount $ N /A TOTAL REVENUE $1(,006

LIST OF EXPENSES FOR PROJECT/PROGRAM

EXPENSES
Tools/Equipment $
Facilities/Rent/Insurance $ D
i
Supplies $ 1G1� '(Cl Z
Marketing $ 3 00
Services $
Foody
Other �v� �� $ 2-1,1 3 3
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; $ Zt(- b HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET $
/`:1.. _.r :- /-O A PIT A 001 1/' A T1/1P 1 0--- 4 n -4: 413

PREVIOUS* FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office —CSF I
Organization:

EXPE
FY 2021-2022 Amount of $
CSF Grant Fund Awarded:

REPORT due on or before September 12, 2022
Name of Project/Program:

Month & Year CSF Grant Received from City:

Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):
qEw Date onExpenditure
Name of Company Receipt/Invoice Description I Purpose
Receipt or Invoice MUST BE ON OR BETWEEN Amount DESCRIBE THE EXPENDITURE I PURPOSE OF EXPENDITURE JULY 1. 2021 - JUNE 30. 2022
1 $
2 $
3 $
4 $
5 $
6 $

EXPENDITURE TOTAL MUST BE EQUAL TO

EXPENDITURE TOTAL
(OR GREATER) THAN TOTAL AWARD AMOUNT.

Tn.........1.. / MAKIT AMMI 1/"ATI/1k1 0nnn 4A nF �7

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said amount of funds to the City. To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to:

I Organization:_
City of Temecula, 41000 Main St., Temecula, CA 92590,
Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Name of Project/Program:

TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: $ was received from City:

1. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the City

MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER EXPENDITURE TOTAL $
Amount
Description

EXPENDITURE TOTAL
!_4....F If.... A:-,- 0..;........I..,.....4 ;.. T,....., .., ,1.. !?OAAIT AOOI 1f%ATIP1k1 0--- 4n ..F 47

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:
• Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
■ Every Community Service Funding application is considered individually and on its own merit. ■ Awards will be given to organizations and activities that directly benefit the residents of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation.

The recognition for Community Service Funding should accrue to the City of Temecula. s Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately.

Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME:

MAILING ADDRESS: -i� S V �� Ae 1;-Q • PHONE: 6L2,) 4-7 - 03 10 ON
e" � ,�0V EMAIL: 1�1.5`1\ `C�Q� � qm%\ •Coflh
PRESIDENT / AUTHORIZED OFFICER: ��'� WOO-- CX� � � D o(^t Ck),(- T I `
SIGNATURE: K' _ DATE: US Lo l L1'
`1-)N 7 ! I, DAY, YEAR

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:
t,A-
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: [email protected] (951) 694-6413
[email protected] (951) 693-3959
11:4.. C.....4:.... i.. !'MAKIT A001 1/"ATI/1A1 0...... 47 -4! 412

ea f)4-
Stoic of California
wFranchise Tax Board
PO Box 1286
Rancho Cordova CA 95741-1286
HIS LITTLE FEET, INC.

PO BOX 11572
SANTA ANA CA 92711
Regarding:

Organization's Name:

CCN:

Purpose:

R&TC Section:

Form of Organization:

Accounting Period Ending:

Tax -Exempt Status Effective:

Tax -Exempt Status
HIS LITTLE FEET, INC.
3776899
Charitable
23701d
Incorporated
07/31
04/13/2015
Date: 02.11.16
Case: 30820600701287076
Case Unit: 30820600701287080
In reply refer to: 760:GRW:F120
Exempt Acknowledgement Letter
We have received your federal determination letter that shows tax exemption under Internal Revenue Code (IRC) Section 501(c)(3).

Under California law, Revenue and Taxation Code (R&TC) Section 23701 provides that an organization is exempt from taxes imposed under Part 11 upon submission of the federal determination letter approving the organization's tax-exempt status.

Generally, the effective date of an organization's California tax-exempt status is the same date as the federal tax-exempt status.

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.

In order for us to determine any effect on the tax-exempt status, the organization must immediately report to us any change in:

Operation
• Character
• Purpose
• Name
• Address
FTB 9944 PASS (REV 12-2014) Exempt Applfcatfon\Correspondence \LTR 001-EAL

.,INTERNAL REVENUE SERVICE
P. O. BOX 2508
CINCINNATI, OH 45201
Date -DEC 14 2015

HIS LITTLE FEET INC

C/O BRIAN MCDONALD
7755 CENTER AVE STE 1100
HUNTINGTON BEACH, CA 92647
Dear Applicant:

DEPARTMENT OF THE TREASURY
Employer Identification Number:
47-3769966
DLN:
17053308318025
Contact Person:

MICHELLE A GLUTZ ID# 31213
Contact Telephone Number:
(877) 829-5500
Accounting Period Ending:

December 31
Public Charity Status:
170 (b) (1) (A) (vi)
Form 990/99o-EZ/990-N Required:

Yes
Effective Date of Exemption:

April 13, 2015
Contribution Deductibility:

Yes
Addendum Applies:

No
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 i70. 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.

If we indicated at the top of this letter that you're required to file Form 990/990—Ezt99V- -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

Form 990
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) Department of the Treasury ► Do not enter social security numbers on this form as it may he made public, Internal Revenue'Servtoe ► Go to www-frs.gev1Form990 for instructions and the latest information.

A For the 2021 calendar year, or tax year beginning
B Check if applicable:

Address change HIS LITTLE FEET INC
Name change 3445 STUDEBAKER ROAD
nitial rebim LONG BEACH, CA 90808
Final return/tennmeled
Amended rehrn
AppnCaFron perdrng F Name and address of principal officer:

Same As C Above
Tax-ezewpt status: N 501(e)(3) Ll 501(c) (insert no,)
J Website: ► WWW.HISLITFEET.ORG
K Form oferganization 1XI C01p01aNG11 Ll Trusf 11 Association Other, art Summate
0Po1e No. 1545.0047
2021, and ending 20
D Employer identification number
47-3769966 _
Telephone number
562 397-0370
G Gross re qft $ 202
I Is IhiS a group return for5ubptdmales? Yes
HIM Are ali subordinates included? Yes
If "Nc," attach a list. See instructions,
4947(a)(1) or 527
X(c) Group exemption number ►
L Year o` forruabon: M state of legal domicile: CA
No
No
1 Briii de_sc_ribe_tile_orga_nizatio_Ws fission or_most signsttrani a_rllvltle_s:T_0_P_R_OV_I_D_E_A_S_SI_S_T_AN_C_E_T_O NEED----------------..__-________------------------_----__----__ _CH_ILDR_E_N_Z_N___
--------------------------------------------------------------- cE
2 __ _______________ ____ _ ____ __ ___ _
Check this box ► If the organization discontinued its operations or disposed of more than 25°% of its net assets. �
— — — — —
f — —
3 Number of voting members of the governing body (Part VI-, line 1 a) . , ... . .. 3
7 °d
N
4 Number of independent voting members of the governing body (Part VI, line 1 b)... ........ . ..... 4
5 Total number of individuals employed in calendar year 2021 (Part V, line 2a) .. ..... . .. , ... 5
0 6
Total number of volunteers (estimate if necessary), • , • , .... ....... 6 0
a
7a Total unrelated business revenue from Part VIII, column (C), line 12 .. 7a
142.
b Net unrelated business taxable Income from Form 990-T, Part I, line 11 .. ..... 7b
0 ,
Prior Year
Current Year
8 Contributions and grants (Part VIII, line 1h)
146 640.
201
F 924.
m
9 Program service revenue (Part VIII, line 2g)
142
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) 11 Other revenue (Part VII'i, column (A), lines 5, 6d, 8c, 9c, 10c, and 11 e).......... 12 Total revenue — add lines 8 through 11 (must equal Part VIII, column (A), line 12) 146,640.
202,065.
13 Grants and similar amounts paid (Part IX, column (A), lines 1.3). ... ....... , 83 950.
14 Benefits paid to or for members (Part IX, column (A), line 4) ....................... 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) ,.- • . 24 713.
43 114.

H
16a
Professional fundraising fees (Part IX, column (A), line Ile) .. . ........ —.,. ... 657.

C
b
Total fundraising expenses (Part IX, column i line 25) ^i— 4,409. 31,155.
17 Other expenses (Part IX, column (A), lines 1la-lId, 1If-24e)- 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25).. .... 25,370.
158
222,
19 Revenue less expBRses, Subtract line 18from line 12....................... . ..... 121 270.
43 844.

Beginning of Current Year
End of Year
20 Total assets (Part X, line 16). ...... ..-.... ................ 96 878.
140
722.
21 Total liabilities (Part X, line 26) - — ... , .. ,"

0. 07
p
i
22 Net assets or fund balances. Subtract line 21 from line 20............... .... ..... 96 878.
140
722 ,
rarz ii I za nature 13loctt
L4kWr penalties of pepury, I declare that i have exampled this return, rnckidIng accorrvanying schedules and stal9ttgRfs, and to the best of my knowledge and belief, it is true, correct, and rpnpllete, Declaration of prepare., (other than officer) 6 bused on all lnlormatiin of WIWI preparer has any knowtgdyb- Sign IsIcnaingoreulcef pale
Here ` HALI WOLF President
TyrW or prnl n:irrve Aml lrlle
Print/Type preparer's name Preparer's signature Date Check Lj it I PTIN Paid Tanya R Lansin E.A. Tana R Lansing,E.A. 5 04/22 selhernployed P0I219573 Preparer Furmsname ' LENNING & CO., INC.

Use Only Firm'saddress ► 13924 Seal Beach Blvd Ste C Firm'sEIN ► 20-2141302 Seal Beach CA 90740 Phonenp 562 594-9729
May the IRS discuss this return with the preparer shown above? See instructions.... . JXJ Yes I I No BAA For Paperwork Reduction Act Notice, see the separate instructions. TEEA01011 09/22121 Form 990 (2021)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #

HOSPICE OF THE VALLEYS

CITY OF TEMECULA
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022
j PROJECT/PROGRAM INFORMATION
Amount Requested: $ 50,000
Project/Program Title: Senior Assistance Program
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Physical Address of Project/Program: Same as below
Start Date: 3/20/20 End Date: 6/30/24

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Hospice of the Valleys Mailing Address; 25240 Hancock Ave. Ste 120
Murrieta, CA 92562

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant
Organization: Hospice of the Valleys Year Founded: 1982 htt s //hos lce mlps:/t www.facebook.som/HospiceoflheValleys Website: P P ofthevalleys.org/ Social Media: hUps:+ANww.+nslasram.commosplreofthevalleyssd Number of Paid Staff: 58 Number of Volunteers: 40
Geographic Area(s) the Organization Serves: Southwest Riverside County Geographic Area(s) the Pro"ect/Pro ram Serves: Temecula NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Melanie House
Contact Person's Direct Telephone: 951-972-2189
Title/Position: Development Coordinator
Contact Person's Email: [email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes Date of Incorporation as a Nonprofit: June 29,1983 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 95-3846314
State Identification Number: 1131444
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. N Attach IRS Deductibility Status using this link: htti)://aps.irs.gov/agp/eos/, 2_ x❑ Attach State Entity Status Letter using this link:
hftps.*I/ www.ftb.ca.gov/online/self serve_gntity status letter/index.as

3. x❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: hitp.i/rct.doi.ca.gov/VerificationfWeb/Search.aSpx?facilitv=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No ❑x Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors x❑
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION

BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES - Hospice of the Valleys Mission is: We foster reverence for life, relief of suffering, and compassion in loss for the terminally ill residents and their families in the communities we serve. Our Vision is:To be a recognized leader of excellence in comprehensive end -of -life care,
Hospice of the Valleys began in early 1982 by two sisters in Sun City, California who recognized the need for specialized end -of -life care for people in their community. In order to make this care available, these sisters received hospice training as volunteers and began going door-to-door raising money on their patients' behalf.

After years as a volunteer -run organization, Hospice of the Valleys eventually became a full -service, nonprofit 501(c)(3) organization. Today, Hospice of the Valleys employs a team of experienced clinicians and administrative professionals, and continues to have a group of dedicated volunteers who touch the lives of our patients each and every day. After 40 years of caring for hospice patients living in Southwest Riverside County and Fallbrook, Hospice of the Valleys remains committed to the mission of its founders by providing loving hospice care to all who need it, regardless of their ability to pay.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes N IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH +YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP Senior Assistance Program
Senior Assistance Program
$ 5,000
January 2021 Community Service Funding
jary 2022 Community Service Funding
I
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020,

HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECTIPROGRAM IN THIS APPLICATION? No ❑ Yes ❑x IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT
MONTH + YEAR

RECEIVED

NAME OF ENITY

FUNDING RECEIVED
$ 5,491
CDBG Temecula
May 2021 (FY 20-21)
$ 7,226
CDBG Temecula
Funds not yet received
_
(FY 22-23)
$
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT, The Senior Assistance Program provides compassionate hospice care to terminally ill patients and support to their families. The Program pays for the direct cost of hospice care for senior citizens and the severely disabled. Direct hospice care includes, but is not limited to, personal visits by physicians, nurses, home health aides, social workers, and spiritual care advisors; the provision of durable medical equipment, medical supplies, medication delivery, and bereavement support services. Our services are extended to our patients and their families while the patient is living and up to at least 13 months after death. After the patient passes, caregivers receive bereavement support that includes phone calls and/ or personal visits by a bereavement counselor or chaplain, access to grief support groups, bereavement books and mailings, as well as memorial services of remembrance twice per year, Hospice of the Valleys does not believe in adding to the burden of patients or their families by asking for reimbursements or co - pays that are not covered by insurance. For example, Medicare does not cover a $5.00 co -pay for each medication that each of our patients are prescribed; however, Hospice of the Valleys takes care of that cost and does not pass the co -pay on to our oatients. During times when end of life is imminent, we do not want our patients and their families to incur yet another expense.

Dur goal is to ensure no one is turned away or provided with limited hospice care simply due to their inability to pay. 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

For every patient on our service. Hospice of the Valleys makes numerous visits to the the patient and their family, to wherever they call home. From nurses, to home health aides; doctors, to social workers; and even spiritual care and bereavement staff we see patients many times a week to care for them as they near the end of their lives. These visits are all hours of the day and night, as well as on weekends and holidays. Funds will be used towards patient care and costs not covered by Medicare or other insurances. This includes, but is not limited to, provisions such as medication delivery services, incontinence supplies, overbed tables, medication co -pays, and mobile shower equipment, just to name a few. We estimate that we will serve approximately 240 patients in Temecula from March 20, 2020 through June 30, 2024 (already served 125 from 3/20/20 to 8/15122) for a total of $20,285 54 spent from 3/20/20 to 8/15/22 and we can project that we will double that by June 30, 2024 ($40,571.08). These items keep our patients comfortable; alleviate the burden to their caregivers; and help with added expenses that families shouldn't have to amass at the end of their loved one's lives. Additionally, our Hospice Hearts have become an invaluable gift we offer to our patients' families and caregivers. When separated, the tiny inner heart can be placed with the loved one who has died as a reminder of their unbroken connection to those who remain behind. Numerous families who have received the hospice hearts have told us how meaningful they are and how they would be treasured. Hospice Hearts are $6 per and we offer an unlimited amount to families when their loved one has passed. 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS We serve approximately 350 patients a year in Southwest Riverside County, and since year 2000, 15% of our patients reside in Temecula. When looking at our patient count, since March 20, 2020, we have served 120 Temecula patients (residents as of 8/15/22) and can estimate that at least one of these patient's family members or friends also benefited from our services (as many of the provisions we provide ease the burden for the caregiver). We can also estimate that our services in the City of Temecula, will double the 120 patients number through June 30, 2024, for a total of 240 patients that we are including in this grant. The patients we serve are presumed low -moderate income persons based on the fact that they are either severely disabled adults and/ or senior citizens (age 62 and above). Our patients have been diagnosed with a terminal illness and have 6 months or less to live, as certified by a physician. While we expect to serve approximately 240 total patients residing in the City of Temecula (from March 20, 2020 through June 30 2024), the scope of our service extends beyond the patient. Our hospice team also assists each patient's caregiver as they journey through the dying process. Our interdisciplinary team is available to assist caregivers in making difficult end -of -life decisions and help families navigate the many issues surrounding death. Once the patient dies, Hospice of the Valleys provides comprehensive bereavement support and education to families/ caregivers, extending the number of individuals we serve 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT I 240
FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 1 20 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

L CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS The Senior Assistance Program provides compassionate hospice care to the terminally ill patients of Temecula and to support to their families. During times when end of life is imminent, we ensure no one is turned away or provided with limited hospice care simply due to their inability to pay.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

The COVID-19 pandemic affected Hospice of the Valleys and in turn, serving the Temecula community, in a number of ways which are listed below:
• The pandemic forced people to remain in their homes and not frequent their doctor's office. As a result the number of patients that were admitted was down considerably; lowering our census and funding. • Patients also were coming on to service later than usual as a result of not visiting their doctor; again causing a deficit to our per day funding/insurance reimbursements.
• Some patients did not want staff in the home for fear of transmission so giving care brought many new challenges. • Our doctors were only allowed to do tele-visits as opposed to in person care. • Volunteers were not allowed to visit patients which put a further strain on caregivers and patients alike. • Staffing shortages as a result of illness and burnout. • Increased costs in terms of PPE (Personal Protective Equipment) as staff had to be protected to work at facilities or patient homes.
• Staff who are not vaccinated needed and continue need to be tested each week at a cost to us. • Significant labor expenses in regards to COVID training, tracking, contact tracing, reporting. • Certain items, gloves for example, were in short supply and cost more than ever before. 6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM-
The U.S. Census Bureau (American Community Survey) estimates Temecula's population to be approximately 110,846 as of 2021, with over 10.5% being 65 years and older. While Hospice of the Valleys provides care to all hospice patients regardless of age, the majority of our patients are senior citizens. Hospice of the Valleys currently cares for approximately 350 patients per year, with 15% of those patients residing in Temecula. As this group of 11,639 senior citizens in the City continues to age, there will likely be a greater need for hospice services in the grant service area. In order to meet this anticipated demand, Hospice of the Valleys will continue to raise funds through grants, donations, fundraisers, community support, and our planned giving program. The work we do with our Senior Assistance Program has been existing since our founding 40 years ago and will be indefinitely ongoing
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM

REVENUES

EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
$ 50,000
Amount of money requested from this City of Temecula
Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ 3,326,212
Organization
Other grants or funding already awarded for Project/Program, if any $12,717
In -Kind match amount or volunteer credit hours estimated amount $ 49,837
TOTAL REVENUE $ 3,438,766

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment I $626,298
Facilities/Rent/Insurance $151,571
Sup p lies :overbed tables, full -electric beds, incontinence supplies, and medication co -pays 3/20/20-6/30/24 $ 40,571.08
$ 33,493
$156,828
$53,146
Marketing
Services
Mileage exp for patient visits
Other Hospice Hearts: 240 patients x 10 hearts/family x $6.00 each $ 14,400.00
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; HOWEVER PLEASE INCLUDE.
$ 2,681,346
$3,757,653.08

TOTAL EXPENSES
$

TOTAL BUDGET
$ (318,887.08)
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Hospice of the Valleys_
MAILING ADDRESS: 25240 Hancock Ave. Ste. 120 PHONE: (951) 200-7800 Murrieta. CA 92562 _ _ EMAIL: [email protected] _
PRESIDENT / AUTHORIZED OFFICER: _Paul Mathias CFO
SIGNATURE: /01uw to

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY: Melanie House
Nr
DATE: September 9, 2022
Development Coordinator
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions. [email protected] (951) 694-6413
Betsy. [email protected] (951) 693-3959
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

STATE OF CALIFORNIA

TAX BOARD
BPO
Q!)FRANCHISE
BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 7/14/2022
ESL ID: 8598323706
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 1131444
Entity Name: HOSPICE OF THE VALLEYS SC

1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board.

3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d. ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Important Information
■ This information does not necessarily reflect the entity's current legal or administrative status with any other agency of the state of California or other governmental agency or body. • If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).
• The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Q HELPB MENU
Home > Tax Exemganization Search > Hospice Of The Valleys Sc < Bla&to Search Results
Hospice Of The Valleys Sc
EIN: 95-3846314 1 Murrieta, CA, United States
Other Names
Publication 78 Data e
Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in determining deductibility of their contributions.

Tax Year 2015 Form 990
Page Last Reviewed or Updated. 20-November-2020 P► Share $ Print

Form 990
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) uepfrrr MIt of Ihq TrNrxury ► Do not enter social security numbers on this form as it may be made public.

InlMeo rRevenue S40
rta ► Go to wwjJrs.AfovIFormB 0 for Instructions and the latest information.

OMG No, 1545-0347
Open to Public
Inspecllan
H ror me zuzu cafenoar year, or tax yenr beginning 2020, and ending , 20 B Checx if applicable; C D gmptoyH Identification numher Addfesschange HOSPICE OF THE VALLEYS SC, INC. 95-3846314 Name, change 25240 HANCOCK AVE, STE 120 E Telephone number Initial return MURRIETA, CA 92562
951-200-7800
Final relurn/terminated
Amended rclurn G Gross mc,l.pU $ 6 297 143.

Application pending F Name and address of principal officer: LYNET E CVAR MfA) Ix INh a group return for nowaolmesi Yes No Same As C Above Ill l Are all subo,drnates included? Yes tic If'No.' attach a list See inslruclions
I Tax-exempt status: X 501(C}{3) 501W (iourt no.) 4947(a)(1) or 527 J Webslte: ► Hllr W.1joSpICEOPTHEVALLEYS.ORG Mil Group exemption number ► K Form of organizalicn: {;prpfpalilHl Trust Association Other"` L Year of lorrnalion: 1983 1 M state of legal domicile: CA r nrerjrry aescnee Inc organlzatfon-s nusslon or roost signiCCant activilies:(�e foster reverence _f_or__1_ifeJ_relief of-----ngs-----m---In in loss for the_ter_Mi_na.1�i11 residents -.and -their families in the communities we serve,_
E- - -- - - - - - -- - - -----_---------
c 2 Check This box ► if the organization discontinued its operations or disposed of more than 25% of its net assets, -------.---------e-------_-_-_._---------- . - - -
0 3 Number of voting members of the governing body (Part VI, line la)... ... 3 9 e'a 4 Number of independent voting members of the governing body (Part Vl, line lb),....... , , , 4 ayi
A 5 Total number of individuals employed in calendar year 2020 (Part V, line 2a). -5 64 6 Total number of volunteers (estimate if necessary) ... _ .. . .... . ......... . .... 6 -52 a 7a Total unrelated business revenue from Part VIII, column (C), line 12 ................ . . ... 7a 0.
b Net unrelated business taxable income from Form 990-T, Part 1, line I ... 7b 0 .

Prior Year
Current Year
8 Contributions and grants (Part Vill, line Ih)........... _
66,351,
531
200_
9 Program service revenue (Part VIII, line 2g), .. .
5, 861 297.
5 704
345.
10 Investment income (Part VIII, column (A), lines 3, 4, an dj 14,323,
16,311.
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9 , I 1 107 795.
42 952.
12 Total revenue - add lines 8 through 1 I (must equal P , co Nnur (A), line 12) 6 049 766.
6 2 4
808.
13 Grants and similar amounts paid (Part IX, column (A), lines 1.3). 14 Benefits paid to or for members (Part IX, column (A), line 4) ... .. . . 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10)..... 3_ 857, 048:
4 306
846.
16a
Professional fundraising fees (Part IX, column (A), line l le),.. . . b
Total Fundraising expenses (Part IX, column (D), line 25) ► 113, 477. 17 Other expenses (Part IX, column (A), lines Ila-1 ld, 11f-24e). 1 783 463.
1 875
r
6I7.
18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) _y1 .t
5 640,511,
,�
6 182
463.
19 Revenue less expenses, Subtract line 18 from line 12 . , . , , . • • • • • , , . , . • • • , _40 9, 255 .

BeAnof Current Year
112 345.

End of Year
6 20
Total assets (Part X, line 16) ......
2 820 982.
2,899,195.
21 Total liabilities (Part X, line 26).... .
363 380.
320
322,
22 Net assets or fund balances. Subtract line 21 front line 20. 2,457,602.
2 57a
.863.

Part
ff Signature Block
penalties of perjury, I declare Ihet I nave examined This returnincluding accptrlpanymg schedules and slatornents, and to line besl of my knowledge and belief, it is true, correcl, Declaration of preyarer (other Ihan nl6i 0 Is based on all information of o i preparer has any knowledge, and
l now
Cernplele.

Sign r 5rrralwaorallkrrr —nai4 —
Here LYNETTE CVAR CA0/CF0
Tpa -, "nnnf nnmo Ww Irulu
Prinlrrype preparer's name Proparel'e signature male Check PTIN Paid Paul J Ka ark, CPA Paul J Ka mark CPA eu-empleyj d P01873961 Preparer FwW, nanr.= ► NIGRO & NIGRO PC _
Use Only F,.,,,; adLfe„ ► 25220 Hancock Ave Ste 400 Furrrs FIN � 30•-0636241 _ MURRIETA, CA 925624 Phow-lo. (951) 698-8783
May the IRS discuss this return with the preparer shown above? See instructions., IXI Yes I T—No BAA For Paperwork Reduction Act Notice, see the separate Instructions. TEen01011- 0111901 Form 990 (2020)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
23 INLAND VALLEY SYMPHONY

AKA TEMECULA VALLEY

SYMPNONY

CITY OF TEMCULA
FISCAL YEAR 2022 - 2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICAMON
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ S* 0 0 O MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Project/Program Title: n � E ASO rJ Of 14 0 P e Start Date: of. I End Date: 70.23 Physical Address of Project/Program: Tfrx¢eAt dj$1I 1 SsS AMCL& VIr+� ��, '��rrirr,+ �• INCLUDE IF DIFFERENT THAN ORGANIZATIONS MAILING ADDRESS Cat u 9L If Grant is Awarded, Make Check Payable to: xN C- w b IA ON �qpkW, TW e Mailing Address:

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant v AM e'
Organization: a Year Founded: q Q R
Website: WWLV-'rEFAF-CI.LA fA11 M Iw. •O�Social Media: w�• IFACEAoOK.CQ rmBcuAA- Number of Paid Staff: '� oZ- Number of Volunteers:

Geographic Area(s) the Organization Serves: 11 fA E
Geographic Area(s) the Prolect/Program Serves: T M r,0 UAA \101 iq NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY US D TO SERVE TEMECULA.

Contact Name: QLQ KA To 0 5
Title/Position: C �W-rrVC IDIAEGTOA
Contact Person's Direct Telephone: SI g• 271 — Contact Person's Email: GJ4AIA Too S 09ai 0 Gon,414. Parr

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes ® Date of Incorporation as a Nonprofit: -I• U - 77 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 15002000 State Identification Number: a 0 r PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this link: hItpA/appsjrs.Aov1app1eos1

2. ❑ Attach State Entity Status Letter using this link:
httl5-9'-:1/ www.ft.c . ov n Ine e f serve entity status letter/inde?x.as

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: htt ://rct.do .ca. avN dfica ion eb/Sears s 0f ilt -Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

4 APPLICATION AUTHORIZATION
Has the organization or any members of the Board of Directors of the organization been involved with any personal business transactions valued over $500 including any business transactions, negotiations Investments, or interests in real property with a Temecula City Council Member during the past 12 months? No Yes ❑ IF YES, BRIEFLY DESCRIBE:

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No � Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee V\] Board of Directors ❑ Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION

BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES,

MISSION STATEMENT
Temecula Valley Symphony aspires to provide quality, innovative, and compelling music programming and serves as a leader of the arlS in our community, through an organization that provides the support necessary for these efforts, in an atmosphere that is fun, positive, and supportive.

MISSION STATEMENT
The purpose of Temecula Valley Youth Symphony is to enrich the lives of student musicians with outstanding educational and performance opportunities for all levels, in a nurturing and challenging environment without discrimination. Working together with parents, private and school music instructors, TVYS will provide the finest possible training with rehearsal and performance opportunities to enable the students to develop, share and Further enrich their lives through the power of music. TVYS believes that music is proven to enhance student performance in all academic areas.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FMDMG SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes P9 IF YES, PROVIDE BELOW,
-' "LiF% vv101wM 0UUKGES—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PRDIIECT OO IN THIS APPLICATION? NO Yes IF YES, PROVIDE INFORMATION IN TABLE BELOW.

City of Temecula Community Service Funding - Reinvestment In Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

Ft ev +z�t�.5
Grant funds will support "SEASON OF HOPE" and allow us to invite Is of school children and senior citizens to our concerts with FREE ADMISSION. Monies will be used for marketing and outreach materials to spread throughout the community. Payment will be made to various musicians for participating in the program and demonstrating their instruments. Printed materials distributed at concerts will contain educational information about the composer, the style of music, and the instruments featured on the concert.
i
2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO. INCLUDE A LIST OF GOODS, EQUIPMEMENT. AND/OR SERVICES THIS ORGANIZATION HAS �— PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

Compensate musicians for performances, website improvements, increase marketing to promote higher visibility and recognition in the community.

TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

Two large concerts will be held at Temecula Valley High School with outreach to local students, music studios, and school band programs. Dv outreach through the Temecula Valley UttiHed school district. Special concert invitations will be distributed at places like the Mary Phillips Senior Center, and various senior housing communities in Temecula, offering FREE Tickets to the concerts. Free tickets will also be distributed to the Boys and Girls Club and other local charities. 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM:

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION 1056
50

Page 8 of 13 ends

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS.

SEASON OF HOPE will focus on providing FREE concert tickets to hundreds of local Temecula residents (focusing on the elderly population), and local students and their families.

Concerts will include some music selections composed by minority or female composers and will include educational elements in the presentation of materials and/or the music performance itself.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

Due to lockdowns, we had to cancel 6 concerts and were unable to schedule further concerts until Covid-19 restrictions were lifted. Consequently we not only lost performance revenues but also most of our sources of donations.

Were it not for a couple of pandemic related relief grants received from the State and Riverside County, we would have been forced to close down our organization completely.

Due to lack of funds we were unable to resume full concert scheduling for both the last and the upcoming season.

Inflationary pressures have increased most of our basic general operating expenses as well as the cost of musicians because of higher cost of living, especially gas prices. 6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

One of our goals for our 2022-2023 Season is to offer FREE CONCERTS to Temecula Valley Uuiflic School District's students and families to educate them about symphonic music which is proven to improve the mental health of students.

We will use grant funds for marketing and outreach throughout the community to also offer free tickets for the elderly and senior citizens in the Temecula Valley.

As part of our educational program we also host a young artist concerto competition and will select winners to perform at our April 22, 2023 concert with the Symphony.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

I - -LINE ITEMS FOR PROJECT/PROGRAM
REVENUES jEXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $ 50 000 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ Organization
19,333
Other grants or funding already awarded for Project/Program, if any $ 3,000
In -Kind match amount or volunteer credit hours estimated amount $ 38,500
— _ TOTAL REVENUE $
110 833

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
a
$
0 Facilities/Rent/Insurance
$
9,275
Supplies
$
- —
2,090
Marketing
I $
16,133
Services
$
50,560 ~
Food
- — I
1,000
Other
$
14,495
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; f

HOWEVER PLEASE INCLUDE,
$
17,280

TOTAL EXPENSES
TOTAL BUDGET' $
110,833 $
110,833
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

ACIK7. O WLEDGEWNTISIGNATURE PAGE
The applicant acknowledges and agrees to the following:
• Recipient Is subject to aft COrnmunityServlce Funding Program requirements inciudingsubmittal deadlines and payment disbursements.
• Every Community .Service Funding application is considered individually and on its own merit. • Awards will be given to organizations and activities that directly benefit the residents of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

Please allow time for checks to be processed.
■ The awarding of Community Service Funding does not constitute an automatic annual allocation. ■ The recognition for Community Service Funding.should accrue to the City of Temecula. • Commurlfty Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were .used apprOpriately.

F Community Service Fund€nggrants will not be awarded or announced within the 60 days before an election In which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as Incomplete.

Vwe hereby certify the information contained in this Application is true to the .best of our knowledge and belief.

ORGANIZATION NAME:

Inland Valley Symphony, Inc. dba Temecula Valley Symphony MAILING ADDRESS: PO Bay. &17
Temecula, CA 92593
PHONE: ( 9511333-4945 (Alwia)
or 818-?31-09314,A�na)
- EMAIL,• W&najoos a) a�Lcnna
PRESIDENT / AUTHORIZED OFFICER: MAIA CANTIRELL
TREASU..RFR
y -Pl ;rNr NA F TITLE
SIGNATURE: DATE: Q� �[)��
IF DIFFERENT TH MQNT}I, DAY, YEAR
A�AI30VF,
APPICATION PREPARED BY:. ALANA 100S - EXECUTWE DIRECTOR

PRINT NAME TITLE
SUBMIT ORIGINAL APPLICATION BY MQNDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn., City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: Stacey.Brown@Temecul,-)CA.gov (951) 694-6413 [email protected] (951) 6W-3959
C€ty of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

Q HELP® MENU E
Home > Tax ExemQrganization Search > Inland Valley Symphony Inland Valley Symphony
EIN: 33-0862000 1 Temecula, CA, United States
Publication 78 Data e
Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in determining deductibility of their contributions.

On Publication 78 Data List: Yes
Deductibility Code: PC
Copies of Returns (990, 990-EZ, 990-13F, 990-T) e
Electronic copies (images) of Forms 990, 990-EZ, 990-PF or 990-T returns filed with the IRS by charities and non- profits.

Tax Year 2020 Form 990EZ
Tax Year 2019 Form 990
Tax Year 2018 Form 990EZ
Tax Year 2017 Form 990EZ
Tax Year 2016 Form 990EZ

STATE OF CALIFORNIA
rry� FRANCHISE TAX BOARD
f r F• 1 S PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 9/9/2022
ESL ID: 5729240826
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 2045812
Entity Name: INLAND VALLEY SYMPHONY
0 I. The entity is in good standing with the Franchise Tax Board, ❑ 2. The entity is not in good standing with the Franchise Tax Board.

X3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d. ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California al a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidabllity of contracts made by the Entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Connect With Us
Web: ftb.ca.gov
Phone: 800-862-5711 from 7 a.ni. to 5 p.m. weekdays, except state holidays 916-845-6500 from outsisie tlu United States
California
Relay Service: 711 or 800-735-2929 (For persons with hearing or speech impairments) FTB 4263A WEB (REV 12-2019)

HOME ABOJI- MEDIA CA R --: E R EGC -AT I 0Nf--; RES0 R S PROGRAMS CUDNT/1U, Registrant Detail
Entry ype Cot por;; e Class u5 registered with the secc2Lai v of e. or based ran fol,r6ng 60CL11 Organization Name: INLAND VALLEY SYMPHONY IRS FEIN: —3.10862000 Entity Type; Public Benefit SOS/FfB Corporate/Organization Number: 2045812 Registry Status: Current Renewal Due/Exp. Date: 11/15/2022 W.-I'Registration Number: CT0162898 Issue Date: 7/19/2010 Record rfy . pe: Charity Registration Effective Date: 7/19/2010 Date of Last Reneivak 11/18/2021 DBA:

MaHing Address
Street: PO BOX 637
Street Line 2.,
City, State Zip: 'I'EMECULA CA 92593
Filings & Correspondence
UWiW=y—ULUaUQ,11 Delinquency 1st Notice
ondi g—DAmmenta
Uarm 990--EZ 412
M1 L-1-=
RKE-11 IQL6
IME-1 2009
&ULZJ�()
I Form 9901?
Lk 7M)
LRE- L 2 QL1
IRUIDGNTP-9 21L L. L"
RS ul t,1 ()9() Z(L
Return Check Letter
Founding Documents
2012 RRLF-I
2012 IRS Form 990-EZ
2004 RR F- 1.
2005 RRF-1
2006 RRF-1
2007 RRF-1
2009 RRF-1
2010 IRS Fonm 990-EZ
2008 RRF-1
2011 RRF-I
2011 IRS Foirn 990-F7
2009 IRS Form 990
2008 IRS Form 990-EZ
Confirmation ol'Registration
First Notice to Register
Secolld Notice to Register
2021
2018
2019

2020
2013 RRF-1
2013 IRS Form 990-1 Z
2015 RRF-1
1 ' -Z 2015 IRS Fonn 990-E.Z
?415 rm-��'1"��w 2015 IRS Forrn 940-F1
2016 RRF-1
�'.511T17 RAF-1 2017
IS { =92017
Annual; Renewal Data
Status of filing: Accepted
Accounting Period Begin Date: 7/1/2009
Accounting Period End Date: 6/30/2010
Filing Received Date: 12/1/2010
Furin RRF-1 Reject/Incomplete Reason:

Form CT-TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason;
Notes From Registry Staff;
Status of Filing;
Accounting Period Begin Date:

Accounting Period End Date:

Filing; Received Date:

Form RRF-1 Reject/Incomplete Reason:

Form CT-TR-I Reject/Incomplete Reason:

IRS Form 990 Rejecl/Incomplete Reason:

Notes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-1 Reject/incomplete Reason:
1, arm CT-TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason;
Notes from Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period Fnd Date:

Filing Received Date;
Form RRF-1 Reject/Incomplete Reason:

Form CT-TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff. -
Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-1 Reject/Incomplete Reason:

Form C'r-'i'R-I Reject/Incomplete Reason. -
IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff;
Status of Filing: - Accounting. Period Begin Date:

Accounting Period End Dates
Filing Received Date:

Accepted
7/ 1 /2010
6/30/201 1
11/17/2011
Accepted
7/ 1 /201 1
6/3 0/2012
10/31 /2012
Accepted
7/1/2012
6/30/2013
11/1K2013
Accepted
7/1/2013
6/30/2014
2/9./20 Li
Accepted
7/ 1/2014

0./3 0/2015
1!5/2016

Form RRF-1 Reject/Incomplete Reason:

Form CT-TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/lncomplete Reason:

Motes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-t RejectAncomplete Reason:

Form CT-TR-I Reject/incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:
]Votes From Registry Staff:

Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Forst RRF-1 Reject/Incomplete Reason:

Forst CT-TR-I Reject/incomplete Reason:

IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Accepted
7/1/2015
6/30/2016
11 /18/2016
Accepted
7/1/2016
6/30/2017
11/16/2017
Status of Filing: TAccepted
Accounting Period Begin Date: 7/1/2017
Accounting Period End Date: 6/30/2018
Filing Received Dale: 11/20/2018
Form RRF-1 Reject/Incomplete Reason:

Form CT-TR-1 Reject/Incomplete Reason:

IRS Form 990 RejectAncomplete Reason:

Nalm From Registry itnff!
Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-1 Reject/Incomplete Reason:

Form CC TR-1 Reject/Incomplete Reason:

IRS Form 990 Reject/incomplete Reason:

Notes From Registry Staff. -
Status of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date-
Forin RRF-1 Reject/Incomplete Reason:

Form CT-TR-1 Reject/Incomplete Reason.,
IRS Form 990 Reject/Incomplete Reason:

Notes From Registry Staff:

Sialux of Filing:

Accounting Period Begin Date:

Accounting Period End Date:

Filing Received Date:

Form RRF-1 Reject/lncomplete Reason:

Form CT-TR-I Reject/Incomplete Reason:

IRS Form 990 Reiect/Incomplete Reason:

Votes From Registry Staff:

Accepted
7/ U2018
6/30/2019
11/12/2019
r+"Up *u
7/1/2019
6/30/2020
5/10/2021
Accepted
7/ 1 / 2020
6/3 N2021
10/20/2021
04 Nay}/~�1 5£•,

I I(7W r,HOU r MECIA CAREERS REGU! ATOMS RE OUROES PROCRWOS 1ONTAC:T Cack on the Organization tYlemn- for details about the registration Or report record, The maximum number of records shown per page Is 5t7. If there are multiple pageq of th, reaulu, the c{ickable page numheis, wilt be d,splavud at tha bottom, If rots get trio many results or do not Sind ttte aryartlzation fur wttfGt you arts searchmQ, rfFrk the 'Sears button and Change the search cdterfa. it Is lft+st to search oy something that I as unique to the Olganiaatlan as Ogsibie sues as State Charity Registratlori Number. FCIN, � Corporate Number, ur an ilnuSual porLium Of their name. TO See pli regI$tratmn and report records aSWoated with an'IN"Metron. avoid "archmg by State Charity Reoistra Number as that Is regard-speciflc.
9earcit►L in I

ORGANIZATION MADE

RECORD TYPE

REGISTRY STATUS

RCT NUMBER
FEI liC17
CharityF�egtstration-- —
_,C.urret}t
330$62000tiEME[

2020 FEDERAL EXEMPT ORGANIZATION TAX SUMMARY (EZ) PAGE 1 INLAND VALLEY SYMPHONY 3R-0862ann
FORM 990-EZ REVENUE
2020
2019
DIFF
CONTRIBUTIONS, GIFTS, AND GRANTS.......

PROGRAM SERVICE REVENUE
40,196
98,769
-58,573
.....................

INVESTMENT INCOME.......
12,973
,
1 83, 744
-70, 771
........ . ...........
1 0
TOTAL REVENUE., ....... . ....... ...... ....
53,170
182,514
-129, 344

EXPENSES

PROFESSIONAL FEES/PYMT TO CONTRACTORS
PRINTING, PUBLICATIONS, AND POSTAGE.......
36,683
119,218
-82,535
OTHER EXPENSES. .... .... I ......... -..........
441
18,521
250
48,445
191
-29, 924
TOTAL EXPENSES .......................................
55,645
167,913
-112, 268

NET ASSETS OR FUND BALANCES
EXCESS OR (DEFICIT) FOR THE YEAR...

NET ASSETS/FUND SAL. AT BFG. OF YEAR....
-2, 475
35,235
14,601
20,409
-17, 076
14,826
OTHER CHANGES IN NET ASSETS/FUND BAL..
1 225
-224
NET ASSETS/FUND BAL. AT END OF YEAR ...
32,761
35,235
-2,474
coy.

Registry of Charitable Trusts
P.O. Box 903447
Sacramento, CA 94203-4470
Telephone: (916) 445-2021
WEBSITE ADDRESS:
ht1 Wa4j.ca.uov1charitiesl
c7V/6 z eo?8

INITIAL

REGISTRATION FORM

STATE OF CALIFORNIA

OFFICE OF THE ATTORNEY GENERAL

REGISTRY OF CHARITABLE TRUSTS
(Government Code Sections 12580-12599.7)
Pursuant to Section 12585, registration is required of every trustee subject to the Supervision of Trustees'and__ Fundraisers for Charitable Purposes Act within thirty days after receipt of assets (cash or other forms of property) for the charitable purposes for which organized.

Every charitable (public benefit) corporation, association and trustee holding assets for charitable purposes or doing business in the State of California must register with the Attorney General, except those exempted by California Government Code section 12583. Corporations that are organized primarily as a hospital, a school, or a religions organization are exempted by Section 12583.

Name of Organization: Inland Valley Symphony, Inc.

Yin:. -- --- - T:.: y,,, uumci r�): „
Official Mailing Address for Organization:

Address: 4035 Kenosha Ave.
city: San Diego
State: CA
ZIP Code: 92117
Organization's telephone number: (858)270-4521
Organization's e-mail address: info@iniandvalleysymphony,org Organization's fax number: N/A
organization's website: In(andValleySymph6ny.Org
All organizations rr►ust'apl�ly Car a F ,. erali rrip3ciye d(„�-,M,iMatlan[Nu bat 'ti brganizatloris'thaf;Haire a` rou 3 ek tons riile'oinucl'returns 't�"'' :.,..,.ls......I—- S. I P a
Federal Employer Identification Number (FEIN): Group Exemption FEIN (if applicable):
33-0862000
x�yk?..• '" llfl Caifiarnia'corpora tlons air�cl fpreigit�.fir corpor7.7 -f the
�umpo
�cr. UnincorrAtecl o'{rjanlzaiion5 3re_AZ91i cl m
California tax.exesnEitin,i .' : ;l��h
[Corporate or Organization Number: C2045812_
Attorney
JUN a 1 2010
Ch:1mof
ie ffusto
CT-1 REGISTRATION FORM (6/2007)

Names and addresses of ALL trustees or directors and officers (attach a list If necessary):

Name Alana Joos Position President
Address 3359 Savannah Way
city Palm Springs state CA ZIP Code 92262
Name Douglas Bast
Position
Vice President
Address 29670 Cottonwood Cove Dr.
city Menifee
state
CA
ZIP code 92584
Name Emily Miller
Position
Secretary
Address 30207 Silver Ridge Ct.
city Temecula state
CA
ZIP Code 92591
Name Linda Daugherty
Position
Treasurer
Address 27041 Rock Bluff Ave.
city Temecula state
CA
ZIP Code 92591
Name Sharon Rollinson
Position:

Coordinator
Address 4035 Kenosha Ave.
city San Diego
Describe the primary activity of the organization. (A Copy or the material submitted with the application for federal or state tax exemption will normally provide this Information-} If the organization is based ouIsIdc California, comment fully on the extent of activities In California and how the California activities relate to total activities. In addition, list all funds, property, and other assets held or expected to be held In California. indicate whether you are monitored In your home state, and I so, by wham.

Attach additional sheets If necessary,
The specific purpose of Inland Valley Symphony is to provide orchestral experience for all age groups, to train younger musicians, to create an interest in musical careers by performing In schools and in public concerts and to improve the cultural experiences available to all citizens in the Inland Valley clgl;mports annualfj
Been.days Jitvr'the:
or',etotai �isseYs'are'a
wehsiter at htlp llac
If assets (funds, property, etc.) have been received, enter the date first received Date assets first received: July 1999
What annual accounting period has the organization adopted? Fiscal Year Ending June 30
Calendar Year
CT-1 REGISTRATION FORM (6I2007)

Attach your founding documents as follows:

A) QQLPRERILPEL5 - Furnish a copy of the articles of incorporation and all amendments and current bylaws, if Incorporated outside California, enter the date the corporation qualifled through the California secretary of State's Office to conduct activities In California.

B) Associatlons - Furnish a copy of the instrument creating the organization (bylaws, constitution, and/or articles of association).

C) Trusts - Furnish a copy of the trust Instrument or will and decree of final distribution.

D) Trustees for char table ur oses - Furnish a statement describing your operations and charitable purpose.

Has the organization applied for or been granted IRS tax exempt status Yes E) No 0 Date of application for Federal tax exemption: Jilly 26, 1999 Date of exemption letter: July 2000 3 Exempt under Internal Revenue Code section 501(c) If known, are contributions to the organization tax deductible? Yes EJ No p (IRS
Attach a cop
y of the Application for Recognition of Exemption IRS Form 1023) and the determination letter issued by the IRS, Does your organization contract with or otherwise engage the services Of any commercial fundraiser for charitable purposes, fundralsing counsel, or commercial coventurer? If yes, provide the name(s), address(es), and telephone number(s) of the provider(s):

Commercial Fundraiser Fundraising Counsel E Commercial Coventurer Name --
Address
city State
ZIP Code
Telephone Number
Commercial Fundraiser Fundraising Counsel Commercial Coventurer Name
Address
City
State ZIP Code
Telephone Number
Commercial Fundraiser ❑ Fundralsing Counsel [ Commercial Coventurer Name
Address
City
State ZIP Code
Telephone Number
I declare under penalty of perjury that I have examined this registration form, Including accompanying documents, and to the best of my knowledge and belief, the form and a�p9 cumenl are true, correct, and complete.

Title Date
CT-1 REGISTRATION FORM (6/2007)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
24 INTERNATIONAL CHRISTIAN

ADOPTIONS

CITY OF TEMECUL&
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022
Amount Requested: $
Project/Program Title:

PROJECT/PROGRAM INFORMATION
18,160
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Community Counseling Start Date: 9/12/2022 End Date: 5/3012023 Physical Address of Project/Program:

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to:

ICA
Mailing Address: 41745 Rider Way, Suite 2
Temecula, CA 92590

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant
Organization: International Christian Adoptions (ICA) Year Founded: 1990 Website: 4achild.org
Number of Paid Staff.. 53
Social Media: @4achild on Instagram and Facebook
Number of Volunteers: 0
Geographic Area(s) the Organization Serves: State of California and North Carolina Geographic Area(s) the Project/Program Serves: Temecula Valley Residents NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Charlotte Paulsen Title/Position: Executive Director Contact Person's Direct Telephone:
(951) 704-4354 Contact Person's Email: [email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes 0 Date of Incorporation as a Nonprofit: 1990 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 33-0412343
State Identification Number: 33-0412343
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this link: http://apps.irs.govta2pleosl

2. ❑ Attach State Entity Status Letter using this link: RECEWED httr)s:lf www.ftb.co.00v/online/self serve entity status letter/index.as 7�t

3. El Attach first page only of most recent IRS Form 990 or attach print out of dejLppd i gb your charity found on this State Registry's Search Tool: http:llrct.doi.ca.gov/VedficatlonNVebl a rc s ?� x faclillv�Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No ❑■ Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors [j Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION

BRIEFLY DESCI
" See Attachec

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Pane R of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes 0 IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP Sunridge Community Church $ 410g0 September 2022 - May 2023 Community Counseling Donation $
$
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECTIPROGRAM IN THIS APPLICATION? NO ❑ Yes [ j IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH + YEAR

NAME OF ENITY

RECEIVED FUNDING RECEIVED
$ q55 U SCRI FY Jul 22 - Jun 23
$ J351 201) U RM Reimbursement Contract 1 FY Jul 22 - Jun 23 ' $ 2-2, / S,2 County Riverside Foster Services FY Jul 22 - Jun 23 $ C�), a#p PAARP Services FY Jul 22 - Jun 23
$ io, 03,q
Heartland
HS -
PRS Contract
FY Jul 22 - Jun 23
$

USCCB-US
Conf.

Catholic Bishops
FY Jul 22 - Jun 23
$
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT - RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE F— ------- — --- ---
1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT. * See Attached Form
12 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT. * See Attached Form — - - - -
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS. * See Attached Form — — —
i
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT FROM THIS PROJECT/PROGRAM: 50 Children & Families
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 10 City of Temecula Community Service Fundinq - Reinvestment in Temecula GRANT APPI Ir.ATlnti D.— A -f 1 a

PROJECT/PROGRAM DESCRIPTION
C'ON77NUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS. * See Attached Form
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.
" See Attached Form
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.
" See Attached Form
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

International Christian Adoptions City of Terneculo
Community Service Funding Reinvestment in Temeculo Grant Program Policy Applicotion 01).12-22 Mission Statement of Organization:

International Christian Adoptions (ICA) believes in the sanctity of life in that all children born and unborn are valued and uniquely made. Our overriding mission is to offer children hope in the love and compassion of Jesus Christ; hope for basic needs; hope for an education and bright future; and hope for a home in a family they can call their own. The mission is fulfilled through adoption, foster care, humanitarian aid, counseling and support.

In addition, the following is our Covenant:
• To promote and secure the emotional, spiritual and physical welfare of children who have been victimized, abandoned or persecuted; found in the streets, war zones, government run institutions, refugee camps or family homes.

To actively engage in providing immigration and refugee resettlement services to those fleeing persecution, war, oppression and poverty.

To provide an environment of peaceful and humanitarian exchange to foreign students and those who go abroad.
• To offer an environment where hard working artisans can be paid a fair wage and a given the dignity of self-determination through fair trade.
• To provide opportunities for orphans to experience culture ad sense of family with camps to America and in their country.
• To widen the horizons of Americans by sending them to foreign countries to experience differing cultures through a myriad of work projects, camps and activities. • Maintain a Haque compliant licensed child placement agency under a different name in accordance with the laws of the State of California in order to provide temporal foster care and adoptive placement.
• Maintain several programs to enhance ICA's mission which is not limited to but includes immigration and refugee resettlement services; foreign student exchange program; fair trade; cultural camps; mission programs and tours, and other social service programs.

1.Describe the project/program the Temecula grant funding will support:

The Child Trauma and Learning Center at ICA provides mental health and counseling services and support to children, youth and families. Our counseling office in Temecula services all surrounding areas including residents of the City of Temecula. We specialize in serving diverse populations: foster and adoption backgrounds, trauma, childhood, adolescent and family issues, anxiety, depression, addiction, trafficking victims, refugee and immigrant youth, under 18 years of age.

Additional services include parent support, case management, educational support/advocacy, etc. It is our desire for children and youth who are struggling with mental and behavioral health concerns, trauma, and grief, can receive the support and services they need in order to attain a well-balanced independent lifestyle, despite any financial hardship.

For this reason, one of the goals of the Child Trauma and Learning Center at ICA is help any member in need of services despite lack of financial means. It is our goal to continue to provide financial assistance through scholarships and financial aid for all support services, including but not limited to: provide trauma -informed, person -centered, comprehensive case management services, facilitating timely access to vital services they need to stabilize and re-establish their ability to live independently. These comprehensive services include, but are not limited to, receiving emergency assistance, housing, safety planning, basic needs, health, legal, education, employment, language support.
pg 1 of 5

international Christion Adoptions City of Terneculo
Community Service Funding Reinvestment in Temecula Gront Program Policy Application 0.9.12.22 Most of our counseling clients/families are referred through Riverside County for Foster Care and two other sources of our programs funded by California Department of Social Services for which our counselors provide services:

The Unaccompanied Refugee Minor (URM) Foster Care Program, helps children or youth who have been separated from their families due to war, conflict, natural disaster or abuse by caregivers who were meant to protect them. These situations create upheaval in their lives forcing them to flee from countries to the United States. ICA's counseling services help to ensure children are placed into safe and secure homes. ICA social workers conduct home visits and ongoing case management services.

The central purpose of the Trafficking Victim Assistance Program (TVAP) program is to help foreign national survivors of human trafficking achieve HHS certification and provide trauma -informed, person -centered, comprehensive case management services, facilitating timely access to vital services they need to stabilize and re-establish their ability to live independently. These comprehensive services include, but are not limited to, receiving emergency assistance, housing, safety planning, basic needs, health, legal, education, employment, language, and assistance in accessing HHS Certification

2. Describe how the organization will spend the grant funding, if awarded:
(Also, include a list of goods, equipment, and/or services this organization has purchased or plans to purchase with awarded funds to support the program/project)

1. A primary goal of the Child Trauma and Learning Center at ICA is to offer counseling services despite a client's inability to pay. It is our goal to continue to provide financial assistance through scholarships and financial aid for all support services. While the Trauma Center program budget carries approximately 4% of the agency's $4.5M budget, the Trauma Center relies on funding from our other state and grant programs to support its professional services. Currently, the program budget receives $216,166 in revenues to cover $240,392 in expenses. Direct Counseling income from clients is projected at $38,643 yet direct cost of counseling services is $61,769.

ICA would like to request a grant to A grant fund from the City of Temecula in the amount of $18,164 to partner with ICA in providing for 80 sessions (8 client/family units at an average of 10 sessions per client/family unit).
(See next page for FY22-23 Program Budget detail).

Iig, � '.,f `.

Internotionol Christian Adoptions
Community Service Funding Reinvestment in Temecula

INTERNATIONAL CHRISTIAN ADOPTIONS
4000 - Contribution Revenues
4100 • Contracts for Services (4% E)asting Contracts)
Grant Proposal - City of Temecula
4109 • USCRI
4111 • State of CA- URM Reimbursable Contract
4112 • CountyRiverside Foster Services
4113 • PAARP Services
4114 • Heartland HS-PRS Contract
4115 • USCCB-US Conf.Catholic Bishops
Total 4100 • Contracts for Services
4200 • Program Service Fees
4220 • Counseling Income
4222 Psychological Evaluation
4223 Counseling Discount
4220 Counseling Income - Other
Total 4220 • Counseling Income
Total Income
Grants Summaryof Expenses
Counseling Services Program
Tools & Equipment
Facilities, Rent& Insurance
Supplies
Marketing
Services
Food
Other
Personnel
Total Expenses
NET Income/Loss
City of Temecula
Grant Program Policy Application 09.12.22
FY22-23
Budget
4,080
455
135,200
22,182
2,240
10,032
3,514
173,623
2,200
(8,938)

45.381
�t:tZ:tIKE
216,346
11,149
12,083
1,282
331
56,269
1,200
12,617
inn Alli
195,262
Grant Request
18,164
(18.164)
21,084 $ 18,164
3: Explain how the grant funding specifically benefits Temecula Residents:
(Temecula residents must benefit from this program/project if awarded city funding) The Child Trauma and Learning Center at ICA offers counseling services to the residents of the City of Temecula despite a resident's inability to pay. Partnership with the City of Temecula would provide a continued and reliable source of financial assistance through scholarships and financial aid. Last year our counselors served 86 clients and 865 sessions. This is an average of 10 sessions per family at a unit cost of $278, yet ICA charged on average only $55 per session. Most clients/families cannot afford to pay so we offer financial assistance.

International Christian Adoptions City of Temecula
Community Service Funding Reinvestment in Temecula Grant Program Policy Application 09,12.22 ICA would like to ask the City of Temecula to consider sponsoring eight families at an average of 10 sessions. The program cost is $18,164.00,
Proiection based on FY21-22Service Records
Number of Clients/Family
N u m be r of Sessi ons
Unit Per Unit Cost
86 $ 2,270
865 $
Average Number of Sessions per Client/Family 10
Grant Request: t 8) Families @ ( 10) Sessions Aver 8
226
2,270.49
18,163.91
Due to the nature of the clients we serve, there is a high level of confidentiality so families in Temecula who are currently struggling with the lack of mental and behavioral health services and who are suffering from economic hardship would still be able to receive counseling services. The City of Temecula would play a vital role in sustaining a healthier community by providing social services to families and children through counseling services on how to maintain positive mental health techniques, implement coping skills, reducing the current trauma in society, and joining in the need for healing. Our agency could be an additional resource to the City.
4: Summary Statement — Summarize answers 1-3 above in 50 words or less ICA is not only an ada2tion aeency. Child Trauma and Learning Center provides mental health counseling services support to families in Temecula Valley. We specialize in foster care, adoptions, trauma, childhood, adolescent and family issues, anxiety, depression, addiction, human trafficking victims, refugee and immigrant youth under 18 years of age.

S. If applying for more than $5,000, please explain how the COVID-19 Pandemic affected this nonprofit organization's ability to serve the Temecula Community.

You may also include inflationary concerns.

The Child Trauma and Learning Center at ICA offers counseling services to the residents of the City of Temecula despite a resident's inability to pay. During the Covid-19 Pandemic, when business was forced to shut down, families struggled not only economically, but also to keep their children active and engaged. Families in Temecula saw a rise in depression and anxiety while their youth were struggling with mental and behavioral health dysfunctions. Now that our city is moving back to a sense of normal business operations, many families cannot afford counseling services. Many are struggling to find gainful employment. Yet the youth continue to internalize the effects of the shutdown as children and youth were forced into isolation and education was moved to distance learning. Today, there are many who continue to struggle to get back to sense of normalcy.

The Trauma Center saw a decrease of in-house counseling services during the shutdown of March 16, 2020 and thereafter. Not having the ability to see children in -person at the office, which is the most beneficial course of therapy for most children, created a backlog of services.

Our counseling team was able to pivot our company completely on-line for Teletherapy services.

However, the retention of clients dropped significantly due to many of our clients who fall under the age of 10, or who suffer from ADD/ADHD had struggles focusing for therapy on a computer screen for any length of time. There were also those clients who did not have the means to a confidential and safe space to conduct therapy, or those children and youth who did not have access to an electronic device and/orinternet.

International Christian Adoptions City of Temecula
Community Service Funding Reinvestment in Temecula Grant Program Policy Application 09,12.22

6. If applying for more than $5,000, explain how funds have or will- (1) CREATE new Project/Program
(2) EXPAND existing Project/Program AND/OR
(3) CONTINUE existing Project/Program

2. A primary goal of the Child Trauma and Learning Center at ICA is to offer counseling services despite a client's inability to pay or inability to attend in-house sessions. It is our goal to continue to provide services through financial aid. ICA's Program Budget for FY22-23 provides for Direct Counseling income from clients at $38,643 and direct cost of counseling services is projected at $61,769. ICA would like to request a grant to A grant fund from the City of Temecula in the amount of $28,164 to partner with ICA in providing for 80 sessions (8 client/family units at an average of 10 sessions per client/family unit).

In the hopes of receiving grant funding from the City of Temecula, and in order to continue providing existing services, ICA has expanded it program budget to include the following:

3. Purchase of 4 iPad Pros for client use at a total of $3,600. The cost of $900 per Wad is a small cost compared to the loss of services for the family members who could not afford an electronic devise and were not able to receive consistent services during times when access to in -office services was not available. Because the Covid variants continue to grow, this method of continuity of services will help serve our client's needs in desperate times. Alternatively, for a family who may not have the transportation means to attend in-house services, this may keep our counselors connected with a needy family.

4. A grant fund from the City of Temecula in the amount of $18,164 providing for 80 sessions (8 client/family units at an average of 10 sessions per client/family unit).

Inflationary cost estimates all already factored into FY22-23 program budget for all our program needs including, but not limited to, office rent utilities, program and therapy supplies. p of

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $18,164 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ Organization 212,264
Other grants or funding already awarded for Project/Program, if any 4,080
In -Kind match amount or volunteer credit hours estimated amount $0 TOTAL REVENUE $234,510

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
Facilities/Rent/Insurance
Supplies
Marketing
Services
Food
—Other
I Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT, HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET $234,510

EXPENSES
$11,149
$121083
$1,282
$331
s56,269
17200
$6,987
$105,961
$195,262
$195,262
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

[==--

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:
• Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. • Awards will be given to organizations and activities that directly benefit the residents of Temecula. ■ Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. ■ Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately, • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: International Christian Adoptions (ICA) MAILING ADDRESS: 41745 Rider Way, Suite 2
Temecula, CA 92590
PHONE: (951 695-3336
EMAIL: [email protected]
PRESIDENT/AUTH RlzEDOFFICER: C arlot Paulsen
WI IN17INTA
SIGNATURE:

IF DIFFERENTTHAN ABOVE, Jennifer Mitchell
APPICATION PREPARED BY:

Executive Director
'IT�E
DATE: 09/12/2022

MONTH, DAY, YEM
Office Manager of Child Trauma & Learning Center
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: Stacey,[email protected] (951) 694-6413
Betsy. [email protected] (951) 693-3959
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

Q HELPB MENU
Home > Tax Exempt Organization Search > International Christian Adoptions International Christian Adoptions
EIN: 33-0412343 1 Temecula, CA, United States
Other Names
Publication 78 Data o
Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in determining deductibility of their contributions.

On Publication 78 Data List: Yes
Deductibility Code: GROUP
Copies of Returns (990, 990-EZ, 990-PF, 990-T) o
Electronic copies (images) of Forms 990, 990-EZ, 990-PF or 990-T returns filed with the IRS by charities and non- profits.

Tax Year 2020 Form 990
Tax Year 2019 Form 990
Tax Year 2018 Form 990
Tax Year 2016 Form 990

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
nTB POCRBOX 942857
SAAMENTO CA 94257-0540
Entity Status Letter
Date: 9/8/2022
ESL ID: 5733937788
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 1664688
Entity Name: INTERNATIONAL CHRISTIAN ADOPTIONS
❑X 1. The entity is in good standing with the Franchise Tax Board.

EJ 2. The entity is not in good standing with the Franchise Tax Board. ❑X 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d EJ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Form 990
OMB No 1545-0047
2020
Return of Organization Exempt From Income Tax
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) Oppeen to Pubfre
lnspecton
"apatbnent of the Treasi,ry
► Do not enter social security rt imbers an this form as it may be made public. tnitrmnl rLevenue Service
► Go to wHrv.irs.govIl'oraifor instructions and the latest information.

A For the 2020 calendar
year, or tax year beginning 7/01 2020, and ending 6/30 .202021 B Check if applicable:
c D Employer Identification number
Address change
INTERNATIONAL CHRISTIAN ADOPTIONS 33-0412343
Name change
INSTITUTE FOR CHILDRENS AID E Telephone number
Initial return
41745 RIDER WAY #2 951) 695-3336
TEMECULA, CA 92590
I anal relurn/leimiratcd
Amondea return
G Gross-e"ipcti $ 4, 228, 400.

Lj Application pending
F Name and address of principal officer: CHARLOTTE PAULSEN K(a) is this a group return for subarnglnTcs� Yes x No Same As C Above HIM Are all subordinates included Yes Do I Tax-exempt status:

If "No;" attach a list- See instructions
K 501(c)(3) 501(1) ( )� (insert flo,) 4947(ax1) or 527
J Website: ► WWW. 4ACHILD.ORG tr(c) Group eiinmphon number ► 6068 K Form of organization
7X Coiperation I I Trust I I Assocalion Ll Other ► L Year of formaton: 1990 lift stale of low, domicile: CA Part I I Summary
1 Brie Illy describe the organi zati o n's mission or most significant activities -TO OFFER CHILDREN HOPE IN THE LOVE AND COMPASSION OF�JESUS CHRIST nk BASIC NEEDSL FOR AN AND BRIGHT U
_EDUCATION _
AND HeOPF FAR A HOME IN A FAMILY THEY CAN CALF, THEIR OWN. THIS I5 FEILFILLED ccFUTURE,_
_TH_R_0_UG_H_ CARES HLUI fANITARIAN CD_UNSE_L_ING AND SUPPORT - - -_ -_ -- - - - - 0 _ADa_PTIa_Nt _F'tiSTER _AID_
2 Check this box ► if the organization discontinued its operations or disposed of more than 25%-of its net assets._ _ _ 0 3 Number of voting members of the governing body (Part VI, line la)....... 3 7 ee
4 Number of independent voting :members of the governing body (Part VI, line ib) 4 w
5 Total number of individuals employed in calendar year 2020 (Part V, line 2a) .. 5 C9 ?
;_
6 Total number of volunteers (estimate if necessary) 6
a
7a Total unrelated business revenue from Part VIII, column (C), line 12 7a 0, b Net unrelated business taxable income from Form 990-T, Part I, line 11 7b Q, Prior Year
Current Year
d
8 Contributions and grants (Part VIII, line IF)
3 851 399.
3 787 276.
9 Program service revenue (Part VIII, line 2g).
134 438.
110 300_
m10
Investment income (Part VIII, column (A), lines 3, 4, and 7d) 267
cc
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 1 le) 2,236.
326 345.
12 Total revenue - add lines 8 through 1 1 (must equal Part VIII, column: (A), line l2) 3, 988, 073.
4,224,188.
13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 19 049.
14 Benefits paid to or for members (Part IX, column (A), line 4) .. a
15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 2, 013 061.
2 r 0320 581.
16a Professional fundraising fees (Part IX, column (A), line Ile) b Total fundraising expenses (Part IX, column (D), line 25) ► uFL
1,365, 589.
1, 564, 992,
17 Other expenses (Part IX, column (A), lines 1 la-11d, l if-24e) 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 3,397, 699,
3 597 573.
19 Revenue less expenses, Subtract line 18 from line 12 590 374,
626 615.
8 Beginning of Current Year
End of Year
2,582, 687.
2,947,255.
m
20 Total assets (Part X, line 16) -
21 Total liabilities (Part X, line 26) ..
513 049.
251 002 .
2 069 638,
2 696 253.
zLL
22 Net assets or fund balances. Subtract line 21 from line 20 ran 11 1 as nature C31UGR
:1ndcrpar47lbm of parjoy. I declare that thave eKam i.ned tf+ o tn. including xc pany1n9 Schedules and stolements, and to the Des of my knowledge and 'belief, it is bile, correct, and compfeto rliecfArat on of prap8tpir (glhar han ef!pci) is "4 oe II lnrarmnnan of QWn rimparri tins my kr•awlydq� Sign
Here
'4Jignalffne or officer 1 v-r+---- ..- — —

CHARLOTTE PAULSEN
Data
Executive Director
ype or print name and tit e,
Paid
PrimType preparer's name
William A Harris III
Preparer's signature
William A Harris III
Date
Check U a
Self-en,ploynn IP00614689
PTIN
Preparer
Use Only
Firm's name ' ELITE FINANCIAL SOLUTIONS
firm'=_address ' 301 E FOOTHILL BLVD., STE. 201
ARCADIA, CA 91006
Firm'sFIN ► 20-8044652
Phone no 626
Z56-1400
May the IRS discuss th s return with the preoarer shown above? See instructions JXJ Yes I I No
BAA For Paperwork Reduction Act Notice, see the separate instructions.

TEEAOl01L 01n9121
Form 990 (2020)

EXECUTIVE SUMMARY
International Christian Adoptions institute for Children's Aid (ICA) is not just an adoption agency. The institute began in 1990 as a non-profit 501(c)(3) corporation with its principal office in Temecula, CA. The institute consists of two major divisions: International Christian Adoptions and the Institute for Children's Aid (ICA) which is inclusive of the Chill ,rrauma Esc Learning Center, We stand on Biblical principles in all we do, lending hospitality and sanctuary to all who are in need. We are a voice For those who cannot speak for themselves, believing that all life is sacred. Our staff is multi-lingual, multi -ethnic and professionally trained to assist in various capacities.

This mission of protecting, supporting, and assisting the most vulnerable within our. community is fulfilled at ICA through adoption, foster cart, humanitarian aid, counseling and support.

Mission Statement
International Christian Adoptions (ICA) believes in the sanctity of life in that all children born and unborn are valued and uniquely made. Our overriding mission is to offer children hope in the love and compassion of jesus Christ; hope for basic needs; hope for an education and bright Future; and hope for a home Ina family they can call their own. The mission is fulfilled through adoption, foster care, humanitarian aid, counseling and support.

Our Covenant
a To promote and secure the emotional, spiritual and physical welfare of children who have been victimized, abandoned or persecuted; found in the streets, war zones, government run institutions, refugee camps or family homes.
• To actively engage in providing immigration and refugee resettlement services to those fleeing persecution, war, oppression and poverty.
■ To provide an environment of peaceful and humanitarian exchange to foreign students and those who go abroad.

To offer an environment where harts working artisans can be paid a fair wage and e given the dignity of .self-determination through Fair trade.
• To provide opportunities for orphans to experience culture ad sense of family with camps to America and in their country.
■ To widen the horizons of Americans by sending theirs to foreign countries to experience differing cultures through a myriad of work projects, camps and activities. • Maintain a Haque compliant licensed child placement agency under a different name in accordance with the laws of the State of California in order to provide temporal foster care and adoptive placement.

Maintain several programs to enhance ICA's mission which is not limited to but includes immigration and refugee resettlement services; foreign student exchange program; fair rralLIC; cultural camps; mission programs and tours,and other social service programs.

ICA is a well -established organization that me:cts the standards and qualification of many accreditations such as Accreditation of Rehabilitation Facilities (CARF), Intercountry Adoption Accreditation and Maintenance Entity. Inc. (IAAME), United States Agency of International ❑evelopment (USAID), National Council for Adoption (NCFA) and Evangelical Child and Family Agency (ECFA). In addition, ICA is a Full -service fosterrcare and adoption agency for International and Domestic Adoptions, as well as multi -County Domestic Foster Care and Refugee Foster Care

programs. ICA also operates a Jubilee Exchange Fair -Trade Store in efforts to educate the commun i ty of the benefits and impact of purchasi ng fair-trade items both locally and world-wide.

Our beautiful hand. -crafted fair-trade items can be found in our office or at various educational events. (Farmers Markets, conferences, pop -ups)

DEMOGRAPHICS AND COVID PANDEMIC
ICA has seen a rise in mental and behavioral dysregulation since the onset of the COVID-19 pandemic with escalated emotional and psychological traumas for children, youth and families in the community. According to a U.S. Census Bureau report, the number of people experiencing acute anxiety, depression and dysregulation are up 42'yo in the US (Leonhardt, 2021). As COVID- 19 protocols loosen, more families are seeking counseling services for their children. This is being reflected at ICA as the average monthly services provided have risen by 38% during the first quarter of 2022 in comparison to that of 2021,
The Narional Alliance on Mental Health (NAM[) (2020) reported that 16% of adolescents (ages

12.17) experienced a major depressive episode (MDE), while 33% of young adults (ages 18-25) experienced a mental illness during the COV [D-19 pandemic. Further, 20%of young people report that the pandemic had a significant negative impact on their mental health. As a society, we must recognize that ouryouth have experienced unique circumstances during the pandemic:, including isolation, transition to virtual learning and drastic changes to routine that severely impacted the mental health of youth and young adults. The impact on children and youth has been significant, and the need far support and care is imperative (NAMI, 2020). Another 2021 study on the mental health of U.S. high school students during the pandemic, conducted by the Centers for Disease Control and Prevention (CDC), showed how impactful the pandemic was on the mental health of high school youth. This study indicated that 37% of students reported they experienced poor mental health during the COVID-19 pandemic, and 44% reported they persistently felt sad or hopeless during the past year (CDC, 2022). The Office of Population Affairs quoted in a Mental Health for Adolescents article, "Globally, the prevalence of youth experiencing clinically elevated anxiety symptoms - roughly 1 in 5 - nearly doubled during the first year of the COVID-19 pandemic", (OPA)(n.d.) (Racine, McArthur, Cooke) (2021).

ICA serves people from diverse backgrounds, including many who have experienced trauma or come from the child welfare system. Half of all youth in foster care have a diagnosable mental health disorder (OPA, md.) (Youth.Gov, 2018). Children who are living in foster care have a substantially greater risk of experiencing mental health disorders, especially those connected with traumatic stress, such as abuse and neglect (OPA, n.d.) (Youth.Gov, 2018). In addition, 21% Of youth ages 6 to 17 who live in poverty have mental health disorders (OPA, n.d.) (Lipari, Hedden, Blau, Rubenstein) (2016). It is estimates! that 49.5% of adolescents have dealt with a mental health disorder at one point in their lives (OPA, n.d.). As a non-profit, [CA seeks to offer low -cast, high duality services to our clients. However, many families who have a great need for services find even these low-cost services a hardship.

PARTNERSHIP
Institute For Children's Aid (ICA) Child Trauma & Learning Center would like to partner with the City of Temecula in Fulfilling the mission of serving vulnerable populations within the Temecula Valley. ICA is requesting the City of Ternecula's consideration for a financial grant. The Institute for C:hildren's Aid Child Trauma & Learning Center serves the community by providing therapeutic support to children, adolescent youth and families. We specialize in serving diverse

populations; Faster and adoption backgrounds, trauma, childhood, adolescent and family issues, anxiety, depression, addiction, trafficking victims, refugee and imrnigrant youth, ranging From 0- 18 years of age. Additional services include parent support, case management, educational support/advocacy, etc. It is our desire for children, youth and families who are struggling; with mental and behavioral health concerns, trauma, and grief, can receive the support and services they need, despite any financial hardships a family may face.

PROGRAM COSTS
In California, the average cost of an hour-long traditional therapeutic session ranges from $65 to $250 for those without insurance (Leonhardt, 2021). As a non-profit 501(c)(3) and as a service to our community, [CA's Child Trauma & Learning Center desires to be as affordable as possible.

The fee charged to our clients for an hour of therapy at ICA is $55 per session. But FY22-23 Program Budget estimates costs her session are $278. The center offers services well under market value and has utilized previously awarded financial donations as scholarships to families who are suffering from economic hardship, sometimes on a sliding scale depending on the scholarship awarded or level of need. Our therapists see the need For and importance of conducting services in office and in person, especially for our young clients who struggle to sit still or focus thmugh an hour-long telehealth session. However, for those clients who prefer, we continue to offer telehealth sessions as an option. The comfort of our clients is always a top priority when offering options for therapeutic care. Our therapists also offer 24/7 on -call support to our clients and families.

With the addition of grant funds, the ICA Child Trauma & Learning Center would have the ability to continue offering scholarship services to families impacted by financial hardships including individual therapy, group therapy, family clinics, parental skills training, life skills training, educational support services, or case management. A financial grant would provide support to families who are unable to cover the weekly or bi-weekly services. This is especially important when considering high risk clients, those with self -harm concerns, and/or suicidal ideation. The program cost for a standard individual therapeutic session is $278. A client/Family unit will be serviced. at an average of 10 sessions valued at $2,270. Therefore, a grant of $18,1.64 would provide financial assistance for 100 sessions or 8 families at 10 individual therapeutic sessions to clients who have a financial need, and at no cost to the client.

THE NEED FOR SERVICES IN OUR COMMUNITY
ICA continues to see the clients despite lack of ability to pay for service. This meets with the California hoard of Behavioral Sciences. ethical standards, until mental and/or behavioral issues resolve, accepting whatever financial compensation the client was able to afford. For example, in one particular circumstance, we accepted $10 per therapeutic session from a previous client who was experiencing a financial hardship. As part of a larger agency, the ICA Child Trauma & Learning Center can operate at little to no over -head costs allowing for continual treatment for clients. Overall, the grant funds would allow the Child Trauma & Learning Center to have a lasting positive impact, promoting mental health and healing by increasing the amount of services that: are offered to the families and children with financial hardships that are suffering in our community.

There is a high need For therapeutic services for children and youth in the Temecula Valley, many offices are overflowing and have had to place prospective clients on wait lists to be seen, sometimes those clients must wait a full-12 weeks before seeing a clinician. At ICA, we do everything we can to see clients within 1 week from the day they initially call the office. After the

past almost three years dealing with a world-wide pandemic, our youth need to be able to receive the help they and their families need. With the addition of grant funds, ICA would also have the possibility to hire another clinician to meet those needs within our community.

Last year (FY) UNN-JUL22), ou r pwgram serviced 86 client/family emits: (59) from the Temecula Valley area, (12-Domestic and Foster care families referred from Riverside County and (5) International adoption families. Services to residents in the Temecula Valley area were 82% of our total counseling services.

The Child Trauma &x Learning Center provides a comfortable office with trait ma -in formed staff, including licensed clinicians and supervised associates. The clinicians have access to any of our five therapy rooms and many therapeutic tools. Each therapy roam is equipped with a variety of warm and welcoming decor, lighting and activities to meet the specific needs of each client. For example, some clients who have experienced trauma and/or have a specific diagnosis/disability, may have sensitivities to fluorescent lighting requiring a warmer light environment, or may require therapy to take place in an open spars, Each of ICA's therapy rooms were intentionally designed for children with adverse bacl(grounds in mint!. The Child Trauma & Learning Center is equipped with various tools: arts and crafts, board games, hooks and toys, along with many sensory tools like sand/bean buckets, sand tables, blanlcers, stuffed animals and weighted therapy blankets designed to help with sensory processing. The staff at ICA create tailored treatment plans to best suit each client and their needs. Our clinicians value their clients input and strive to create a sense of empowerment and investment from the client's ixrspective. The clinicians take a holistic approach tocach client's case, in order to hest serve their needs, The: client is paired with theclinician that would have the best approach and potentially strongest therapeutic relationship with the client. By doing this, the greatest outcome for therapeutic success for the client can be achieved.

To make this achievable, ICA's C:hilcl Trauma &r Learning Centcrnnakes available multiple options for scheduling to allow families to receive the support they need. Adhering, to COVID-19 CDC Guidelines, ICA offers services through telchealth, in -person and in -home therapeutic services (when therapeutically appropriate). Understanding our client's hesitancy regarding COVID-19, ICA provides options, to make each client feel comfortable with their therapeutic experience Therapeutically, we use a combination of the following to provide the most effective approach to healing for each client: evidenced --based modalities including Trauma Focused Cognitive Behavioral Therapy (TF-C BT), Cognitive Behavioral Therapy .(C13T), Dialectical Behavioral Therapy (DBT), SOlution-Focused, narrative Therapy, Trust Based Relational Interventions (TBRi), and evidenced -based techniques (such as Guided Imagery, Mindfulness, Play Therapy, Art Therapy, deep breathing, etc.). After determining the best modality for each client, our clinicians will provide tailored treatment places with adapted techniques suited for each client and decide with the client and fain the hest option for success. An individualized plan will be developed for cacti client to determine the best course of healing. In order to maintain growth and sustained progress, our clinicians will frequently re-evaluate the plan for each client.

Due to the Child Trauma &z Learning Center being part of a larger organization with many different programs, the center can thrive without touch overhead costs, allowing fees for services to remain low For clients. This allows For a long-term presence of therapeutic services being available to the community. With the acid itionaI grant funds from the City of -f emecula, the Child rratima &r Learning Center would he equipped to provide support and services to more children and famiIics who are currently struggling with the lacl< of mental and behavioral health services.

Through this, we can have a greater impact to reach and sustain our community by teaching the families and children how to maintain positive mental health techniques, implement coping skills, reducing the current trauma in society, and joining in the need for healing.

Thank you for your consideration in partnering with ICA in support of our children and families in need. The support is appreciated and will aid in the healing, empowerment and growth for the children that we serve in our local community.

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2021 Annual Report

OUR MISSION
International Christian Adoptions (ICA) began in 1990
as a non-profit 501(c)(3) corporation with its principal office in Temecula, CA. ICA consist of two major divisions; International Christian Adoptions and the Institute for Children's Aid. We stand on Biblical principles in all we do lending hospitality and sanctuary to all who are in need.

We are a voice for those who cannot speak for themselves believing that all life is sacred. Whoever you are, and whatever your need as a family, we are here to help you. ICA is dedicated in helping children and their families around the world and in the United States. Our staff are multi- lingual, multi -ethnic and professionally trained to assist in various capacities.

ICA believes in the sanctity of life in that all children born and unborn are valued and uniquely made.

Our overriding mission is to offer children:
• HOPE in the love and compassion of Jesus Christ
• HOPE for basic needs
• HOPE for an education and bright future
• HOPE for a home in a family they can call their own.

This mission is fulfilled through adoption, foster care, humanitarian aid, counseling and support.
2 ` 2021 Annual Report

OUR SERVICES
3 Everything we do is for the children. We have comprised a set of comprehensive services and programs to provide children with loving and safe homes. We work closely with the parents and forever families to ensure an environment where the child can continue to grow and become their
best self. Contact our caring and professional staff to learn more.

Adoption Services
r As a licensed, non-profit adoption
agency, ICA provides compassionate
and caring services to the adoptive
triad (birth parents, adoptive parents
and children).

Foster Family Services
Providing loving support and comfort
to abused and neglected children
through mentoring programs,
reunification services and respite care.

Humanitarian Aid
Providing relief services to foreign
and domestic orphanages and to
the children in domestic residential
facilities. This relief includes goods
delivered, foreign exchange programs,
transitional homes and micro
business support.

Child Trauma & Learning Center
up
Qualified, well -trained Christian
professionals provide counseling
services and support groups to birth
parents, adopted children, adoptive
parents, foster children and foster
parents.

Family Training
We provide ongoing support to the
adoptive family and the children they
are parenting, both before and after
placement. These classes prepare the
adoptive and foster families for the
special emotional and developmental
challenges that they can expect when
raising children who have been in
institutional care.

a 2021 Annual Report 4
Children's Peace Exhibit
Institute for Children's Aid presents the first registered museum of its kind to Southern California's Temecula Valley. The Children's Peace Exhibit offers an interactive journey for children and adults of all ages, where they travel through the complexity of contemporary issues affecting children on a global scale.

Children and Adults start theirjourney with their own exhibit passport and work through 14 exhibits tackling problems that many children face such as abuse, child slavery, child labor, war, refugees, homelessness, hunger, education and others. Each exhibit is designed to equip and inspire its visitors to learn the facts, identify the problems and become an important advocate for change. The Children's Peace Exhibit is an experience all in itself with the purpose of educating others of the plight of children worldwide while providing innovative ways to make a difference. Interactive stations and artwork provide a unique forum to view exhibits from museums around the country, giving tangible depictions of challenges to children's rights that are rarely discussed or seen.
0 Explore Children's Rights Connect for Positive Change This interactive exhibit showcases Discover, support, and work children's universal rights and the 0 alongside a variety of groups and problems/conflicts they face on a day organizations that seek to protect to day basis when those rights are and support sustainable change for suppressed or violated. children worldwide.
0Understand the Issues Care for Children
�;� This exhibit engages with individuals �� Cultivate compassion and care for and communities on an interactive these children. Be equipped to make level to bring about understanding a difference within your local and and cooperative action. global community.

` 2021 Annual Report

RECRUITMENT
In 2021, due to the pandemic and cultural shifts, our
primary way of meeting for all programs was through
digital conference calls. We shifted from monthly in -person and on site Info Meetings to individually planned and
focused Info Meetings through Zoom. Towards the end of
2021, we were able to thankfully host 1 in -person event. ' Tem- Temecula
CH- Citrus Heights
D - Durham
Info Meetings (Total Number of Families: 94)
Tem-4, CH-7, D-1
■ Tern-5, CH-8, D-0
Tem-5, CH-5, D-0
• Tem-6, CH-7, D-7
Tem-3, CH-5, D-0
Tem-3, CH-2, D-0
Tem-2, CH-0, D-0
a Tem-3, CH-1, D-0
- • Tem-3, CH-2, D-0
0 Tem-2, CH-8, D-0
• Tem-2, CH-6, D-0
e - Tem-2, CH-1, D-0
Significant Events for 2021
Due to Covid 19 Restrictions, we were only able to hold 1 Pastors & Leaders Breakfast in October.

2021 Annual Report

SOCIAL MEDIA
1,034 Facebook Followers
754 Instagram Followers
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Facebook • 7,034
facebook.com/4achild
754
instagram.com/4achild
6 With seeing the need to improve our digital
presence, it has become of major importance
to streamline all of our digital and graphical
presentations. In 2021, we have seen the need to
continue to establish our "brand", we have done
so with a slight logo update, fonts, colors, social
media shifts, PowerPoint implementation and
website updates.

Our goal is to continue with stability of posts, but
with an emphasis on streamlining our brand. In
order to streamline the overall process, it started
with our social media and has since branched into
every other department and a lot of our forms and
documents. We learned that our families were
receiving a disconnect in the Recruitment Process
from beginning to placement because we hadn't
kept the ICA brand intact. It has been a slow -going
process, but a fruitful process as our families have
been blessed by the shift.

AV2021 Annual Report

INTERNATIONAL PROGRAMS
International Adoptions
7 ICA is Hague Accredited and fully licensed to do adoption related services in both incoming and out -going cases. It also serves relative families who are adopting related children in the US or out -of -country. ICA has statewide licenses in California and North Carolina but can also work in other states through its partner agencies. ICA is registered in Bulgaria, India, Latvia, Philippines, Poland, Romania, and Taiwan and works in partnership with other Hague approved agencies in many other countries. In addition, ICA offers supervisory services in Hungary and China. ICA conducts a 4-week Welcome Home Program in the countries of Latvia and Philippines for children who are eligible for adoption. We track International families adopting in countries where ICA is registered. ICA is considered the "Primary Provider", which means ICA receives the referral of the child. When ICA is the "Supervising Provider", the adoptive family is working with another agency (who becomes the Primary Provider), ICA completes the home study and supervision reports which are submitted to the Primary Agency. An ICA social worker will typically be assigned to these cases.

Respite Care
Qualified foster families are needed to provide after school care, transportation to medical/ dental appointments, tutoring, mentoring or temporary care for a child. Temporary care can extend for a few hours, to overnight or weekend visits. This allows primary caregivers and/or child a break from their routine. It a Iso assists families who may have out of town obligations or celebrations wherein the child is not allowed to leave the country (24 hours or more). The hallmark of this program is that foster families help each other. Multiple families provide this ca re.

all
2021 Annual Report
N

DOMESTIC PROGRAMS
New Beginnings
We provide counseling to expecting parents to determine the best plan for them. Should the birth parents decide to make an adoptive plan, they participate in selecting a family profile of home study approved adoptive families. ICA provides services and support for the adoption triad (child, birth parent, and adoptive parents.) Inquiry meetings between interested families and ICA have taken place.

Safe Harbor 0
This is our domestic traditional foster care
program for children. Resource Families
become an extension of the Court system,
"safe harboring" children with the goal of
reunification with their birth family. A Resource
family interfaces with the birth parents,
supervises visitations, transports to medical/
counseling appointments while caring for
the wellbeing of the child. Resource families
continue to care for and support the child
through the different phases of the child's
cou rt case. Resou rce pa rents a re a vita I pa rt of
the child's team. This program includes infants,
toddlers, school aged children, teens, and non -
minor dependents. Resource Families receive
monthly financial aid for the care of the child
and the children receive Medi-Cal benefits.

ON
4 2021 Annual Report
NOW

DOMESTIC PROGRAMS
America's Orphans
These are children currently in placement within the foster care system. ICA holds contracts with multiple County Department of Children's Service agencies. At any given moment there are over 423,997 children nationwide within the Foster Care System and over 122,216 are waiting to be adopted (Children's Bureau, June 23rd, 2019). School -aged children, sibling groups, boys, and teens are currently available for adoption. This is a no -agency fee program with minor incidental costs for assessment. Once families are assessed and approved they are considered Resource Families. Resource Families will be challenged to equip themselves through books, videos, seminars, and live trainings to meet the needs of these children on their path towards healing. Resource Families receive monthly financial aid for the care of the child and the children receive Medi-Cal benefits.

A 2021 Annual Report

JOURNEY OF HOPE
IoLong Term Foster Care (LTFC)
On March 1, 2003, the Homeland Security Act of
2002, Section 462, transferred responsibilities for
the care and placement of unaccompanied children
from the Commissioner of the Immigration and
Naturalization Service to the Director of the Office of Refugee Resettlement (ORR). Unaccompanied children
apprehended by the Department of Homeland Security
(DHS) are transferred to the care and custody of ORR.

ORR promptly places an unaccompanied child in the
least restrictive setting that is in the best interests of the child, taking into consideration danger to self, danger to the community, and risk of flight. ORR takes into
consideration the unique nature of each child's situation and incorporates child welfare principles when making
placement, clinical, case management, and release
decisions that are in the best interest of the child. Long- term foster care is the care plan for a child/youth to remain in a specific fostering placement for an extended period of time until the child's18th birthday. This is the least restrictive, most family -like environment for children in care. The population served are mainly children from
Central and South America who have migrated to the US
for various reasons of safety, economic or political turmoil, community violence, etc. Children in LTFC receive the
following services; case management, legal/immigration, mental health, medical/dental/vision, psychiatric as
needed, educational, independent living, cultural support, and extra -curricular.
10 AV2021 Annual Report

JOURNEY OF HOPE
Gunaccompanied Refugee Minor (URM)
ICA works with the most vulnerable populations.

The URM program ensures that eligible youth
populations receive the full range of assistance,
care and services available to all foster children
in the state by establishing a legal authority to
act in place of the child's unavailable parent(s).

Our programs encourage reunification of
children with their parents or other appropriate
adult relatives through family tracing and
coordination with local refugee resettlement
agencies. However, if reunification is not possible,
each program works to design a case specific
permanency plan for each minor oryouth in care.
11 kK
2021 Annual Report

JOURNEY OF HOPE
Special Family Finding
ICA is opening homes for Unaccompanied Refugee Minors (URM) and Unaccompanied Children (UC) and is leaning away from traditional terminology by calling the homes Trauma Based Caregiver Families instead of foster homes. Technicallythey continue to fall within the foster -care systems. Some specialized homes are for female youth who have been trafficked and are struggling. These youth will be given 24/7 care to include evidence -based trauma counseling in Cognitive Behavioral Therapy (CBT). Other homes are for youth who have aged out of the systems like foster care or residential care. They learn independent living skills to include how to applyfor a job, resume writing, taking care of a home, budget planning, shopping, dating and many other valuable tools. 19 Family Preservation & Reunification Services (PRS)
ICA helps to ensure unaccompanied children are safe, healthy, resilient and thriving, and that parents and caregivers are supported to create a safe and nurturing home environment.

ICA does not endorse situations where these children are separated from safe family and helps to reunite them
with loved ones who are well-equipped to care for them.

Every child has the right to life, access to clean water, food, education, a safe environment and most of all HOPE for a future.

1 2021 Annual Report

JOURNEY OF HOPE
eTraff icking Victim Assistance Program (TVAP)
ICA a partners with USCRI. TVAP supports foreign national adults and minors who have experienced human trafficking and are pursuing the Department of Health and Human Services (HHS) certification —a process that allows certified survivors access to public benefits and services under any federal program to the same extent as refugees. NAP facilitates timely access to vital services to stabilize and reestablish survivors' ability to live independently through needs -based financial assistance and comprehensive, trauma- infnrmorJ r Y . ,., ..* -•'-L- _
13 2021 Annual Report

CHILD TRAUMA & LEARNING CENTER
The Child and Family Counseling Services program offers community -based counseling services in the Riverside County area. ICA has many years of expertise in assisting families and children, especially those children who come from trauma based circumstances. Many children come into a family through "blended" circumstances; many may have come from foster care; many have come from orphan institutional care and adoption. We understand the issues and the challenges many are facing. Our goal is to help our clients'unglue'the situations and get back to a healthy functioning family. There are a variety of individual, family or group sessions using strength -based therapeutic techniques. We provide services primarily to children, including individual and family, through Play Therapy, Trauma -Focused Cognitive Behavioral Therapy, etc.

Sessions: 782

Afto-
` 2021 Annual Report
15 JUBILEE EXCHANGE ry.�
Fair Trade
Jubilee Exchange is a Fair Trade shop that promotes connecting producers and consumers in ethical trading partnerships through wholesale retail. Your support, provides long-term stable incomes and self sufficiencyto people in otherwise impoverished areas. Local artisans are paid above -market wages which provides a higher quality of life for themselves and their children.

This ethical marketplace brings many fun and functional gifts and products to local consumers by partnering with a vast network of fair trade certified organizations such as Equal Exchange (Worldwide), SERRV (Worldwide), Altiplano (Guatemala), Prosperity Candle (Worldwide), Divine Chocolate (Ghana), UPAVIM (Guatemala), Rahab's Rope (India), Child's Cup Full (West Bank), Darzah (West Bank), Mayan Hands (Guatemala), Sak Saum (Camobdia), and Ten Thousand Villages (Worldwide), to name a few. Jubilee Exchange is a separate non-profit under the umbrella of ICA. ICA has expanded its services to include the fair trade store, artisans, assisting missionaries who will be working alongside prospective artisans, job training and employment for young adult refugees in this country (teaching them warehousing, clerical skills, store management, inventory control, etc.) The shop items are mobile and are taken to various invitational events used to encourage an open dialog of our various programs. Sales from the Jubilee Exchange shop are used to do good and make a positive difference in the lives of children, families, and communities worldwide.

r Local Business Support
WCarter's children's clothing brand
and local businesses donated
clothing to the children in our Foster
to Adopt programs.
r Christmas Gift Program
r We partnered with Calvary Chapel
Bible College who hosted a toy
drive and Fair Trade Bazaar which
collected Christmas gifts for children
in our Foster and Refugee programs.

We also received toy donations from
Rose Again Foundation which we
distributed to children throughout
all our programs.

MyStuffBags Foundation
My Stuff bags Foundations granted
ICA duffel bags filled with travel -
sized hygienic products, blankets,
toys, and books/puzzles for
distribution to the many foster care
children and foster care agencies in
the California counties.
` 2021 Annual Report
16 HUMANITARIAN AID
Local Church Support
r Over a dozen churches in
'9 the Riverside and San Diego counties
including; Rancho Christian, Calvary
Murrieta, and Calvary Chapel Bible
College participated in sponsoring
events and toy drives. They also
invited families and individuals to
participate by donating Hope Paks
designed to support children in
need. Each child in the Transitional
Foster Care Program was provided
with at least one 40 lb. bag of
humanitarian aid items when they
reunited with their family.

Haiti & Philippines
Throughout the year, ICA staff and
our supporting families happily send
donations and funding to children in
Haiti and the Philippines.
r Local Community Support
The local community, along with
Rose Again Foundation of Temecula
have donated new clothes, shoes,
school supplies, educational toys,
diapers, wipes, toiletries, gift cards,
and backpacks year-round. These
items were distributed to children
throughout our programs including
our foster to adopt program, as well
as any child in the community who
had a need.

` 2021 Annual Report

HAITI PROJECT
ICA has built a transition home for orphan children receiving care in Haiti. Currently the home is being managed by the local Nazarene Church and the house parents are volunteering from the U.S. to help get the program started.

Haiti has had such horrible disasters in the past years leaving its people without homes, food, adequate water and medical care. In a response to the needs of Haiti, in 2013, ICA reached out to the government, met with them and asked what the greatest need was. The resounding answer was homes for children in transitions. So, ICA began a long process that ended in an amazing partnership with Haitian nationals and a U.S. Church denomination.

ICA will be building a "village" that will provide a home for children on the streets; a garden to help feed everyone and teach skills; sheep to herd; 'a small recreational area; a well for safe drinking water (which is very difficult to fix in Haiti) and a church. This is quite an undertaking for us. Some funds have been raised but we are farfrom our goal. ICA needs your help and support. Together with the local Haitians, we have designed our programs to protect children, preserve families, promote economic independence, all while proclaiming the gospel. We hope to empower future generations with a life of hope and possibility.

Our mission is to prevent orphans and building strong families and communities in Haiti, We seek to help the most vulnerable families stay together and to encourage extended families and local communities to care for the orphans among them.

�P42021 Annual Report

FINANCIALS
Revenues Earned
18 Revenues by Program - 2021
rM a long-term Fos ter Care (International(
3$!
Unaccompanied Refugee Mnors
(internatlonal)
America's Orphans - Foster (domestic)
Private Adoption Agency Reimbursement
Program (PAARP)
■ Counseling
4 International adoptions llnternatlonal)
■ Contributions, grants and donations
a JubileeStae sales
EPcst-release
2021
ton Lterm ForterCert ntOrr WOrtel
1 298,s71
Unworn PAnt wtJ a M11 ns"ntsrnatton81
I8 U95
AJ WIn'LG! hsna•f a, demestIl
596 1011
Prh*taAdo t{on en RefrnbUr111MWtPrp s6PAARP
i14000
Mal
44 321
lions: n11*ratfone!'
85,971j
CcnA'hw1on tsend don wons
362802
Jub11*rStarera16
2,604
Rcrt release
112,91E
Totet
$ 4 22R 401,00

OFUNCTIONAL EXPENSES
Expenses by Function - 2021
■ Domestic
12 International Foster & Refugee
a Institute
Administrative
2021
DotileAic
$ 894,201
International Foster & Retu ee
2,136,532
Institute
46,159
Admanj#rat;va
467,437
Total
$ 3.594,329
25%
61%
1%
13%

Hope Paks(Humanitarian Aid Gifts)
Child Sponsorship
Family Sponsorship Fund
Gift of Life Fund
Gifts of purpose
Amazon Smile Program
Shop Jubilee Exchange (Fair Trade Store)
Monetary Donations/Gift Cards
Child Trauma & Learning Center Scholarships
~7 ^�
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~ A~.�^/, . `u,
n�N�~ n
ZOO
�
�
' -..
.CQrf". IAWE

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
25 JACOB,pS HOUSE INC.

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No [NJ Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND I I I LE WITHIN THE ORGANIZATION.

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors ❑■
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

Jacob's House is a home of refuge where families and loved ones of those in hospitalized traumatic medical need can find hope, comfort, peace, and inspiration. We are a community resource dedicated to serving families in crisis. We do this by providing a shelter for the physical, emotional and spiritual support.

FINANCIAL STATEMENTS

UPON REQUEST, COPIES OF THE ORGANIZATION'S CURRENT BUDGET/FINANCIAL STATEMENTS (BALANCE STATEMENT AND INCOME STATEMENT), AND IF AVAILABLE CPA'S AUDIT, MAY 13E rgEEDED UPON REQUEST TO DEMONSTRATE SOUND FINANCIAL MANAGEMENT. DO NOT SUBMIT NOW.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP Jacob's House $ Feb. 2022 City of Temecula CSF Grant
Jacob's House $ Feb. 2021 City of Temecula CSF Grant
City of Temecula CSF Grant
Jacob's House $ Jan. 2020
$
S
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? NO ❑ Yes L] IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH + YEAR

RECEIVED

NAME OF ENITY FUNDING RECEIVED
$ 5,000
$ 2,500
$ 1,500
Morongo Band of Mission Indian Grant Apr. 2022
Stater Bros. Foundation Grant t Jan. 2022
Riverside County BOS Community Improvement Designation Grant f Jul. 2022 $ 16,458 Small Business Administration (SBA) Paycheck Protection Program (PPP) Grant I Feb. 2021 $ 2,625 The Schultz Family Foundation
$ 3,000 Harrah's Casino
$ 15,000 California Relief Grant
$ 420,000 Anonymous Medical Group (earmarked ONLY to payoff our mortgage) Mar. 2-021
Sep. 2021
Oct. 2021
Dec. 2021 �
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

Jacob's House's City of Temecula Grant Application seeks to secure funds to sustain program services extended to families displaced by a medical crisis. Success is measured based on two formulas including: number of individual family members served, and number of nightsllength of stay. This total is calculated by 4 rooms by the number of days per year 365 aqua ling 1460 total nights of occupancy opportunities for the year. During the program years 2022-23 Jacob's House intends to serve a minimum of 100 family members, and provide a minimum of 500 overnight stays. These projections seek to maintain the current level of services in the wake of COVID-19, which reflects a 76% increase in program impact from Jan -Jul 2021 vs 2022. A continued partnership with the City of Temecula's more robust grant opportunity will help Jacob's House sustain services provided in Temecula Valley, where Jacob's House remains the sole provider of emergency lodging for families displaced by a traumatic medical crisis. The second important benefit is engaging Temecula residents with a unique opportunity to strengthen community ties to each other and with the larger community. This also provides a vehicle that broadens Temecula's support network, plus exposes Temecula citizens to other residents with common interests, neighborhood resources, and fun and fulfilling activities. Our hope is to extend our partnership, leverage these funds and stakeholder's support that comes with being awarded with a Temecula City grant. Finally, with expanded funding we will continue our mission in providing a physical refuge, emotional comfort, and financial solvency to the area's families facing an emergent medical crisis. 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

As Southwest Riverside County's only healthcare hospitality home, funding sources, be they from municipalities (including the City of Temecula), foundations, businesses and/or endowments, will be instrumental in meeting the uptick trend in families experiencing a traumatic medical event resulting in Jacob's House providing services. Expenses will/may take the form of expanded direct mission delivery services for families, purchase inventory, deferred maintenance, repairs, marketing campaigns, outreach events, new equipment, furnishings .and/or social service programmatic guest experience enhancements that strengthen human services programs like Jacob's House.
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

Ways that Jacob's House has met and will continue to meet the needs of the local Community is by providing the citizenry of Temecula an opportunity to give back ever since our opening In December 2012. Be it sweat equity, development, Fundraising, maintenance, guests family services, service projects andlor outreach, Jacob's House has become that vehicle for businesses, community based organizations, students, retirees, faith -based communities, and area stakeholders to utilize their experience, learn new skills, make a connection, develop new bonds, and profoundly make a difference in the lives of their brethren through community volunteerism.

Temecula volunteers' role In the community is a unique one, where they can measure their resolve by their commitment to helping other. This Includes bull is not limited to, helping reduce stress and ffnanclai burdens for famllies when they must travel far from home when their loved one has a health Care emergency, in turn allowing families the ability to stay together when there loved one is sick or Injured. Another benefit to corn munity Is when an area's citlzenry is engaged In the welfare of others in the community, the community itself begins to thrive. With Jacob's House's size, mission, and scale of volunteer service opportunities, we are uniquely positioned so Temecula residents can give back in meaningful ways. We believe that significant changes can and does occur with individuals. cotes and communities when the adage of "being of service" Is realized through a stable, respected and valued entity. Throughout It all, we have been able to serve as a critical Temecula resource, showing up during times of need and helping families, be they Temecula residents or visitors, with the support during their most vulnerable times. Jacob's House is proud to serve through a network of more than 70 Temecula volunteers, 100's of businesses. CBO's, houses of warship, School districts' students and countless service groups, such as National Charity League, Boys/Girls Scouts, etc, in benefiting both volunteer and recipient of that kindness. 3b ESTIMATEFROM THISDNUMBER OF PEOPLE PROJECT PROGRAM FROM TEMECULA EXPECTED TO BENEFIT �170 3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 70 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS, With the City of Temecula 2022-23 grant, Jacob's House will provide 700 nights of emergency lodging for family members enduring a traumatic medical crisis, preserving their physical, emotional, and financial stability. While simultaneously providing 70 residents, businesses, community based organizations, faith -based communities, and service groups the ability to connect to our community, make a difference in the lives of families experiencing a traumatic ,event, and prove that Temecula's well earned reputation extends to both residents and visitors 'alike.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

Like every heaindss, ondly, and henlihcara hosp0lady llorhe like Jotob's House, we were Impaclad by and had to make ehanges In the way we du tluslnass In resppnse to ine COVID-19 9tothil pendomlc, M a unique soclal6en+ioaa provider and ngaource In Tlimecaiti, wq are span And continue 10 provide families expathenctng a tfatrrnaH : VWLal avant with lodging, menls, anaftary rusoauc m. aril umallonal sappoft, Hihvever, She rgautl 01 this psmtemic Impaa wat, exportonc2d In 0ro folloM g weyo. hr 2019 we bnofly (1 112 ri"jilwo 41gd to coasod sctvKee In order Iq work wilh iho CDC. Statu lioallh• and Fkrversldn County Honhh Dolow"onls so wa dould reopen whh Ilse lato8 Piociedunes, pr0ih4pdas and strategies that kept 1wl only der liimlll0.y aofo but also our Temecula v0lunhiara and staff Irian) ccolnncsing the dir,eA.sa. Developed pmnarahlps that provided JrK4W,% Hwism wilh 4A kind services, prodncsa Adlo nr htvan" to rnanm90 the charges needed to aparulo sarety, 311eh as the PuroCloan Company. Tony provlda a hoapilet favgl 1 dioenfacting el north main rind common areas afrar a famRy chodts out. Our occupancy Impact it; based on ptr, matrix, which is 4 AK(rlps House ravens k 369 drays per year -1460 N14J11t maximum lotaf of how "sang nights we can pruvldu DCCdPanGy In q cptandAr year. In 2020 our svrYlru rrccupnncy was r4duud to2a11 niahls booed An fiaepikrl vlsifaflen realriattgn& In 2021 Our ocWponcy was 477 nights. On Invesso at 182% in aewices provided. In 2022 arc goal ✓s 400 n,ghu of occupancy: 110mvor, we have (daehed 500 as 01 WKwAling wish d mtlniks loft in ti calendar year duo W mcreaaa riaods and Mowledgo 0 ruac urces In iemocllla, As pr4viously Ineoliongd, eve lino open In fanliOs who no ad tin, and in doing in we have radoplehl sirnlmgia miiigoring op iraUWxat prune, end pracaall"N to prokaet our auenhi. who Are lacing Cril kftl medical Chilgangua on lheir own. Ewan Ae wa 4kM*ry those Extra aporalinnal CaitA duo to COV10-14, for nva"a'a prolnctkm, wo are alill Ohio to safely pfrnldP IoNing at the hiphnr expectud IA n of occulancy. By w4wkinf with our national aadeoclufloh, Use Heallhmu Hopp,taldy Natwolk, ruprescO g hoollneare "pilailty homes, Hka iftowa House, and 0150 xwvnyina our 7 VAlkxy hU$yltrils. Wit Nwo had to reedjuor our fetch an include n 46% Increase IWm I,Nt yHol`$ servlCa numbers of roo nlghls of kw*ig. The safoly 01 Ilia IriimrkOs we Servo, .And Uxa iafaly or our sinfl, 15 at rho Ioderr0A1 of overylhing we do and every dWision we maim nogbrdfoss Of increased costs. It m ourpdnnty to moat p!u nestle of the familles who depend an us by providing ,I safe, &,hart and welcoming Faomuwwayrrarrx-hole). 6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

Our goal is to make sure people experiencing a traumatic medical event receive safe, secure lodging. traversing through their loved ones emergency care. Fully funded at the grant request amount, Jacob's House will be able to expand our ability to keep families financially solvent by providing free services to the tune of 700 nights of lodging for the year. Our analysis of Healthcare hospitality home trends, based on engagement between Jacob's House and the 7 hospitals in the Valley that we partner with, shows that we can expect an increase of services needed of approximately 40% (500 nights occupancy to up to 700 nights:
based on 4 Jacob's House rooms x 365 nights per year = 1460 total maximum nights that we can provide service). In each case, having a "home away from home" allows the family in need to focus all of their energy on their loved one. With further funds to leverage, Jacob's House will be able to meet the increased demand and expand our services while continuing our partnership with other Temecula CBO's, businesses, faith -based communities, school districts and/or concerned residents, helping mitigate and lighten the burden of these exact families in need due to an emergency medical event.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

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PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM

REVENUES I EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $ 50,000 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ 193,000 Organization
Other grants or funding already awarded for Project/Program, if any $ 14,000 In -Kind match amount or volunteer credit hours estimated amount $ 1931 TOTAL REVENUE $ 257,000

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
Facilities/Rent/Insurance f
I
Supplies
Marketing
Services
Food '
Other
VStaffing Expense
THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT;
HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET 1 $
$1,850
$3,700
$ 5, 000
$6,400
$31,000
0 $48, 725
$101,585
$198,260
$58,811
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS* FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21/22 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

If the funds were not spent in accordance with the approved/awarded application, the organization will be required to return the amount of funds to the City, To substantiate that Fiscal Year 2021-2022 funds received from the City were spent appropriately, proper back-up documentation including the completed table below with accompanying receipts/invoices, must be submitted to the City on or before due date: September 12, 2022.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization: Jacob's House Inc.

Name of Project/Program:

FY 2021-2022 Amount of
CSF Grant Fund Awarded: $ Month & Year CSF Grant Received from City:

Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):

Date on _
Name of Company Receiptllnvoice
z on Receipt or Invoice MUST BE ON OR BETWEEN Amount
`2: _ JULY 1. 2021 - JUNE 30. 2022
EXPENDITURE TOTAL $
Ex enaiture _
Description Purpose

DESCRIBE THE EXPENDITURE I PURPOSE OF EXPENDITURE

EXPENDITURE TOTAL MUST BE EQUAL TO
(OR GREATER) THAN TOTAL AWARD AMOUNT.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
If your organization Is awarded a Community Service Funding Grant In FY 2021-2022 by the City of Temecula, then this information is not due until Monday, September 12, 2022 If your organization is awarded a Community Service Funding Grant in Fiscal Year 2021-2022 by the City of Temecula, all grant funds received must be expended anytime on or between July 1, 2021, and June 30, 2022. In addition, all grant funds must be substantiated with proper bath -up documentation. Failure to provide proper documentation may jeopardize any future funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent.

If the funds are not spent in accordance with the approved purpose stated on the Application, the organization will be required to refund the amount of funds. To substantiate that Fiscal Year 2021-2022 funds received from the City were spent appropriately, proper back-up documentation including the table below with accompanying recei tslinvoices must be submitted to the City on or before due date: Monday, September 12, 2022.

EXPENDITURE REPORT due on or before Monday, September 12, 2022

1. Provide the number of beneficiaries living in 92590, 92591 and 92592 that directly - z benefitted from this program (approximate number of beneficiaries if you don't have a precise , ``• number): 2. Fill out this table (include additional copies if needed to explain all expenditures)^?

3. Attach Receipts/Invoices (in the same order as listed in this table)

4. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manag is Offic CIF �11N i 2022
Organization: Name of Project/Program: JACOB'S HOUSE INC. r Number of Temecula Residents Served/Engaged: 37
d�
�;)
Amount of Grant Fund Awarded: Month +Year Grant Received from City: $5000 2021-2�2 - Name of
Date (Mo/Day/Yr)
Amount
Describe...

Explain
Company on
Receipt/invoice
on
Receipt/Invoice
of
Expenditure
(1) what the expenditure
was (2) purpose of the
...
how the
expenditure
Must be dated on or
expenditure
specifically
between July 1,
benefitted Temecula
2021 - June 30,
2022
MUST support Project/Program
description on Application + Award
residents
residents it
Letter
names/addresses of Temecula
beneficiaries are available,
please attach.

Temecula
Paid 12/1/2021
$300
Membership provides the
It allows us to inform
Chamber of
residents of Temecula the
and engage the
Commerce
opportunity to represent JH,
community in a well
leverage relationships,
respected platform
receive in -kind services and
donations
2 NAIC- Paid 12/1/2021 $2766 Up to date insurance This provides Philadelphia Ins. protects the agency, Temecula residents Co. Temecula resident who volunteer that
volunteers and guests we have the
appropriate
coverage to operate
safely

3 GotJunk? Paid 12/13/2021
$459 Keeping the JH property
Keeping the JH
safe, clean & provide
property safe, clean
emotional renewal for
& provide emotional
guests
renewal for guests
4 Nonprofit Paid 1/4/2021
Software Corp
$440 Membership fee database
It provides
management of guest
transparency,
services
making it easier for
agencies, residents
and/or supporters
can determine data
usage
5 Healthcare Paid 11/5/2021
Hospitality
$600 Membership fees to our
Assures residents,
Network
national organization
donors that we
follow national
guidelines and are
certified by the
agency representing
healthcare
hospitality homes
6 First Team Paid 5/2/2022
Printing
$492 JH Brochures
To inform, engage
our community
about JH services
7 Note: Expenditure Total must be equal o EXPENDITURETOTAL:
than)
awarded arded"
greater the Amouant�of Grant Fund Awt (above) provided by the City

SIGNATURE PAGE
The applicant acknowledges and agrees to the following:
• Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. • Awards will be given to organizations and activities that directly benefit the residents of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval. Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately.
• Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due elate or this application may be rejected as incomplete.

We hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: JACOB'S HOUSE INC.

MAILING ADDRESS: 31525 JEDEDIAH SMITH ROAD TEMECULA, CA 92592 PHONE: (951) 452-2627 EMAIL: 8MRTILORG
PRESIDENT / AUTHORIZED OFFICER: MARTIN BARRERA-MARTINEZ EXECUTIVE DIRECTOR SIGNATURE: _ DATE:

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:

Print Name Title
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 13, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: [email protected] (951) 694-6413
Betsy. [email protected] (951) 693-3959

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said amount of funds to the City. To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receiptslinvoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula" Organization:

EXPENDITURE REPORT DATED
TOTAL FY 2022-2023
Amount of Grant Fund Awarded: 9
Name of Project/Program:

Month & Year FIRST $5,000 check
was received from City:

1. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the City

3. Is this Expenditure Report is submitted to request reimbursement of funds? No-- or Yes If yes, Amount of Request S Number of beneficiaries living in 92590, 92591, 92592 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) v Date on Expenditure
Name of Company Receipt/invoice MUST SUPPORT PROJECT/PROGRAM IN APPLICATION &AWARD LETTER m E on Receipt or Invoice MUST BE ON OR BETWEEN
q Z March 20, 2020 - JUNE 30, Amount Description Purpose 7r )A
3 EXPENDITURE TOTAL $

EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
■ The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME, Jacob's House Inc.

MAILING ADDRESS: 31525 Jedediah Smith Road
Temecula, CA 92592
PRESIDENT/ AUTHORIZED OFFICER: Martin Barrera- Martinez PHONE: (951� 452-2627
EMAIL: [email protected]
Executive Director
SIGNATURE: �V1 " DATE: Aug' 25, 2022

MONTH, DAY, YEAR

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:

PRINT NAME 1.TLE
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

11M12ML REVENUE SERVICE
P- 0. BOX 2508
CiNC_1*WI, OH 45201
Date Nov 0 3 2008
JACOD I S HOUSE, INC.

C/O IQRTIN A WEISS
ONE 13ETTERWORLD CIRCLE, SUITE 300
TBM,!ULA, CA 92590
Dear Applicant:

DEPARTMMT OF THE TREASURY
Employer Identification Number:
26-1183832
DM:
17053106310008
Contact Person:

JOANNA YMMY ID# 95078
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:

August 16, 2007
Contribution Deduotibility:

Yes
Addendum Applies:

No
We are pleased to inform you that upon review of your application for tax exerrpt status we have determined that you are exempt from Federal income tax under section 501(c}(3) of the Interned 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 pEhlic charity wader the Code section(s) listed in the heading of this letter.

Please meat enclosed Publication 4221-PC, Cpmpliance Quide for 501(c)(3) Public Charities, for some helpful information -about your responsibilities as an exempt organization.'
Letter 947 (DO/CG)

ORS a -file Signature Authorization
Fong 8879-EO for an Exempt Organization
For oWendar year 2016. or 5=10 yaw b%inning , 2016, and ending .20 Gap&rnnmr or me 1Yeasuy ■ no not send to the IFIS. Keep for yourrecords.

Mtamal Revenueswloo Information abaut.Form W79-EO and ha instructions Is at www.1rs.00v11orm88Moo- OMB Na iblfi-i B7a
2016
JACOB'S HOUSE, INC. 26-1183832
Name ano me or omcer

SHAWN NELSON

PRESIDENT
Part I I Type of Return and Return Information (Whole Dollars On[y) Check the box forthe retum for which you are using this Form 8879-EO and enter the applicable amount, If any, from the return. If you check the box on line Is, 2a, So. 4a, or 6a, below, and the amount on that line for the return being filed with this form was blank, then leave line 1b, 2b, 3b, 4b, or 6b, whichever is applicable, blank (do not enter •0). But, if you entered -0- on the return, then enter -0- on the applicable line below. Do not complete more than 1 line In Part I.
to Form 990 check here W-® b Total revenue, if any (Farm 99D, Part "ll, column (A), line 12) ........... ........ 1b 195,9.94. 2a Form 990-EZ check here 0-E:1 b Total revenue, if any (Form 990•EZ, line 9).................................... 2b 3a Form 1120•POL check here ■ Q b Total tax (Form 1120•POL, line 22)..,...........................I_ 3b 4a Form 990-PF check here 0-0 b Tax based on Investment income (Forth 990•PF, Part A, line 6) .. 4b tia Form 8865 check here 1/ C] b Balance Due (Form 8808, line 3c) Partli Declaration and Signature Authorization of Officer Under penalties of perjury, I declare that I am an officor of tha above arganlzatinn and that I have examined a copy of ths organizatlon's 2 63 6 electronic return and accompanying schedules and statements and to the best of my knowledge and belief, they are true, correct, and complete. I furlhor declare that the amount in PsA I above fa the amount shown on the copy of the organization's electronic relum. I consent toaliow my Intermediate service provider, transmitter, or electronic rot um a riginato r (ERO) to send the organlzationIs rotum to the IRS and to receive from the IRS (al an acknowledgement Of receipt a reason for rejection of the transmission, (b) the reason for any delay in processing the retum or refund, and (c) the data of any refund. If applicable, I authorize the U.S. Treasury acid its des(gnate d Financial Agent to fnitlate an electronic funds withdrawal (dlrect debit) entry to the ffnaneta] Institution account Indicated In the tax preparation software for payment of the arganlzation's federal taxes owed an this return, and tho financial institution to debit the entry to this account. To revoke a {payment. I must contact tha U.S. Treasury Financial Agent at

1.808-353.4537 no later than 2 business days prior to the payment (settlement) date. I also authorize file linanclal Institutlons involved In the processing of the alectfonic payment of taxes to face Iva confidential information necessary to answer inquiries and resolve Issues related to the payment. I have selected a personal identificatlon number (PIN) as my aignaturo for tho organization's aloctronic rat um and, If applicable, tha a rganiza t ion's consent to electionic funds withdrawal.

Officer's PIN: check one box only
® I authorize PRUDHOMME ASSOCIATES CPAS , INC_- to enter my PIN ERO firm name Enter live nu►nbers, but
do not enter all zeros
as my signature an the organization's tax year 2016 electronically filed return. If I have indicated within this return that a copy of the return is being filed with a state agency(fes) regulating charities as part of the IRS Fed/State program, I also authorize the aforementioned ERO to enter my PIN on the return's disclosure consent screen. 0 As an officer of the organization, I will enter my PIN as my signature on the organization's tax year 2016 electronically flied return. If 1 have Indicated within this ret r that a copy of the return is being filed with a state agencyges) regulating charities as part of the IRS FeW tote program, I will on r an retum's disclosure consent screen.

Officer's signature 0- Date 0-
Part III Cairtification ancl Authentication ti
ERO's EFIN/PIN. Enter your six -digit electronic filing Identification number (EFIN) followed by your five -digit self-selected PIN. 0 7 5 0 912 4 4o not enter all zeros
I certify that the above numeric entry is my PIN, which is my signature an the 2016 electronically filed return for the organization indicated above. I confirm that I am submitting this return in accordance with the requirements of Pub.4163, Modernized e•File (MeF) Information for Authorized IRS e-fife Providers for Business Rotuma.

ERO'ssignature � Date ® +_
ERO Must Retain This Form - Us Instructions
Do Not Submit This Form To the IRS Unless Requested To Do So LHA For Paperwork Reduction Act Notice, see Instructions. Form8879-EO (2018) 121011 09 2fi-19

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
F T B PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 1 /21 /2020
ESL ID: 5284048908
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 3013750
Entity Name: JACOB'S HOUSE, INC.
® 1. The entity is in good standing with the Franchise Tax Board, ❑ 2. The entity is not in good standing with the Franchise Tax Board.

CI3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d. ❑ 4. We do not have current information about the entity.

The above information does not necessarily reflect:

The entity's status with any other agency of the State of California or other government agency. e If the ontity's powers, rights, and privileges were suspended or forfeited at any time in the past, or the entity did business It, Calirornia at a time when it was not qualified or not registered to do business in California- [) The status or voidability of any contracts nude in California by the entity at a Vine when the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1), o For entities revived under R&TC Section 23305b, any time limitations on the revivor or limitation of the functions that can be performed by the entity.

Connect With Us
Web: ftb.ca.gov
Phone: 800.852.5711 from 7 a.m. to 5 P.M. weekdays, except state holidays 916.845.6500 from outside the United States
TTY/TDD: 800.822.6268 for persoris with hearing or speech impairments FTS 4263A WEB (REV 02-2019)

Form 990 t20
545-0047
Return of Organization Exempt From Income Tax 21
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) _ Department of the treasury ► Do not enter social security numbers on this form as it may be made public, Open to Public Internal Ftcvenua Servko ► Go to wwwJf$.goiWorrn990for Instructions and the latest Information. Inspection A For the 2021 calendar year, or tax year beginning , 2021, and ending 40 r
Chock if applicable: C � Employeridenli€€ealion number
Addre6schange JACOB'S HOUSE, INC. 2ti-1183832
Name change 31525 JEDEDIAH SMITH RD E Telaphonenumtg
Initial return TEMECULA, CA 92592 at
(951) 458 8681
Final return/lerminaled
Amended return 389 396.

G Gross receipts
Application pending F Name and address of principal officer: SHAWN NELSON Hfa] IS fhi.s a group return for subetd€na7'e'&.'?rYes NoSAME AS C ABOV)~' H(b) Are all subordinates included? NoTax-exempt status: }{ 501(f ){3) 501c) ( 527I€^No,"attach a list. See Inslrucllo J Website: ► WWW.JACOBSHOUSETEMECULA.DRG
N(c) Gawp exemption number ►
rll3yiefly
lxalion: }( Corporallon 7rus1 Association Other ►
L Year of formation: 2007 M State of ttgai domicile: CA mma
describe the organiaatton`s mission or most significant activities:` SCHEI2UJ�E_Q_ _�^- - _ ____--- ____-_.�___. ____ _- ..,___,�__,_—_ -..-._-----_---- —. .-.----_--__--.----—.-._.__-----_- 2 Check this box ► if the organization discontinued its operations or disposed of more than 25% of its net assets. 3 Number of voting members of the governing body (Part VI, line 1 a) ................... . ............. . .. 3 8 d 4 Number of independent voting members of the governing body (Part VI, line lb).......... 8 4 5 Total number of individuals employed in calendar year 2021 (Part V, line 2a).......... , , , , . , , , . , g -- 2 6 Total number of volunteers (estimate if necessary
) .................................... . ........
d a otal unrelated business revenue from Part VIII, column (C), line 12.......... 7a b Net unrelated business taxable income from Form 990-T, Part I, line 1 I ..................... , , , , , , , , , , , 76 0

4. Prior Year Current Year
� B Contributions and grants (Part Vlil, line lh),.. ...., $lq 42q, 231 591. 9 Program service revenue Part VIII, line 2 ( g).............. .......... 10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) ............. . . . . . . • , . , .. 1 186. cc 11 Other revenue (Part Vlll. column (A), lines 5, 6d, 8c, 9c, 1 Oc, and T'Te)........ . . . . . . . .97,265. 24 12 Total revenue - add lines 8 throw h i t must 32 527. 97, 265 • g ( equal Part VIII, column (A), line 12)..... , 548, 737. 13 Grants and similar amounts paid (Part IX, column (A), tines t-3)............ . 14 Benefits paid to or for members (Part IX, column (A), line 4)................ 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10)...... 83 129. 85, 351 m 16a Professional fundraising fees (Part IX, column (A), line 1le).. . .. . . . . . . .. . . . . .
x b Total fundraising expenses (Part IX, column (D), line 25) "' ► 1, 396.
17 Other expenses (Part IX, column (A), lines 1 T a• l Id, 1)1-24e),,, , , , , , , , , , , .10 B 576. 92 Q13 , 18 Total expenses. Add lines 13.17 (must equal Part IX, column (A), line 25)............. 191 705. 177, 374. 19 Revenue less expenses. Subtract line 18 from line 12 .............. 357,032. 151,506. sS
"p 20 Total assets (Part X, line 16) Beginning of Current Year End of Year 21 Total liabilities (Part X, line 26). 0 0
144 300. 1,862
zw 22 Net assets or fund balances. Subtract line 21 from line 20.. ... .. .... .... 739, 635 . 891 141 . Part 11 Si 1lature Bloc Undw penalties of perjury. I dotfare that I have ewsmined this return, including accemppanying setwdulas and slolemants, and to the best of my knowledge and belief, it is true, correct, and complete. oeclaration at Wepsrar (other than officer) is based on all information of wh}ch nreparar has any knowledge.

Sign Slgnnlurenrafr€eor - Dale
Here � MARTIN BARRERA-MARTINEZ EXECUTIVE DIRECTOR
pe or print name Roo
Print/Type preparers name
-,Paid .roux D. NOTTINGHM, CPA
'reparer Firm's name ► NOTTII GHAM & ASSOCIATES
Jse Dnly Firm's address ► 43460 RIDGE PARK DR STE 240
TEMECULA, CA 92590 May the IRS discuss this return with the preparer shown above? See instructions.......... . �.+.+ rur rnlrerworK rceauctlon Act Notice, see the separate instructions Check U if PTiN
self-rurlpinyod P0016B412
Firm's EIN ► 2D-2D82681
Phone no. 951-296-1698
... x Yes I I No
TEEA0101L 09/22121 Form 990 (2021)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
26 JDS CREATIVE ACADEMY

:,I, , 1 :1 h 1
FISCAL YEAR 20= - 2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ 48,000 MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Project/Program Title: DigiF■st Temecula 2023
Start Date:.10LLt?A22 End Date: 09130/2023
Physical Address of Project/Program: 28089 Diaz Road, suite D, E, a F, Temecula CA 92590

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: JDS Greatly* Academy Mailing Address: 39870 Camden Court
Temecula, CA 92591
ORGANIZATION AND GEOGRAPHIC: AREA SERVED
Name of Applicant
Organization: JDS Creative Academy
Year Founded: 2014
Website: d@CMOtiveacedem .of ld ihmttemecula.❑ Social Media: 001glFestTemecule Number of Paid Staff: 11
Number of Volunteers: 50
Geographic Area(s) the Organization Serves: CIV ofTernecuia Southwest Rivetaide County, Riverside Coun Geographic Area(s) the Profect/Pro ram Serves: City of Temecula Southwest Riverside County., Riverside County NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Diane Strand
Contact Person's Direct Telephone: (961)2964715
Title/Position: Executive Director
Contact Person's Email: [email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes Date of Incorporation as a Nonprofit: 2014 No IF NO. THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 45-5293183
State Identification Number: 3782600
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS)AND STATE (FTB) AS FOLLOWS:

1. ® Attach IRS Deductibility Status using this link: htt ./la sirs. via eosl

2. ® Attach State Entity Status Letter using this link:
https://www.ftb.ca,gov/online/self serve entit status letter/index.as

3. A] Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: hit Jlrct.d .ca. pvNerilicationlWeblSearch.as x?facilit =Y City of Temecula Community Service Funding - Reinvestment In Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No © Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organizations:

Executive Committee ❑ Board of Directors x❑
Members -at -Large ❑

NIISSION STATENIENT OF ORGANIZATION

BRIEFLY DESCRIBE THE ORGANIZATION'S MISSIONIGOALS AND OBJECTIVES j The mission of JDSCA Is to advance education and training in the visual, performing, and digital arts: theatre, music, J creative writing, fine art and digital -production art, JDSCA classes and programs fulfill the VAPA requirements, per the California Education Standard for K-17, the Apprenticeships Standards for the State of California and the Title-17 training standards for Inland Regional, providing hzruls•orn tralning to the home school, online school, traditional school, and trade school populations. JDSCA {provides opportunities to gain creative enrichment, self-confidence, leadership, and collaborative skills so that our students can obtain the expertise needed to advance to higher arts education and prosper in a competitive marketplace.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment In Temecula GRANT APPLICATION Page 6 or 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes O IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANTOR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP DiglFestTemucula In -Kind Economic Development
Funding for Special Events
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECTIPROGRAM IN THIS APPLICATION? NO ❑ Yes © IF YES, PROVIDE INFORMATION IN TABLE BELOW - AMOUNT MONTH +YEAR

RECEIVED NAME OF ENITY

FUNDING RECEIVED
$ 2,S00 / year Abbott — Jan. 2021 and Jan. 2022
i
" - I
$ 5001 year Ranch RV and Self Storage Jan, 2021 and Jan, 2022 $ S00 1 year Cal State University San Marcos I Jan. 2021 and Jan. 2022 $ 1,5001 year Mt, San Jacinto College
$ 1,5001 year United Health Services
$ 5001 year
$ In -Kind
$ In -Kind
Jan. 2021 and Jan, 2022
Jan. 2021 and Jan, 2022
DCH Jan, 2021 and Jan, 2022
JDS Video & Media, Rosenstein and Associates, Starway Productions, Economic Development Coalition Jan. 2021 and Jan. 2022
KATY, The Vine, Temecula Valley Chamber of Commerce, Visit Jan. 2021 and Jan, 2022 Temecula, Oak Grove Culinary Creations,
City of Temecula Community Selvlce Funding - Relnvestmenl In Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAN-1 DESCRIPTION
IMPORTANT- RECEIPTS+INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATI ON SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT,PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

JDS Creative Academy NDSCA) will use the Temecula grant to enhance support DiglFest Temecula, the organization's annual digital media festival, conference, and fundralsing event, now In Ks seventh year, DigiFest Temecula is JDS Creative Academy's reinvention of the Temecula Valley International Film and Musical Festival which closed in 2014.

DigiFest Temecula Is an annual three-day event celebrating all forms of digital media including, but not limited to. photography, video games, short film and videos, music, music videos, animation, graphic design, websites, and digital art, The event promotes networking, appreciation, knowledge, training and recognition opportunities for students, amateurs, and professionals while continuing to be accessible to all wKh nominal admission and competition tees, 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS EQUIPMEMENT, AND;OR SERVICES THIS ORGANIZATION HAS

PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAMJPROJECT, JDS Creative Academy will spend the grant funding on supporting the procurement of high-level speakers as well as bolstering the organization's marketing and advertising efforts. The organization will use the funds to support DigiFest Temecula speaker honorariums, travel, and hotel accommodations. JDS Creative Academy will also use the grant funds to purchase social media ads, Google ads, television commercial air time, and billboa►ds to more effectively Inform those in Southern California about DigiFest Temecula and draw more attendees to the City of Temecula. Additionally, JDS Creative Academy will also put a portion of grant funding towards new equipment such as a lighting control board, a camera, and LED lights which will further improve DigiFest Temecula event experiences. 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM?PROJECT IF AWARDED CITY FUNDING, EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

The grant funding specifically benefits all Temecula residents through the DigiFest Temsculs event. The event will bring in tourism which drives revenue to Temecula hotels, sate ries, and businesses as well as bringing in additional tax dollars which will indirectly benefit the entire community of the City of Temecula. Temecula students have historically been the population which has bonefitted the most from DIglFest Temecula since the ovont gives students the opportunity to gain Industry recognition as well as build up a pmtessional network within the Industry, all without having to leave the city of Temecula.
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT FROM THIS PROJECT/PROGRAMS 111,985 people
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 50 volunteers City of Temecula Ccmnuinity Service Funding - Reinvestnw,_nt In Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION
CONTI1 UE, D
4 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS.

Grant funds will elevate DigiFest Temecula, assisting with marketing, advertising, oqulpment, and speaker costs, Resklents of Temecula bonefit by having thn arts highlighted and the city gaining additional tax revenue. TVUSD students benefit from community service work, learning opportunities, and award recognition. Temecula businesses by volunteering and contilbulirrg resources opportunities. 5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

In 202D and 2021, due to the COVID•19 pandamic. JDS Creative Academy was unable to host an In -person DigiFest Temecula, The organization shortened the event to a virtual, one -day 01glDay event in 2020 which caused the organization to miss out on one of its largest fundraising events, as well as lose money from event deposits. In 2021, the organization returned to its three-day format and prepared a virtual event due to the pandemic still being in offecLThe event still had a lower number of attendees compared to pre pandemic years, This past year, DigiFest Temecula 2022, still was unable to completely recover from the effects oI the COVI0.19 pandemic seeing a lower rate of in•person attendance in ail aspects Including speakers, screenings, and the awards banquet. The pandemic has severely impacted JDS Creative Academy's ability to bring networking and professional development opportunities to the Temecula community. JDS Creative Academy hopes that the funding will bring back in -person attendance which we expect to surpass the highest attendance numbers seen in the past.
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

The grant funds will be used to expand on JDS Creative Academy's efforts to bring high-level speakers to DigiFest Temecula, as well as expand on the organization's marketing and advertising efforts for the event. The organization aims to use Dig€Fast Temecula as a chance to bring tourism and digital -media Industry exposure opportunities to the City of Temecula. JDS Creative Academy expects the funding will expand in -person attendance.

City of Temecula Community Service Funding - Reinvestment In Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not till In shaded areas)
r

LINE ITEMS FOR PROJECT/PROGRAM REVENUES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $
Community Services Grant (Not to exceed $50,000) 48,000 Amount contributed to the Project/Program by the Applicant $ Organization $1,250
Other grants or funding already awarded for Project/Program, if any $ 0 In -Kind match amount or volunteer credit hours estimated amount —$ 25,000 TOTAL REVENUE 5' 124 5o

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
Facilities/Rent/Insurance
Supplies
Marketing
Services
Food
Other
Staffing Expense
THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT;
HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET $124,250

EXPENSES
S 18,000
$ 10,000
$ 2,000
$' 15,0oa —
$ 2,000
$ 2,500
$ 15,000
$ 41,250
$ 105,750
$ 105,750
City of Temecula Community Service Funding - Reinvestment In Temecula GRANT APPLICATION Page 10 of 13

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual alloration. • The recognition for Community Service Funding should accrue to the City of Temecula.

Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: TID5
MAILING ADDRESS: acwv& PHONE:
1 EMAIL: 6L ► [.a .' offm
r

PRESIAUTHORIZED OF ICER
l .'RIfJT NAh1�C
SIGNATUR y C�e��•�r� ::::A
DATE:

ON'H, DAY, V[Ar
IF DIFFERENT THAN ABOVE, j
APPICATION PREPARED BY: `. LG YLQ k .�C-xof.hkve n. , , L-- Trr:_J
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
s F T B`PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 9/12/2022
ESL ID: 6732335723
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID; 3782660
Entity Name: JDS CREATIVE ACADEMY

1. The entity is in good standing with the Franchise Tax Board.

2. The entity is not in good standing with the Franchise Tax Board, 0 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d.

El4. We do not have current information about the entity.

EJ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 233O5b).

INTERNAL REVENUE SERVICE.

P. O. BOX 2508
CINCINNATI, OH 45201
Date: .,OCT 2114

JDS CREATIVE ACADEMY
39870 CAMDEN CT
TEMECULA, CA 92591
Dear Applicant:

DEPARTMENT OF THE TREASURY
Employer Identification Number:
46-5293183
DLN:
17053122345034
Contact Person:

J'ASON T SAMMONS ID## 31616
Contact Telephone NwEtbet:
(877) 829-5500
Accounting Period Ending:

December 31
Public Charity Status:
509 (a) (2)
Form 990 Required:

Yes
Effective Date of Exemption:

April 11, 2014
Contribution Deductibility:

Yes
Addendum Applies:

No
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. 2S22 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.

Return of Organization Exempt From income Tax OMB Nc, 1545-0047 Form � -— -
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) � 21 Department of the Treasury ► Do not enter social security numbers on this form as it may be made public.

Internal Revenue Service ► Go to www.1mgov1Form990 for instructions and the latest information.

A For the 2021 calendar year, or tax year beg Innln , 2021, and ending 120 B Check if applicable: C. Name of organiaallon ,3DS CREATIVE ACAL)ENy D Employer identification number ❑ Address change Doing business as 4 6 - 52 9 3 183
❑ Name change Number and street (or P.O. box if mall is not delivered to street address) Room/suite E Telephone number ❑ Initial return 39870 CAMDEN COURT (951)296-6715
El Final roturn/torminated City or town, state ui piuvinue, country, and ZIP or foreign postal code ❑ Amended return TEMECULA, CA 92591 Q Gross mcarpts $1 18 g 194 ❑ Application pending F Name and address of principal officer: H(a) Is this a group return for subordinates? ❑ Yes © No DIANE STRAND?, 39870 CAMDEN COURT TEMECULA CA 92591 H(b) Are all subordinates included? ❑ Yes ❑ No I Tex -exempt status: ® 501(c)(3) ❑ 501(c) [ ) ,4111 (insert no.) E] 4947(a)(1) or ❑ 527 If "No," attach a list. See instructions.

J Website: ► N/A
H(a) Group exemption number ►
K Form of organlratlom MODrporation ❑ Trust ❑ Association ❑ Other ► L Year of formation: 2 0 151 M State of legal domicile: CA 1 Briefly describe the organ€zation's mission or most significant activities: 1t1 pnvIDi 6gAT10t MD YFAiiIIL., IH M VISUAL flICiflhL p&RP�IIi�G dxi5 --.--,-.-.--••------••- •-----•---- _ 0.1 --�--•---........AP $ FOR AT RISK AND POSTER 1'flLTTII, DgVELQPMENTAL ❑ISABILITIES.- AUTISM, ADULTS.r - . -- - -- - - -- ...-- .......••---..

N 5tW00L, ANI) €tA1H5TR P(}i UTI 5 THRbUG3[OUT THE REGION AHD THE LOCAL C4i4 MITY. ---_WE ARE A TITLB -- Y8.... Willi IHfAVIi REGIONAL CSI7fEIt. 2 Check this box / ❑ if the nrg8�n€ iGin- d€st:ontlnued its operations or disposed of more than 25% of its net assets. 3 Number of voting members of the goveming body (Part VI, line I a) . . . . . . . . , 3 9 Of 4 Number of independent voting members of the governing body (Part VI, ling 1 b) 4 9 5 Total number of individuals employed in calendar year 2021 (Part V, line 2a) . . . . , 5 26 6 Total number of volunteers (estimate if necessary) . . . . . . . . . . . . 6 50 a 7a Total unrelated business revenue from Part VIII, column (C), line 12 . . . . . , . . 7a 7. b Net unrelated business taxable income from Form 990-T, Part 1, line 11 7b 0.

Prior Year Current Year
8 Contributions and grants (Part VIII, line 1h) . . . . . . . . . . . . 28,639. 229,135. 9 Program service revenue (Part VIII, line 2g) . . . . . . . . 938,605. 960,3S2. 10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) . . . . . . 6. 7 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11 e) . . , 12 Total revenue —add lines 8through 11(must equal PartVill, column( , line 12 967 250. 1 1,89 t94. 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) _6,752, 23 14 Benefits paid to or for members (Part IX, column (A), line 4) . . . . . . 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 562,349. 578 843 . 16a Professional fundraising fees (Part IX, column (A), line 11 e) a b Total fundraising expenses (Part IX, column (D), line 25) ► _ 68, 118 . 17 Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e) -. 438 145. 528, 345 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 1,007,244. 1 1077 211. 19 Revenue less expenses, Subtract line 18 from line 12 -39 , 994 . 82,283. ° Beginning of Current Year End of Year
q 20 Total assets Part X line 16 . . . . . , ( � ) 218 830, 194 1.54. 21 Total liabilities (Part X, line 26) . , . . . . . . , , . 116,002. 9 053. zu. 22 Net assets or fund balances_ Subtract line 21 from line 20 102 828 . 185 111 . $I nature Block
Under penalties of periury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all Information of which preparer has any knowledge. 0 04 Z 2022
Sign Signature of officer Date
Here DIANE STRAND PRESIDENT
Type or print name and title
Paid Print/Type preparer's name Preparer's signature Date Check ❑ if PTIN Preparer MICHAEL E GREENBERG MICHAEL E GREENBERG self-employed IP00200027 Use Only Firm'sname ► MICHML E. GREENBERG, CPA INC. Firm'sEIN ► 46_4574678 Firm'saddress ► 43015 BLACKEII;ER LOOP #102 TEMECULA CA 92590 1 Phoneno. 951235-6255 Ma the IRS discuss this return with the pnarer shown above? See Instructions i] Yes ❑ No For Paperwork Reduction Act Notice, see the separate instructions. BAA REV 07/26122 PRO Form 990 (2021)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
27 LIVE CARE FOUNDATION INC.

CITY OF TEMECUI[A
FISCAL YEAR 2022 - 2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

I PROJECT/PROGRAM INFORMATION I
Amount Requested: $ 50,000 (or as available)
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Project/Program Title: Temecula Valley Support Project
Start Date: Q3-2022 End Date: TBD
Physical Address of Project/Program: 43460 Ridge Park Drive, Suite 200-S, Temecula, CA 92590

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Live Care Foundation, Inc.

Mailing Address: 43460 Ridge Park Drive, Suite 200-S,
Temecula, CA 92590

I ORGANIZATION AND GEOGRAPHIC AREA SERVED I
Name of Applicant
Organization Live Care Foundation, Inc.

Website: https://LiveCareGrants.org/
Number of Paid Staff: 0
Year Founded:

Social Media: N/A
Number of Volunteers: Ranges (1-5)
Geographic Area(s) the Organization Serves- Mostly Southern California (but can serve broadly) Geographic Area(s) the Proiect/Program Serves: Temecula Valley (or wider if there is a tie to Temecula) NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA Contact Name: Greg Di Cristina
Contact Person's Direct Telephone: 951-541-0414
Title/Position: Executive Director
Contact Person's Email: [email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes ® Date of Incorporation as a Nonprofit: 12/21/2018 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 32-0587960
State Identification Number: 4221321
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑ Attach IRS Deductibility Status using this link: tt ://a sirs_ ov/a /eos/

2. ❑ Attach State Entity Status Letter using this link:
httl2s:// www.ftb.ca.gov/ontine/self serve entity status letter/index.as

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: hit :/trct.doi.ca. ovNerifi tion/Webl r ?f ili =Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No ® Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ® Board of Directors
Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

Live Care Foundation exists to serve our senior community, disabled persons and veterans with care needs.

By extension we are also able to help families of our served community who are often bearing the brunt of out- of-pocket cash support for their loved ones' assisted care needs. We offer several options to ease the overall financial responsibilities, and help to assess which options are available and best suited to family needs.

Assisted care costs are high and are expected to rise significantly as providers, facilities, and caregivers race to keep up with demand and inflationary costs. Live Care Foundation helps reduce these burdens.

We are neither a facility nor a care provider. Instead, we work with certified, licensed, and insured care providers. We do not make grants to individuals, but, instead, support our care -receiving clients by working directly with their care providers to help ease the out -of -pockets costs associated with care delivery.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANTOR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP I
I
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? No ® Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT - RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT, The Temecula Valley Support Project will benefit seniors, disabled persons and veterans with care needs who are based in or around the City of Temecula. Grant support to their care providers directly benefits and addresses the needs of their Temecula -based clientele.

The project will also provide relief for Temecula -based families of individuals requiring care in instances where the families are burdened with providing monetary support for the care of their loved ones.

Live Care Foundation does not make grants directly to individuals per its IRS -approved bylaws and mission disclosures. Instead, we work with the licensed, certified care organizations to provide the grant support that will directly reduce out-of-pocket costs for Temecula's care recipients and their families. 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED j ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

Live Care Foundation makes small, targeted and limited grants to licensed and certified assisted care providers.

These grants are intended to subsidize the cost of care for Temecula seniors, disabled persons and veterans as well as Temecula -based families who are bearing the costs of providing assisted care services for their loved ones.

The organization receives requests for grant assistance, and then conducts and assessment and eligibility evaluation to determine if grant support is warranted. The assessment includes an evaluation of the care provider or facility to ensure State, County and City compliance for delivering assisted care services.

Assisted Care Grants are typically awarded in small increments which range but usually don't exceed $500 monthly, and are awarded with 3-6 month minimum support periods. Applicants may reapply for support, but if demand exceeds our budget capabilities then awards are allocated equally among eligible applicants based on need -based criteria and size of applicant pool. 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS, The Temecula Valley Support Project will be limited to Temecula -based seniors, disabled persons and veterans with care needs as well as the Temecula -based families of individuals with care needs in cases where the families are tasked with providing monetary support for their loved ones' care services.

In all cases, applicants must provide and prove preexisting care support services, and may also be asked to provide proof of prior monetary payments to service and care providers.

First time care support cases may also apply, but the burden of proving needs may also include financial statement review and need -based eligibility requirements.

There are nearly a dozen in -home care providers that serve scores of Temecula area residents. 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 25 - 50 care recip FROM THIS PROJECT/PROGRAM: 50-100 family me
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 1-2 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PRO.IECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS.

The Temecula Valley Support Project provides support to Temecula -based seniors, disabled persons and veterans with care needs as well as the cost -bearing, Temecula -based families of individuals with care needs.

We make grants available to the care providers who provide assisted care services to this community. 5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

During the brunt of the C-19 pandemic Live Care Foundation's fundraising efforts and results were curtailed owing to regular business disruption across the spectrum of fundraising sources.

At the same time, the demand for support spiked and as a result our organization's resources were rapidly depleted, a situation which continues to this day. One of our care support programs provides assistance with burial and funeral costs on needs -based eligibility cases. We were unprepared for the spike in requests for this type of support, and is the most direct impact that C-19 had on Live Care.

Currently, we are working to secure more sources of financial support, but, predictably, so are many other charitable organizations who experienced similar situations and conditions.

Competition for scarce grant resources is at a high, and we would be very grateful for any amount of f support the City of Temecula may _provide.

J
rIF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM. —
City of Temecula funding will be used exclusively for the new Temecula Valley Support Project.

This project will limit its support to Temecula -based seniors, disabled persons and veterans with care needs as well as Temecula -based families who currently provide monetary support for their loved ones with assisted care needs. To clarify, while this population are the ultimate beneficiaries of Live Care Foundation support, they are not the direct grantees. Grants are exclusively issued to certified and licensed care -giving organizations. The grants are made on behalf of the intended beneficiaries in order to reduce the amount of direct cost billed to the recipient or his/her family.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)
I

LINE ITEMS FOR PROJECT/PROGRAM REVENUES EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $50,000 (or Community Services Grant (Not to exceed $50,000) (any available) Amount contributed to the Project/Program by the Applicant $ 5,000
Organization
Other grants or funding already awarded for Project/Program, if any , $ N/A In -Kind match amount or volunteer credit hours estimated amount $25,000 TOTAL REVENUE $80,000

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment
Facilities/Rent/Insurance
Supplies
Marketing
Services
Food
Other
Staffing Expense
I MIN IS INtLIGIBLL tO BE FUNDED BY CITY'S GRANT;
HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES
TOTAL BUDGET $55,000
$0
$ 2,500
$1,500
$ 1,000
$0
$ 50,000
$0
$ 55,000
$ 55,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS* FISCAL YEAR (FY) 2021,2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office —CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization: Name of Project/Program: N/A
FY 2021-2022 Amount of $ N/A
CSF Grant Fund Awarded: Month & Year CSF Grant Received from City: N/A Number of Beneficiaries Living in 92590, 92591, 92592 that Directly Benefitted from this ProgramlProject (approximate number of beneficiaries if you do not N/A have precise number):
a ~
Date on Expenditure
E Name of Company Receipt/Invoice Description Purpose
..ion Receipt or Invoice MUST BE ON OR BETWEEN Amount DESCRIBE THE EXPENDITURE PURPOSE OF EXPENDITURE Ji A." 1. 2021 - JUNE 30, 202i
3 5
i -
6 EXPENDITURE TOTAL MUST BE EQUAL TO

EXPENDITURE TOTAL
- F (OR GREATER) THAN TOTAL AWARD AMOUNT
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

f
FISCAL YEAR (FY) 2022-2023 COMPLIANCE REPORT
If your organization is awarded a Community Service Funding - REINVESTMENT IN TEMECULA Grant in FY2022-2023 by the City of Temecula, follow these instructions.

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up informatton to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said amount of funds to the City. To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [if you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursedfor the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula" EXPENDITURE REPORT DATED —
Organization: Live Care Foundation, Inc.

TOTAL FY 2022-2023
Amount of Grant Fund Awarded: $
Name of Project/Program: Temecula Valley Support Project Month & Year FIRST $5,000 check
was received from City:

1. Is this Expenditure Report is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received of the total FY 2022-23 Grant Fund awarded by the City

EXPENDITURE TOTAL
Expenditure

MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER Amount I Description I Purpose

EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

Every Community Service Funding application is considered individually and on its own merit.

Awards will be given to organizations and activities that directly benefit the residents of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation.

The recognition for Community Service Funding should accrue to the City of I emecula. o Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. o Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.

The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Live Care Foundation, Inc.

MAILING ADDRESS: 43460 Ridge Park Dr., Suite 200-S
Temecula, CA 92590
PRESIDENT / AUTHORIZED OFFICER: Greg Di Cristina
PHONE: (951 ) 541-0414
EMAIL: [email protected]
Executive Director
SIGNATURE: / DATE: ��

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:

SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
FTB PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 7/2/2022
ESL ID: 4339927033
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter Entity ID: 4221321
Entity Name: LIVE CARE FOUNDATION, INC.
0 1. The entity is in good standing with the Franchise Tax Board.

2. The entity is not in good standing with the Franchise Tax Board. 0 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d. 0 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

If the entity's powers, rights. and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Connect With Us
Web: ftb.ca.gov
Phone: 800-852-5711 from 7 a.m. to 5 p.m. weekdays, except state holidays 916-845-6500 from outside the United States
California
Relay Service: :711 or 800-735-2929 (For persons with hearing or speech impairments) FTB 4263A WEB (REV 12-2019)

INTERNAL REVENUE SERVICE
P. 0. BOX 2508
CINCINNATI, OH 45201
Date: J 11 N A 201

LIVE CARE FOUNDATION INC

CIO GREGORY DI CRISTINA
32863 LEVI CT
TEMECULA, CA 92592-1482
Dear Applicant:

DEPARTMENT OF THE TREASURY
Employer Identification Number:
32-0587960
DLN:
17053060 3U2U29
Contact Person:

LISA A RONAN IDN 17305
Contact Telephone Number:
(877) 829-5500
Accounting Period Ending:

December 31
Public Charity Status:
170(b)(1)(A)(vi)
Form 990/990-EZ/990-N Required:

Yes
Effective Date of Exemption:

December 21, 2018
Contribution Deductibility:

Yes
Addendum Applies:

No
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.

It 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.

Letter 947

LIVE CARE FOUNDATION INC
Sincerely,
Director, Exempt Organizations
Rulings and Agreements
Letter 947

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FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
28 MAKE-AmWISH

ORANGE COUNTY
INLAND EMPIRE INC.

C11`1r OF T11,1NI UCUI.:'tt
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAMS APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ 20,000 MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Project/Program Title: Wish Granting in the City of Temecula Start Date: 9/1/22 End Date: 8/31/23 Physical Address of Project/Program:

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Make -A -Wish Orange County and the Inland Empire Mailing Address: 3230 El Camino Real STE 100
Irvine, CA 92602

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant
Organization: Make -A -Wish OCIE
Website: wish.ocie.org
Number of Paid Staff: 21
Year Founded: 1983
Social Media: https://www.facebook.com/MakeAWishOCIE
Number of Volunteers: 550
Geographic Area(s) the Organization Serves: Riverside, San Bernardino and Orange Counties Geographic Area(s) the Project/Program Serves: City of Temecula NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Gloria Jetter Crockett Title/Position: President and CEO Contact Person's Direct Telephone: (714) 573-9474 x 214 Contact Person's Email: [email protected]

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes Date of Incorporation as a Nonprofit: 1983 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 33-0036556
State Identification Number: 8315236986
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:
1- E Attach IRS Deductibility Status using this link: htt ://a s. irs. ovla /oos/

2. EjJ Attach State Entity Status Letter using this link:
httos:// www.ftbrCa.igovtonfine/self serve entity status letter/index.as

3. V Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: h i ://rct.dai.ca. ov/Verification/Web/Search.as x?facilit =Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No © Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors N Members -at -Large ❑ MISSION STATEMENT OF ORGANIZATION —I
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

Our mission is to grant life -changing wishes for children with critical illnesses between the ages of 2'/2 -18 in Riverside, San Bemardino and Orange counties.

Currently there are 528 local children with critical illnesses waiting for their wishes to be granted. These children need the strength to fight against their illness, and Make -A -Wish is committed to ensuring no child waits one unnecessary day for their wish to be granted.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ® Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP $
$
_ I
$
$
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? * No ❑x Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW. *All unrestricted funds raised by Make -A -Wish OCIE goes to support wish granting in all 3 counties. Funds from this community service grant will be used to grant wishes in the City of Temecula.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT, Make -A -Wish OCIE is committed to further expanding its wish granting capacity in Riverside and San Bernardino counties. Funding for this project will allow us to reduce the number of children waiting for their wish. by granting wishes in the City of Temecula.
2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

Grant funding will be used to fund expenses directly associated with granting the waiting wishes of Temecula wish children.
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

Currently there are 9 local Temecula children with critical illnesses waiting for their wishes to be granted.

Funding for this project will allow us to grant a minimum of 2 wishes for children in the City of Temecula [3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 27 FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 18 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS.

Currently there are 9 local Temecula children with critical illnesses waiting for their wishes to be granted.

These funds will allow Make -A -Wish to grant a minimum of 2 wishes in Temecula and reduce the number of children with critical illnesses waiting for their wishes to be granted. 5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

Over the past two years, our wish granting program has been significantly impacted by COVID-19, as over 70% of the wishes we grant involve some form of public transportation andfor large gatherings. Given the health concerns for our immuno-compromised families, many wishes were put on hold during the pandemic.

With many travel wishes, which generate some of the largest annual expenses for the organization, on hold during 2020-2021 and a portion of 2022, our overall wish expenses decreased significantly, and ultimately led to a temporary reduction in our functional program ratio. In order for us to continue our mission and maximize our community impact, our chapter reduced its fundraising costs and was also able to receive Paycheck Protection program (PPP) loan forgiveness.
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

Make -A -Wish OCIE is in the midst of a 5-year Strategic Plan (FY21-FY25). As part of this effort, Make -A -Wish has plans to grant 450 wishes per year by 2025 and is committed to ensuring no child in the City of Temecula waits one unnecessary day for their wish to be granted.

This effort will require significant funding, and Make -A -Wish is committed to raising significant funds through a diverse series of events across our three counties, enhanced youth fundraising efforts with local schools, and establishing key relationships with local companies and organizations to provide critical funds and in -kind resources to help maximize our wish granting efforts.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $20,000 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $50,000 14 Organization
Other grants or funding already awarded for Project/Program, if any $0 In -Kind match amount or volunteer credit hours estimated amount $20,000 TOTAL REVENUE $90,000

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment $
Facilities/Rent/Insurance $
Supplies $
Marketing $
Services $
Food
Other Direct wish expenses $ 90,000
Staffing Expense I THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; $ HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES $
TOTAL BUDGET $ $90,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Make -A -Wish Orange County and the Inland Empire MAILING ADDRESS: 3230 El Camino Real Ste 100
Irvine, CA 92602
PRESIDENT / AUTHOR17kD OFFICER: Gloria Jetter Crockett

PRINT NAME
SIGNATURE: x

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY: Clarissa Morales
PHONE: (714) 573-9474
EMAIL: [email protected]
President and CEO
TITLE
DATE:

MONTH, DAY, YEAR
Development Manager

PRINT NAME TITLE
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: Stacey. [email protected] (951) 694-6413
[email protected] (951) 693-3959
City of Temecula Community Service Funding - Reinvestment In Temecula GRANT APPLICATION Page 13 of 13

Internal Revenue Service
District Director
Department of the Treasury
Date:

Noy p 1 1984
Make -A -Wish Foundation of Orange
County, Inc.
833 Dover Drive
Newport Beach, CA 92663
Dear Applicant:
4CEIVED NOV 199
Employer Identification Number:
33-0036556
Accounting Period Ending:

December 31
Form 990 Required: W Yes ❑ No
Person to Contact:

L. Bakion (RH)
Contact Telephone Number:
(213) 688-4889
Based on information 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(c)(3) of the Internal Revenue Code.

We have further determined that you are not a private foundation within the meaning of section 509(a) of the Code, because you are an organization described in section 509(a)(1) and 170(b)(1)(A)(•vi).

If your sources of support, or your purposes, character, or method of operation change, please let us know so we can consider the effect of the change on your exempt status and foundation status. Also, you should inform us of all changes in your name or address.

As of January 1, 1984, you are liable for taxes under the Federal Insurance Contributions Act(social security taxes) on remuneration 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).

Since you are not a private foundation, you are not subject to the excise taxes under Chapter 42 of the Code. However, you are not automatically exempt from 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.

The box checked in the heading of this letter shows whether you must file Form 990, Return of Organization Exempt from Income Tax. If Yes is checked, you are required to file Form 990 only if your gross receipts each year are normally more than $25,000. If a return is required, it must be filed by the 15th day of the fifth month after the end of your annual accounting period. The law imposes a penalty of $10 a day, up to a maximum of $5,000, when a return is filed late, unless there is reasonable cause for the delay.
(over)
P.O. Box 2350, Los Angeles, CA 90063 Letter 947(DO) (Rev.10-83)

You are not required to file Federal income tax returns unless you are subject the tax on Wrj%lated business income under sectioir 511 of the Code. If you are subject to this tax. you must file an income tax return on Form 990-T, Exemrt Organization Business Income Pax Return. In this letter. we are not determining whether any of your present or proposed activities are unrelated trade or business as defined in section 513 of the Code.

You need an employer identification number even if you have no employees. If an employer identification number was not entered on your application, a number will be assigned to you and you will be advised of it. Please use that number on all returns YOU file and in all correspondence with the Internal Revenue Service.

Because this letter co4d`help resolve any questions about your exempt status and foundation status, you should keep it in your permanent records.

If you have any questions, please contact the person whose name and telephone number are shown in the heading of this letter.

Sincerely yours,
to( '� C-�t �- t�c�
District Director

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 9/8/2022
ESL ID: 5438109377
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 1169838
Entity Name: MAKE -A -WISH FOUNDATION OF ORANGE COUNTY AND THE INLAND EMPIRE, INC. ® 1. The entity is in good standing with the Franchise Tax Board.

EJ 2. The entity is not in good standing with the Franchise Tax Board. ® 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d,

4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

** PUBLIC DISCLOSURE COPY **
Return of Organization Exempt From Income Tax 01AFS No, 16d5.OD1! Form 990 Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) (Rev. January 2020) 2019
Department of the Treasury I ► Do not enter social security numbers on this form as it may be made public. Open to Public lnfwnal Aevanue seryica Go to www.irs.gov/Form99O for Instructions and the latest information. InspecVon A For the 2019 calendar year, or tax year beginning SEP 1 2019 and andina AUG 31, 2020 S Chock if C Name of organization
applloahlo: MAKE -A -WISH FOUNDATION OF ORANGE COUNTY
�cpl AND THE INLAND EMPIRE, INC.
�Name
charl Doina business as
O eulwn Number and street (or P.O. box if mail is not delivered to street address) 1:1Fnol
r3230 EL CAMINO REAL
termin-
ated City or town, state or province, country, and ZIP or foreign postal code ��oAn
flrn � "d IRVINE. CA 92602
=VW.A F Name and address of principal officer: GLORIA SETTER CROCKETT pondmp SAME AS C ABOVE
J Websitil OCIE.WISH.GRG
D Employer identification number
33-0036556
Room/suite E Telephone number
00 714-573-9474
43 Gross ril 5,213,481.

H(a) Is this a group return
for subordinates? __ DYes 91 No
H(b) Are all subordinates Included? L�j Yes [_1 No
r 527 If "No," attach a list. (see instructions)
K Form of ortgarkaliow L:K] Corporation J_J Trust [ I Association J I Other ► J L Year of formation' 1983 I m Siate of lanai domidle' CA 1 Briefly describe the organization's mission or most significant activities: TOGETHER, WE CREATE v

LIFE -CHANGING WISHES FOR CHILDREN WITH CRITICAL ILLNESSES, A
2 Check this box ► = if the organization discontinued its operations or disposed of more than 25% of its net assets. c3
Number of voting members of the governing body (Part VI, line 1a) 3 23 23
c9
4 Number of independent voting members of the governing body (Part VI, line 1 b) 4 ee
(4
5 Total number of individuals employed in calendar year 2019 (Part V, line 21 5 35 ;,E
- --• . - _
6 Total number of volunteers estimate if necessary) 6
700
C,
a7
a Total unrelated business revenue from Part VIII, column (C), line 12 7a b Net unrelated business taxable income from Form 990-T line 39 17b

0. Prior Year
Current Year
4, 224, 901.
3, 763, 197,
y
8 Contributions and grants (Part Vlll, line 1h)
188, 400,
79,921.
v9
Program service revenue (Part VIII, line 2g)
10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) 129,868.
106,133.
cc
11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) -24 807,
,
-49, 856.
4,518.362.
3,899,395.
12 Total revenue • add IInas 0 itlrorf h 11 must ual Part VIII column fin 12 13 Grants and similar amounts paid (Part IX, column (A), lines 1.3) 2,259,595.
1,309,159.

0. tl.
14 Benefits paid to or for members (Part IX, column (A), line 4) 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5.10) .. - 1,780,039.

1.558.555.

0. 0.
16a Professional fundraising fees Part IX, column (A), line 11 e b Total fundraising expenses (Part IX, column (1)), line 25) Jim-1,000,516. 1, 038, 465,
1,101. 654,
17 Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e) 5,078, 099.
3, 969, 368.
_
18 Total expenses. Add lines 13.17 (must equal Part IX, column (A), line 25) 19 FievenwIII ex mSubtractline18fromOne12
-559,737.
-69,973.

Beginning of current Year
End of Year
2,904,150.
2,775,036.
20 Total assets (Part X, line 16) ......,
852, 303.
740 1156
21 Total liabilities (Part X, line 26) ..
2 051 847 ,
2, 034, 921.
r 22 Net assets or fund balances. Subtract line 21 from line Pit ..................

Ill a 11 I p1a1106LIrp 47III
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true correct and Corn leie. declaration of pnorer other than afffcer is based on all information of which preparer has any knowledge.

Sign Signature of officer Date
Here GLORIA JETTER CROCKETT, PRESIDENT & CEO
Type or print name W fide
Print/Type preparer's name Preparer's signature /f� q Date check Q PTIN Paid '.HRISTINE KAWECKI 1i4.'f^ f Ot7�22/2U21 sag-ProIE Eti Preparer Firm's name III DELOITTE TAX LLP Firm's EIN bb, 86-1065772 Use Only Firm's address 0. Two JERICHO PLAZA
JERICHO, NY 11753 Plfnnn nn 516-918-7000
,ft the IRS discuss this retum with the ereporer shown above? see instructions . .......--_-.. LLJS No 932001 01-20-20 LHA For Paperwork Reduction Act Notice, see the separate instructions. Form 9W (2019)

TAX RETURN FILING INSTRUCTIONS
FORM 990
"" FORM 990 PUBLIC DISCLOSURE COPY "

FOR THE YEAR ENDING
AUGUST 31, 2020
PREPARED FOR:

MAKE -A -WISH FOUNDATION OF ORANGE COUNTY
AND THE INLAND EMPIRE, INC.
3230 EL CAMINO REAL NO, 100
IRVINE, CA 92602
PREPARED BY:

DELOITTE TAX LLP

TWO JERICHO PLAZA
JERICHO, NY 11753
AMOUNT DUE OR REFUND:

NOT APPLICABLE
MAKE CHECK PAYABLE TO:

NOT APPLICABLE
MAIL TAX RETURN AND CHECK (IF APPLICABLE) TO:

NOT APPLICABLE
RETURN MUST BE MAILED ON OR BEFORE:

NOT APPLICABLE
SPECIAL INSTRUCTIONS:

THIS COPY OF THE RETURN IS PROVIDED ONLY FOR PUBLIC DISCLOSURE PURPOSES. ANY CONFIDENTIAL INFORMATION REGARDING LARGE DONORS HAS BEEN REMOVED.

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
29 MICHELLEYS PLACE

CANCER RESOURCE CENTER

CITY OF ZTMECYTLA
FISCAL, YEAR 2022 M 2023

COMMUNITY SERVICE FUNDING M REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ 50,000
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Cancer Support Services
Project/Program Title: Start Dater End Date: i� .a3
Physical Address of Project/ Program: 41669 Winchester Rd. Temecula CA 92590 INCLUDE IF DIFFERENT THAN ORGANIZATION's MAILING ADDRESS If Grant is Awarded, Make Check Payable to: Michelle's Place Cancer Resource Center Mailing Address: 41669 Winchester Rd
Temecula, CA 92590

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant Michelle's Place Cancer
Organization: Resource Center
Website: www.micheliesplace.org
Number of Paid Staff. 10
m Year Founded: 2001
Social Media: @pinkribbonmp
Number of Volunteers: 121
Geographic Area(s) the Organization Serves: Riverside County, North San Diego County Geographic Area(s) the Pr jecttl?ro ram Serves: Temecula NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE ExcLus Vj ELY USED TO SERVE TEMECULA.

Contact Name: Kim Gerrish Title/Position: Executive Director Contact Person's Direct Telephone: 951-699-5455 Contact Person's Email: kim michellesplace.or 9 NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes Date of Incorporation as a Nonprofit: 2001 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 33-0951216 State Identification Number: 2267780 PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ® Attach IRS Deductibility Status using this link: htt2:l1ap-0s.irs.q vlappleasl

2. ® Attach State Entity Status Letter using this link:
htt s:/� //www,Ftb.ca.00vlonline/self serve entity stater�lgtter/index.asa

3. 1 Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: Ilr a. v e ifi t1vnlWetal5earch.as x7f,-Ilitv=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

APPLICATION AUTHORIZATION
Has the organization or any members of the Board of Directors of the organization been involved with any personal business transactions vaiued over $500 including any business transactions, negotiations, investments, or interests In real property with a Temecula City Council Member during the past 12 months? No ■o Yes ❑ IF YES, BRIEFLY DESCRIBE:

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No [■J Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organizations. � y Executive Committee ❑ Board of Directors ❑ Members -at -Large [kj

MISSION STATEMENT OF ORGANIZATION
-- 1
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

Empowering individuals and families impacted by cancer through education and support services.

Michelle's Place is a full service cancer resource center providing free resources for families dealing with cancer.
r FINANCIAL STATEMENTS

UPON REQUEST, COPIES OF THE ORGANIZATION'S CURRENT BUDGET/FINANCIAL STATEMENTS (BALANCE STATEMENT AND INCOME STATEMENT), AND IF AVAILABLE CPA's AUDIT, MAY BE NEEDED UPON REQUEST TO DEMONSTRATE SOUND FINANCIAL MANAGEMENT. DO NOT SUBMIT NOW.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No ❑ Yes N IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT
AMOUNT
MONTH + YEAR

NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP

FUNDING RECEIVED

OR SPONSORSHIP
Pink Ribbon Asst. Program
$ 2,000
6/1/20

CMD CSF
Cancer Support Services
1/29/21
CSF
CSF
1 $5,000
$ 5,000
Cancer Support Services
1/2022
Purple Ribbon Assistance
$1,000
6/2022

CMD CSF
Purple Ribbon Assistance
$1,000
6/2022

CMD CSF
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? No ❑ Yes 0 IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH +YEAR

RECEIVED NAME OF ENITY
FUNDING RECEfVED
$ 10,000 Riverside County Transportation Comission 7/22 $ 10,000 CDBG - Murrieta 12/21
$ 10,000
5,000
Is 10,000
$ 25,000
$ 24,500
$ 45,000
CDBG - Menifee _ 6/22
San Manuel Band of Mission Indians 9/22
Inland Empire Community Foundation 7/21
Stater Bros. Charities 4/21
Kaiser Permanente 12/21
Inland Empire Health Plan 1/22
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROD , CTIPROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT The cancer support services program provides free resources for cancer patients, education on prevention and early detection, patient navigation, temporary financial assistance, transportation to medical appointments, and support to families dealing with cancer. Michelle's Place hosts 23 different programs and support groups over 50 times a month for cancer patients and their families. 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EGIUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

The Center currently relies on donated items for the cooking program, art expression and husbands hangout groups. Funding through this grant will enable Michelle's Place to purchase supplies for these classes and allow for more attendees. They will also be used to purchase items for the chemo kits and mastectomy kits. Funds will also be used to provide temporary financial assistance to people in active cancer treatment that are struggling to feed their families.

Funds will also be used to provide transportation to medical appointments, fund MRI's and lymphedema supplies not covered by insurance. Funding will support a 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAMIPROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

Michelle's Place is the only cancer resource center in the County and is located in the City of Temecula. Residents can access the Center and receive a variety of support Monday through Friday.

From July 2021 to June 30, 2022, Michelle's Place helped 318 Temecula cancer patients with 2,126 free services.
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT FROM THIS PROJECT/PROGRAM: 425
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECTIPROGRAM: 121 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECTIPROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT -- SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS The Temecula Community Service Funding - Reinvestment in Temecula grant will! provide over 400 Temecula residents and their families facing cancer with navigation, psychosocial support, temporary financial assistance, transportation, and education on early detection and prevention. No one will face cancer alone in Temecula.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

The Covid-19 pandemic limited Michelle's Place ability to serve Temecula because of the many restrictions. Cancer patients could not access support groups or classes during the pandemic, leaving them feeling less supported.

Michelle's Place implemented zoom for many classes and groups to reach more of those affected.

During the Pandemic, many cancer patients struggled financially. The need for financial resources was significant. The increased need added a financial burden to Michelle's Place. Transportation to medical appointments also became a huge need but was unavailable due to the restrictions on the transportation company.

Today, the cost of fuel has created new restrictions on the program. We are only 6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

Funding will expand the current programs for Temecula residents at Michelle's Place. We will be able to provide more transportation, have more people in classes and programs, ensure families get financial assistance and we will be able to highlight the programs and groups available in the Center through a new Program Calendar. This funding will enhance the program experience as well as serve all who need help while going through cancer in Temecula.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas) i
LINE ITEMS FOR PROJECT/PROGRAM REVENUES _I EXPENSES
LIST REVENUES/INCOME FOR PROJECT/PROGRAM f
Amount of money requested from this City of Temecula $ 50,000 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ 23,000 Organization
Other grants or funding already awarded for Project/Program, if any $ 26,600 San Manuel Tribe of Mission Indians
IECF
HUD - Food Insecurity RCTC IEHP
In -Kind match amount or volunteer credit hours estimated amount $ 12,000 TOTAL REVENUE $ 111,600

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment Michelle's Place Program Calendar
Facilities/Rent/Insurance
Supplies Chemo kits - 159 x $75 = 11,925 Transport
Art Supplies - $500 per month (24 clients) p
$ 3,125
$
$ 17, 925
Marketing Printing and duplicating, educational materials on cancer related topics. p
Services Transportation - 40 rides x $125 = 5,000
$1 125
$ 5,000
Food Grocery gift cards - 30 families x $350 = 10,500
Other Mastectomy kits - 25 x $50 = 1,250
Husbands Hancout - 3 support events x $250
$ 10,500
$ 2 000
,
Staffing Expense

THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT,
HOWEVER PLEASE INCLUDE.
_
$ 1 925
,

TOTAL EXPENSES

TOTAL BUDGET
$
$ 1$111,600
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 2V22 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

If the Funds were not spent in accordance with the approved/awarded application, the organization will be required to return the amount of funds to the City. To substantiate that Fiscal Year 2021-2022 funds received from the City were spent appropriately, proper back-up documentation including the completed table below with accompanying receipts/invoices, must be submitted to the City on or before due date: September 12, 2022.

I. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table,)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
Organization. Michelle's Place Cancer
Resource Center
FY 2021.2022 Amount of $
CSF Grant Fund Awarded:

Name of Project/Program: Cancer Support Services
Month & Year CSF Grant Received from City:

Number of Beneficiaries I-iving in 92590, 92591, 92592 that Directly Benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number):
c Name of Com an Date on Expenditure
r `w p y Receipt/invoice on Receipt or Invoice MUST BE ON OR BETWEEN Amount Description Purpose QE JULY 1, 2021 . JUNE 30, 2022 DESCRIBE THE EXPENDITURE PURPOSE OF EXPENDITURE 2 3
4 $
5 $
6 $
EXPENDITURE TOTAL $ EXPENDITURE TOTAL MUST BE EQUAL TO
(OR GREATER) THAN TOTAL AWARD AMOUNT,
City Of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

FISCAL YEAR (FY) 2022-2023 COMPLIANCE REPORT
If your organization is awarded a Community Service Funding - REINVESTMENT IN TEMECULA Grant in _ _ FY2022-2023 by the City of Temecula. follow these instrurtinnc_ I€ your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in PY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30. 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any Funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the a pp rove dlawarded application, the organization may not receive and/or will be required to return said amount of funds to the City. To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no laler than June 30, 2024. to demonstrate grant funds were spent in accordance wlth the Application, (if you were awarded less than $6,000, submit Expenditure Report for that amount.)
S. If awarded grant funds exceeding $5,000. A) Follow 41.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed far the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than ,tune 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment in Temecula"

EXPENDITURE REPORT DATED
Organization: Michelle's Place Cancer Name of Project/Program: Cancer Support Services Resource Center o
TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: S was received from City:

I. Is this Exponditure Report Is to provide documentation for first $5,000 awarded and received? Yes or No_ (already submitted).

2. My organization has already received $ of the total FY 2022-23 Grant Fund awarded by the city

3. Is this Expenditure Report Is submitted to request reimbursement of funds? No or Yes It yes, Amount of Request 5 Number of beneficiaries living in 92590, 92591, 92592 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) m
i
aZ
Name of Company
on Receipt or Invoice
Date on
Receipt/lnvoice

MUST BE ON OR BETWEEN
March 20, 2020 - JUNE 30,
2024
Expenditure

MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER Eli
EXPENDITURE TOTAL $
Amount + Description Purpose
I

EXPENDITURE TOTAL
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. ■ The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. ■ Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete. 1/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Michelle's Place Cancer Resource Center MAILING ADDRESS: 41669 Winchester Rd
Temecula, CA 92590
PRESIDENT / AUTHORIZED OFFICER: Kim Gerrish

PRINT NAME
SIGNATURE: 11 G� aAA�G

IF DIFFERENTTHAN ABOVE,
APPICATION PREPARED BY:
,,M NA
U
PHONE: c 95 y 699-5455
EMAIL: kim [email protected]
Executive Director
DATE: 9/9/2022
TITLE
NiONTI-I, DAY.'([ -AR
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

City of Temecula
Community Service Funding
Attn: City Manager's Office
41000 MAIN STREET
TEMECULA, CA 92590
Questions: Stacey. [email protected] (951) 694-6413 [email protected] (951) 693-3959
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 13 of 13

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
�T g PO BOX 942857
SACRAMENTO CA 94257.0540
Entity Status Letter
Data- 5/29/2020
ESL ID: 1897482817
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 2267780
Entity Name: MICHELLE'S PLACE CANCER RESOURCE CENTER
0 1. The entity is in good standing with the Franchise Tax Board. u 2. The entity is not in good standing with the Franchise Tax Board.

LRJ 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d El4. We do not have current information about the entity.

The above information does not necessarily reflect:
• The entity's status with any other agency of the State of California or other government agency.

If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or the entity did business in California at a time when it was not qualified or not registered to do business in California:
o The status or voidability of any contracts made in California by the entity at a time when the entity was suspended ar forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1). o For entities revived under R&TC Section 23305b, any time limitations on the revivor or limitation of the functions that can be performed by the entity.

Connect With Us
Web: ftb.ca.gov
Phone; 800.852,5711 from 7 a.m. to 5 p.m. weekdays, except state holidays 916.845.6500 from outside the United States
TTY/TDD: 800.822.6268 for persons with hearing or speech impairments FTB 4263A WEB (REV 02-2019)

Q HELPB MENU
`Me- > Tax Exempt Organization Search > Michelles Place Breast Cancer Resource Center < Back to Searchexults
Michelles Place Breast Cancer Resource Center
EIN: 33-0951216 1 Temecula, CA, United States
Other Names
Publication 78 Data o
Organizations eligible to receive tax-deductible charitable contributions. Users may rely on this list in l termining deductibility of their contributions,
On Publication T8 Data List: Yes
Deductibility Code: PC
Copies of Returns (990, 990-EZ, 990-PF, 990-T) o
Electronic copies (images) of Forms 990, 990-EZ, 990-PF or 990-T returns filed with the IRS by charities and non- profits.

Tax Year 2020 Form 990
Organization Name:

Michelles Place Cancer Resource Center
EIN:
33-0951216
Tax Period:
202012
Return ID:

2657067
Filing Type:

E
Return Type:
990
Copy of Return:
2020 Form 990 Filing
I
Tax Year 2019 Form 990
Tax Year 2016 Form 990
Page Last Reviewed or Updated: 20-November-2020 04 Share $ Print

Form 990 oNte No. 1545 0047
Return of Organization Exempt From Income Tax - 2021
Undersectlon 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) f r1 bnnnl of the Treaxrrry � Do not enter social secailly numbers on Ihls font as It may bem ile public. Open to Public fnSernaf Revenue Samce ► Go to nrww.fra.gov1Farm980for instructions and the latest information. inspection A For the 2021 calendar year, or tax year beginning 2021, and ending .20 B Check fapplicabla: C f) Employer identification number AtIdfCSAchange MICHELLE' S PLACE 33-0951216
Name change CANCER RESOURCE CENTER TelophoAn number
Imbal return 41669 WINCHESTER RD. STE 101 951-699-5455
Foal r@turOlermi0aled TEMECULA, CA 92590 hh ILnende;i return G Gos5receipts •7 1,169,118.

Apphcabon pending F Name and address of principal officer: MARILYN R. WATSON RM 15 rtus a group rrtmen for subwonates' HYes 6 No SAME AS C ABOVE Nfb) Are all subordinates included? Yes No If'No,' anach a list. See mstouclions
I Ta 10 Investment income (Part VIII, column (A), lines 3, 4, an d cc 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, , 1 c, I ... ............ 383 255. 4fl3 452. 12 Total revenue — add lines 8 through f I (must equal F , coumn (A), line 12), . 962,134. 929 850. 13 Grants and similar amounts paid (Part IX, column (A), iines 1.3)..-....-.....-.... -. 14 Benefits paid to or for members (Part IX, column (A), line 4) ........... .. . . 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) _... 473,043. 518, 679. m
16a Professional fundraising fees (Pail IX, column (A), line IIe)..... ........ ... m b Total fundraising expenses Part IX, column D , line 25 w g p ( () 1 _ 83, 720._
17 Other expenses (Part IX, column (A), lines 11a-11 d, 11 11`-24e). . . ........ . . .. 258,957. 253 924, 18 Total expenses, Add lines 13-17 (must equal Part IX, column (A), line 25)_ ....-. .. 732, 000. 772 603. _ 19 Revenue less expenses. Subtract line 18 from line 12 ................. ........... ... 230 134. 157 247.

E 6 Beginning of Current Year End of Year
21 Total liabilities Part X, line 26 ......... ..... 3, 352 533. 3,813,088. 1 20 Total assets (Part X, line 16)
( ).........--..................-... � 2,352,533. 2,279r188. x 22 Net assets or fund balances. Subtract line21 from line 20,,.__.................... 1, 362, 781. 1, 533, 900.

Part II Si na re oc
under pena%os of perjury, I declare that I have examined this reltim, indi;dlno Xco-npnnyino schedules and st0mit' 5, and to the best of my knowledge and belie!, d is !rue, correct, and complete. Declaration of preparer Collier Than officer) is based on all mfo•mabron of vows preparer has any knowledge.

Sign 5,jy,61ureOre1hcer -- oale
Here ` KIMBERLY GERRIS14 EXECUTIVE DIRECTOR
yno or pr.nt name am line
PrinllType preparc,'s name Preplrrr5 sianeluro Dale Check U if PTIN Paid LESLIE A. DOPE€TY CPA LESLIE A. DOHERTY, CPA sdf•empuyrd IP0044929L Pre})arer Fnm's name ► LESLIE A DOHERTY & COMPANY, PC
Use Qnly Firm'saddress 41880 KALMIA ST STE 170 Firm'sEIN 1 20-2082661 MUR€ ZETA CA 92562 Phone no. (}51� 698-2260
f,4ay the IRS discuss this return with the preparer shown above? See instructions ..... ............................... -- JXJ Yes I I No BAA For Paperwork Reduction Act Notice, see the separate instructions. TEEA011311- 091220 Form 990 (2021)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
30 MILIVET

CITY OF TFAMCUTA
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ 10, L7 C) MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Project/Program Title: y Q -Je rA &3 r 1 WyA acc c-1 u,n r Start Date: t t End Date:

Physical Address of Project/Program: ,,r r

INCLUDE IF DIFFERENT HAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to:

Mailing Address: 0' for -
rYX A c

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant
Organization: M, L- Year Founded: .. O t 1Q
Website: ,,,� �y„ ,,�,�, (�,.�- �,�� Social Media:

Number of Paid Staff: C Number of Volunteers:

Geographic Area(s) the Organization Serves: i Q
Geographic Area(s) the Proiect/Proaram Serves: A t J Q)iyef , NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Q c► v e n t-1 ; e, 3 Title/Position: C E a Contact Person's Direct Telephone:95-/ 901- 96Ft1 Contact Person's Email: CP rN r %;

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes [Date of Incorporation as a Nonprofit: --1n1,Sn 2-0 1 (p No IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: -51- 18,-i I �l to 3 State Identification Number: J 3 PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. [R Attach IRS Deductibility Status using this link: htt Ha s.irs. gov/app

2. [$ Attach State Entity Status Letter using this link:
httl)s:// www.ftb.ca-ciov/online/self serve entity status letter/index.as

3. t Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: htt :l�t.doi-c ovNerificatiorVWeblSearch.aspx?facility=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No ' Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organizations:

Executive Committee Board of Directors ❑ Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES. 1 m"t'J k 4 11I h SC: C ►1�✓� P 1`G 1 �v �� c `.z t� L �1 2 v 1 /tJ� ri' C sn��f ( Y- -� -} I`t. CU,tiM�-�: _ ``'�i 0'_"r q. 1WY Pf'U vi N i ✓L" r11 11 l J
ry� � 'tom n�S $� VP (ArJj� `�c Vc IV\ 4-
A
P C c, r A l y (� .. v c c l N J n rO Yam` + G Y -4 �,, �/ C, ✓Z J y S-il-- a-e P SS C,,o l L7 s +i e -4 (P-7 -r- yr v
ivs -r(� C L:"v,r�u 'k � Y,

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No x Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT MONTH +YEAR NAME OF CITY GRANT
FUNDED BY THE CITY GRANTOR SPONSORSHIP AMOUNT I FUNDING RECEIVED OR S�ONSORSHIP OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? NO ❑ Yes"K IF YES, PROVIDE INFORMATION IN TABLE BELOW.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT- RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT - I
I) d e -1r : A .J L. i � ► ,r•+ rt 1 S '. �] �'- /1 �_ D .' %J r� r7. ✓✓� � �� : ��j 11 1 � C� � eil S S�� J Tom' n ��^', �,s rA-��.��J .✓�c�prars
S 1--� L � 1l J � � � � ✓1 Q 1- T
J-4-
[a �'�a.l. .lo .� r t ..e •1 .rti. �7 r•'a .. 1 H C ._ J]h... .._1. _%.. _ . I n _ l f y. _ � 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

G s � ..-� � r1� c� i ✓\J �„� ;1 \ 4�aS� �_, i -} � �cl c'� i �•-+ a-.. ��.�.. �q ✓� 1A c � •�-e /- S I "\ P r 2 vYl , ii' _ ; 1, h �' b Cris S P ✓► / �,
,,ti.; \u -,A ,�.: \� �_\S G b c. c h �. �v c_o✓�-� • �-� +-- ti U cl; ---VD Ve
6 a GL t[
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS. ^� `Jb o `'r VQ-�2 �r.3s A S'�✓ v�rS 'c'Scr�, �n -F�
C' o f TD N. P c c t P, c,•S -i`� H C c �- w�L J f s e -% r ��;.D�,.,,CC--..j---i.,.�,.,� `� i �,�/� 1-� c, � � S ©�., f p ✓ li -•�' ,. ,.v,, L � Q it , ,,,,� ,•� ,_,- �, �}-[ r V P /-I tiJj 4S C:,( A "
1a.-�- �� S f1 I� r.�.�� e. S p� ,� l c "� . ►%� c r� ✓� -�(� , P o-f.re v�
'r(�wY�I.IA �In Tp.�t [wl� � � .s �r�� !''ufr�r°-�.4 VA r^ CC14
3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BE FROM THIS PROJECT/PROGRAM: U
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM:
t
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS.

TYN. \V Z'� � : U .� � CLQ S � ice. -ii C &. \ S -, Q 1, A f11 r^ 1 ll �N �C C-L "C A, +' c� ��y� I J�� r f Av�N -1 �'� l !� + c�• r�-� l ` I f' s. �'k-D- 0 I/ , -i - 1 A 1j A i W7 � J s : J +" ✓\ C e- , J j f'c1_M ( ,S'l-1. �'•�. � ya 1a c,. z l, -1 i r ✓� C� e iv, e ,� C c i C-� J S' '. -I c- nC-Q- IQ' ry ^ f,r�c� -i I2 Ti7rhPCc.i�r1 L/e-I Cai
I lrla ry c_1
k�,`tiP�(� l /a �%�liJ i (�r1G' Irt'S C1 �Y ( C r 7 C.✓� i L --+' �` 1 y.-1NC4 lr�L �c1i h L"lAk 'e L) c&S C.� �.-�; �� j �+ '3'r- /• A . ,1C to k-"i 42-- 0Cp f- r - -
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.
i Lv J,Ct - I r-A PAt-,Aer-i('� C✓ P c:. ecJ .,-ssf/e- C / o� i✓) V r r —,6 f- c (A k •r^ S os ki c 1 ' i N n-^a-•nJ ve
nr Q. e- k. y,O,tit Lv-Js •'` -rS
�;"r nJ etc'• Lr � � -}�� ' ..:, n r-I1 i c � J i
�QJ CaiO'.iO�I/ ��`r} KGVl✓1
of ^ Pc� 1 ^ C o r✓, e. V e , I C4 -p, C P � {-v
C�A.v n�C1 -S J- J�iN� 1�1Cr2(
r
a 7 ^ 1 Qr
Cis
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.
� �r`c �� '� � -� rn ,�► � 1 r► �,--� �,.s.r, s� :.� c;z. S „(� � � r^f- G..•� J iCU,] S
c:✓.cl ,v.l,lc !1 ,emu c�_`� ` S ,.,�o pi,lL-.:> c � S ...: �- L... �l s -/ /Y! n k�7��1 � i Y� 1 v �'+2-�[') ..Ll,.r,Jy'i _ l� C�% L 1 � f r'l,W r j �� C L� � ., � c` _ �hi •J nJ ,-}�+ f 1 v`•-� J'C l_�� 1``ci.J'� .�L' r 6/2 ('� lily-1 �, Cj' rL � f r City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)
LINE ITEMS FOR PROJECT/PROGRAM REVENUES 1 EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $
Community Services Grant (Not to exceed $50,000) " C)
Amount contributed to the Project/Program by the Applicant $ Organization
Other grants or funding already awarded for Project/Program, if any $ 1 O , r'-Z�
In -Kind match amount or volunteer credit hours estimated amount $ 1p+ o TOTAL REVENUE $ gU► 0-77

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment $ J DOC>
Facilities/Rent/Insurance $ 191 t M 0
Supplies $
Marketing $
Services $
_
Food
Other $ e nn
(D t w V
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; HOWEVER PLEASE INCLUDE. $ O
TOTAL EXPENSES $
TOTAL BUDGET . n-C) $ �D 613-D
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

Please allow time for checks to be processed.
• The awarding of Community Service Funding does not constitute an automatic annual allocation. • The recognition for Community Service Funding should accrue to the City of Temecula. • Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately. • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds, The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: (—Y\
t��la5al
MAILING ADDRESS: p r<GVti
'r .• w 104 91tir9
PHONE: (911) e p
EMAIL:

PRESIDENT / AUTHORIZED OFFICER: ROev
SIGNATURE: f
DATE: _•_

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:

WOW NA611
IM
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

of the Treasury
raDepartment
Internal Revenue Service
Tax Exempt and Government
Date:

Entities
PO Box 2508
august 20, 2021
>DQ
Cincinnati, OH 4520i
Employer ID number:
37-1841663
Form 990 required:
990, YES
MILVET
Person to contact:
° r R.A%7EN L I IILDEN
Name: S Lenard
ID number: 0203196
30777 RANCHO CALIFORNIA .RD 8925? 1
TFNTF.CULA, CA 925,39
Dear Sir or Madam. -
We're responding to your request dated August 16, 2011. about ,your tax-exempt status.

Wo issued you a determination Ictter in December 2016, recognizing you as tax-exempt under Internal Revenue Codc (IR(-') Section 501(013).

We also show you're not a Private loundation as defined under IRC Section 509(a) hecause you're dcscrihed in IRC Section 509(a)(2).

Donors can dedu,a contributions they make to you as provided in IRC Section 17f1. You're also qualified to recei'Ve tax-deductible bequests, le`��acies, devises, transfers, or gifts under IRCSections 21355, 2 106. and 2522.

In the heading, we indicated whether you must file an annual information return. lt'you're required to I& a return.

Y'ou must li]e one of the following by the 15th day of the 51h month after the end of your annual accounting period. • Form 1990, Return ot'Organizattion Exettapt 17ront Inctrrne Tax . For"' t)t]0-EZ, Snort Form Reta.lrn 01'()rganization Exempt Frorn Incotnc Tax • Form 990-N, Electronic Notice: (e-Poslcard) Im Tax -Exempt Organizations Not Required to File Form 990 or borne 990LZ
. Form 990-PF, Return ul'Private 1,oundation or 5ec:iun 4947,,u1( 1) Trusl `treated as Privire Fsjundution According to IRC Section 6033(j), ifyota don`t file a required annual intiamt;tlion return or notice liar 3 Ceanseculit c }carsa, e'I1 revoke your tax-exe:tnpt status on the due date of the 3rd required return or notice.

You can fact IRS forms or publications you need from our websitc at w w.irs.gw 4ornts-pubs or by calling 800-1 AX- FOR-M (M10-829-3676),
If yuu have questions, call 1107-829-5500 between M a.m. and 5 p,m.. local time. Mouday through Friday (Alaska and IfaWaii li�llow Pacific time).

Thank you for your cooperation.

Sincerely.

Slephen A. Martin
Director, F.zcntpt Organizations Ruling~ and Agreements Later 4168 (Rev. 09-2020)
Cetatog Number 66666G

INTERNAL REVENUE SERVICE

DEPARTMENT OF THE TREASURY
P. 0. BOX 2508
CINCINNATI, OH 45201
Employer Identification Number:

Date: D E C 2 3 2.016
37-1841663
DLN:
26053756003026

VALLEY RESOURCE CENTER
Contact Person:
42097 DAHLIA WAY
CUSTOMER SERVICE ID# 31954
TEMECULA, CA 92591-0000
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
Effective Date of Exemption:

October 28, 2016
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.

Letter 947

-z-

VALLEY RESOURCE CENTER
Sincerely,
Jeffrey I. Cooper
Director, Exempt Organizations
Rulings and Agreements
Letter 947

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
78)
PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 8/22/2022
ESL ID: 8590949861
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 3958913
Entity Name: MILVET
0 1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board. 0 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Important Information
• This information does not necessarily reflect the entity's current legal or administrative status with any other agency of the state of California or other governmental agency or body. • If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).
• The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

Fonn ��Z Short Form OMB No. 1545-0047
Return of Organization Exempt From Income Tax 2021
Under section 501(c), 527, or 4947(a)(i) of the Internal Revenue Code (except private foundations) ► Do not enter social security numbers on this form, as it may be made public. • • ' • • Department of the Treasury •
tntemal Revenue Service ► Go to www.1rs.gov1Form990EZ for instructions and the latest information.

A For the 2021 calendar year, or tax year beginning 01/0112021 and ending 1213112021 8 Check If applicable: 0 Name of organization D Employer identification number ❑ Address change MILVET 37.1841663
❑ Name change Number and street (or P.O. box It mail is not delivered to street address) suite E Te!ephono number ❑ Initial return 30777 Rancho California Rd 892521
Final return/terminated 951-384.0110
Amended return City or town, state or province, country, and ZIP or fomeipn postal code F Group Exemption Applicallen p"dWg Temecula, CA 92589 Number ►
G Accounting Method: r Cash D Accrual Other (specify) ► H Check ► 0 if the organization is not Website: No, www,mlivet.or required to attach Schedule B J Tax-exempt status (check only one) — ID 501 c ❑ 501 c(insert ncLj ❑ 4947 a 1 or ❑ 527 (Form 990).

K Form of organization: ❑✓ Corporation ❑ Trust ❑ Association ❑ Other L Add lines 5b, 6c, and 7b to line 9 to determine gross receipts. If gross receipts are $200,000 or more, or If total assets (Part II, column (B)) are $500,000 or more, file Form 990 instead of Form 990-EZ . . . . . ► g 134,735 Revenue, Expenses, and Changes In Net Assets or Fund Balances (see the instructions for Part 1) Check if the organization used Schedule O to respond to any question in this Part I . . p 1 Contributions, gifts, grants, and similar amounts received . . . . . . . . . 1 134,735 2 Program service revenue including government fees and contracts . . . . . . 2 0 3 Membership dues and assessments . . . . . . . . . . . . . . . . . . . . 3 0 4 Investment income . . . . . . . . . . . . . . . . . . . . . 4 0 5a Gross amount from sale of assets other than inventory . . . . 5a 0 b Less: cost or other basis and sales expenses . . . I 5b 1 0 c Gain or (loss) from sale of assets other than inventory (subtract line 5b from line 5a) 5c 0 6 Gaming and fundraising events:
a Gross income from gaming (attach Schedule G if greater than $15,000) . . . . . . . . . . . . . . . . .I I Ba
0 b Gross income from fundraising events (not including $ 0 of contributions from fundraising events reported on line 1) (attach Schedule G if the sum of such gross income and contributions exceeds $15,000) . 6b 0 c Less: direct expenses from gaming and fundraising events . 6c 0 d Net income or (loss) from gaming and fundraising events (add lines 6a and 6b and subtract line 6c) . . . . . . . . . . . . . . . 6d 0
7a Gross sales of inventory, less returns and allowances . . . . 7a 0 b Less: cost of goods sold . . . . . . . . . . . . . 7b 0 c Gross profit or (loss) from sales of inventory (subtract line 7b from line 7a) 7c 0 8 Other revenue (describe in Schedule O) . 8 0
9 Total revenue. Add lines 1, 2, 3, 4, 5c, Ball, 7c, and 8 . ► 9 134 735 10 Grants and similar amounts paid (list in Schedule O) . . . . . . . . . . 10 0 11 Benefits paid to or for members . . . . . . . , . . , . 11 0 12 Salaries, other compensation, and employee benefits . . . 12 0 w 13 Professional fees and other payments to independent contractors . 13 � a
14 Occupancy, rent, utilities, and maintenance . . . . . . . . . . . . . . . . 14 46,831,723 15 Printing, publications, postage, and shipping . . . . . . • . . . . . . . . 15 2, 723 654
16 Other expenses (describe in Schedule O) .5ee schedule O Statement 1 16 97 028 17 Total ex uses. Acid lines 10 throe h 16 . ► 17 134 236 H 18 Excess or (deficit) for the year (subtract line 17 from line 9) 18 499 H 19 Net assets or fund balances at beginning of year (from line 27, column (A)) (must agree with end -of -year figure reported on prior year's return) . . . . . . . . . . . . . . 19 15,000 Z 20 Other changes in net assets or fund balances (explain in Schedule O) . 20 0 21 Net assets or fund balances at end of year. Combine lines 18 through 20 ■ 21 15,499 For Paperwork Reduction Act Notice, see the separate instructions. Cat. No. 106421 Form 990-EZ (2o21)

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
31 MOTHERHOOD STEPS

CITY OF TEMECULA.

FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 12, 2022

F- PROJECT/PROGRAM INFORMATION
Amount Requested: $
50,000
MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION
Rental assistance and financial program 01/2023 12/2023 Project/Program Title: Start Date: End Date:

Physical Address of Project/Program, 44731 Corte Gutierrez Temecula, CA 92592 INCLUDE IF DIFFERENT THAN ORGANIZATION's MAILING ADDRESS If Grant is Awarded, Make Check Payable to:

Nikia Ellis
Mailing Address: 44731 Corte Gutierrez
Temecula, CA 92592
j ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant
Organization: Motherhood Steps
Website: moth erhoodsteps.org
Number of Paid Staff:

Year Founded: 2021
Social Media: Motherhood steps
Number of Volunteers: 3
Geographic Area(s) the Organization Serves: Temecula CA Geographic Area(s) the Prolect/Program Serves: Temecula CA NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Nikia Ellis
Title/Position: President
858-922-5133 motherhoodsteps2021 @gmail
Contact Person's Direct Telephone: Contact Person's Email:

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes ® Date of Incorporation as a Nonprofit: 10/29/2021 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 87-3493543
State Identification Number: 4805679
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:
1, X❑ Attach IRS Deductibility Status using this link: hM:ll�DsJrs.ctov/app/eos/

2. ® Attach State Entity Status Letter using this link:
https://www.ftb.ca.gov/onlinelself serve entitV status letterlindex.as

3. ❑ Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: http;/lrct.doi.ca _govNerification/Web/Search.asox?facility=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No ® Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ❑ Board of Directors ® Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION
BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES.

Motherhood Steps is dedicated to assiting families in reaching self sufficency by providing an array of resources to further enhance stability within communities.

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No 2 Yes ❑ IF YES, PROVIDE BELOW.

NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT

FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP Target $ 250 06/08/2022 Gift Card
$
$
$
I
$
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM ENTITIES (NOT INCLUDING THE CITY) FOR THE SAME PROJECT/PROGRAM IN THIS APPLICATION? NO ® Yes ❑ IF YES, PROVIDE INFORMATION IN TABLE BELOW.

AMOUNT MONTH + YEAR

RECEIVED NAME OF ENITY

FUNDING RECEIVED
$
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT - RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

The program will aid in housing attainment and sustainability. We porvide necessary assistance to nurture independence an ability to grow and strive in the city of Temecula. 2 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

Housing is fundamental in stability and families being able to provide efficiently for their children to grow in safe and nurturing environments. With the funding we will aid in paying the deposit for rentals then assist with rent with guidance of budgeting to make them financially aware of paying rent and other household obligations, so they are still living independently in a safe, clean, and stable environment together as a family.

We will be providing books for fiancial, budgeting and credit class. We also have created a financil assistant power point for our class we will be providing to clients. we will be needing paper, ink file folders and marketing brochures we also will be marketing on our website. 1 3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

R EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

The residents will not have to relocate out of the city and still feel successful knowing they have a place to call home. It is even more stressful having to make such a big move leaving a city you already have roots in or have begun to root. The grant will help give families the relief they need while keeping Temecula thriving with the love and hope of its citizens. 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 1-15 FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 3 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
4 SUMMARY STATEMENT — SUMMARIZE ANSWERS 1 — 3 ABOVE IN 50 WORDS OR LESS.

If awarded the grant, our organization will aid Ternecula families with housing attainment and sustainability to nurture the health and stability of daily living. 5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

Motherhood Steps was born in 2021, still amidst the pandemic. It was painfully evident of the effects of the Temecula citizens. Increasing in rapid numbers, more and more families have begun facing the seriousness of homelessness. We want to fill that need but with tight budgets of other families trying to stay above water themselves, donations have been low only allowing us to serve families with basic needs such as food and diapering needs. With this grant we will be able to relieve much needed recipients of the burden of possibly living on the streets by helping them attain and maintain housing.
6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

Being awarded this grant will give us ample opportunity to assist those in financial hardships associated with housing.Our program is still in its infant stage and with proper funding we can grow into fulfilling our vision of bringing stability within the community.

Providing rental assistance coupled with budgeting courses is our approach to guide citizens from homelessness towards a self-sufficient lifestyle.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET (do not fill in shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM

REVENUES

EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $
Community Services Grant (Not to exceed $50,000) 50,000 { Amount contributed to the Project/Program by the Applicant $ Organization
0 Other grants or funding already awarded for Project/Program, if any $ 0 In -Kind match amount or volunteer credit hours estimated amount $ 43,200

TOTAL REVENUE
$ 95,700

LIST OF EXPENSES FOR PROJECT/PROGRAM
Tools/Equipment $ 0
Facilities/Rent/Insurance $ 0
Supplies $ 1,036
Marketing $ 417
Services
$ 48,547
Food
0 Other
_
$ 0
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; $

HOWEVER PLEASE INCLUDE,
O
$ 50,000

TOTAL EXPENSES

TOTAL BUDGET
$
$ 50,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

PREVIOUS' FISCAL YEAR (FY) 2021-2022 COMPLIANCE REPORT
*IF YOUR ORGANIZATION WAS NOT AWARDED A COMMUNITY SERVICE FUNDING GRANT IN FY 21122 (LAST YEAR), THEN SKIP THIS PAGE.

If your organization was awarded a Community Service Funding Grant in FY 2021-2022 (last year) by the City of Temecula, please submit this information.

1. Fill out table below (make additional copies if needed to explain all expenditures.)

2. Attach copies of receipts/invoices (in the same order as listed in this table.)

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590 Attn: City Manager's Office — CSF EXPENDITURE REPORT due on or before September 12, 2022
I
Organization: Name of Project/Program:

FY 2021-2022 Amount of $
CSF Grant Fund Awarded: Month $ Year CSF Grant Received from City:

Number of Beneficiaries Living In 92590, 92591, 92592 that Directly Benefltted from this Program/Project (approximate number of beneficiaries if you do not have precise number):

Ex enditure
Name of Company Date on I
E ;, p y Receiptlinvoice
E on Receipt or Invoice MUST BE ON OR BETWEEN Amount Description Purpose a2 JULY 1, 2021 - JUNE 30, 2022 DESCRIBE THE EXPENDITURE PURPOSE OF EXPENDITURE i
6 I

EXPENDITURE TOTAL
I

EXPENDITURE TOTAL MUST BE EQUAL TO
(OR GREATER) THAN TOTAL AWARD AMOUNT
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 11 of 13

If your organization is awarded a Community Service Funding Grant - REINVESTMENT IN TEMECULA in FY2022-2023 by the City of Temecula, all grant funds received must be expended anytime on or between March 20, 2020 and June 30, 2024. In addition, all grant funds must be substantiated with proper back-up documentation. Failure to provide proper documentation may jeopardize any funding. City of Temecula reserves the right to conduct an audit and/or require additional back-up information to substantiate how funds received from the City were spent. If the funds are not spent in accordance with the approved/awarded application, the organization may not receive and/or will be required to return said amount of funds to the City, To substantiate that grant funds from the City are spent appropriately, proper back-up documentation including the table below with accompanying receipts/invoices, must be submitted to the City as outlined on this page.

1. Fill out Expenditure Report table below. Make additional copies if needed to explain all expenditures.

A. If awarded $5,000. Submit the following Expenditure Report within 60 days after spending $5,000 no later than June 30, 2024, to demonstrate grant funds were spent in accordance with the Application. [If you were awarded less than $5,000, submit Expenditure Report for that amount.)
B. If awarded grant funds exceeding $5,000. A) Follow #1.A above first. B) To receive grant funds exceeding $5,000 (between $5K-$50K), submit the following Expenditure Report to be reimbursed for the remaining balance of award to demonstrate funds were spent in accordance with the Application. This report can be submitted in $10,000 increments (but no less than $10,000 unless the remaining grant award funding amount is less than $10K). This report must be submitted to the City no later than June 30, 2024 to receive remaining grant funds.

2. Attach copies of receipts/Invoices (in the same order listed in table below).

3. Send to: City of Temecula, 41000 Main St., Temecula, CA 92590, Attn: City Manager's Dept. "CSF-Reinvestment In Temecula" Organization:

EXPENDITURE REPORT DATED
Name of Project/Program:

TOTAL FY 2022-2023 Month & Year FIRST $5,000 check
Amount of Grant Fund Awarded: $ was received from City:

1. Is this Expenditure Report Is to provide documentation for first $5,000 awarded and received? Yes_ or No (already submitted).

2. My organization has already received E of the total FY 2022-23 Grant Fund awarded by the Clty

3. Is this Expenditure Report is submitted to request reimbursement of funds? No or Yes If yes, Amount of Request $ Number of beneficiaries living In 92590, 92591, 92592 that directly benefitted from this Program/Project (approximate number of beneficiaries if you do not have precise number) Date on
E Name of Company Receipt/Invoice
u E on Receipt or Invoice MUST BE ON OR BETWEEN
go March 20, 2020 - JUNE 30,
Q z 2024

EXPENDITURE TOTAL
Expenditure

MUST SUPPORT PROJECT/PROGRAM IN APPLICATION & AWARD LETTER Amount I Description

EXPENDITURE TOTAL
Purpose
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 12 of 13

Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement. • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: Motherhood Steps
MAILING ADDRESS:
44731 Corte Gutierrez
Temecula, CA 92592
PRESIDENT/AUTHORIZED OFFICER: Nikia Ellis
SIGNATURE: N-.�

IF DIFFERENTTHAN ABOVE,
APPICATION PREPARED BY:

PHONE: (8g) _922-5133
EMAIL:

DATE: 08/22/2022
N!()N1 H, _:1AY Y[A.2
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
(,FT B PO BOX 942857
SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 8/22/2022
ESL ID: 8239891442
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter Entity ID: 4805679
Entity Name: MOTHERHOOD STEPS
❑X 1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board. ❑ 3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 . ❑ 4. We do not have current information about the entity. ❑ 5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

of the Treasury
jrjDepartment
Internal Revenue Service
Date:
02/16/2022
Tax Exempt and Government Entities
rIDQ P.O. Box 2508
Employer ID number:

Cincinnati, OH 45201
87-3493543
Person to contact:

Name: Customer Service
ID number: 31954
Telephone:877-829-5500

MOTHERHOOD STEPS
Accounting period ending:
44731 CORTE GUTIERREZ
December 31
TEMECULA, CA 92592
Public charity status:
509(a)(2)
Form 9901990-EZ 1990-N required:

Yes
Effective date of exemption:

October 29, 2021
Contribution deductibility:

Yes
Addendum applies:

No
DLN:
26053749002581
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.

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.

Sincerely,
-a rc 4 . ` z ,tti_
Stephen A. Martin
Director, Exempt Organizations
Rulings and Agreements
Letter 947 (Rev. 2-2020)
Catalog Number 35152P

I� i �'I i'.E'. . i I •iE ' �I .,,1 ', , i '. ; I .. I 'E � i •:I . I , ,
-
Organization Name:

MOTHERHOOD STEPS IRS FEIN:

Entity Type:

Public Benefit SOS/FTB Corporate/Organization Number: 4805679 Registry Status:

Not Registered Renewal Due/Exp. Date:

RCT Registration Number:

Issue Date:

Record Type:

Charity Registration Effective Date:

Date of Last Renewal;
DBA:
a g Ad d res.,-v
Street:
44731 CORTE GUTIERREZ
Street Line 2:

City, State Zip:

TEMECULA CA 92592
o ,,^
ke
No Related Documents
nuall Renewal Data
No Annual Renewal Data
Related ��.,::g s ratg0ns & Event ie
s,
Arl
No Related Records

From: Nikia Ellis
Sent: Friday, September 9, 2022 11:59 AM
To: Stacey Brown
Subject: 990 form letter
CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.

Hello I'm Nikia Ellis the President of motherhood steps noprofit organization We did not file a 990 form this year this will be our first full year serving the community. If you have any questions please contact me.

Thank you
From: Nikia Ellis
Sent: Thursday, September 8, 2022 8:34 PM
To: Stacey Brown
Subject: Application corrections
Attachments: 01-Policy-and-Application-2022-2023-74-FILABLE (1).pdf CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe.

Good evening I was able to correct the first page of the application. I read the funded one very carefully and I am not being funded by any other entity for this program I have received $250 gift card to help a mother in need in June of this year but it was not for this program. Can you let me know if I still need to fill that out thank you.

FY 2022/2023

COMMUNITY SERVICE FUNDING

REINVESTMENT IN TEMECULA
GRANT APPLICATION #
32 MY SISTER'S KEEPER
SUCCESS INSTITUE INC.

CITY OF TEMECUTA
FISCAL YEAR 2022.2023

COMMUNITY SERVICE FUNDING - REINVESTMENT IN TEMECULA

PROGRAM APPLICATION
(Please Print or Type)
DUE ON OR BEFORE: MONDAY, SEPTEMBER 1 2, 2022

PROJECT/PROGRAM INFORMATION
Amount Requested: $ 35,000 MAXIMUM ALLOWABLE: $50,000 PER ORGANIZATION Math Genius Program - Math
Project/Program Title: Tutoring Start Date: Jan 2023 End Date: Dec 202:

Physical Address of Project/Program: Local Schools Participating in TVUSD

INCLUDE IF DIFFERENT THAN ORGANIZATION'S MAILING ADDRESS If Grant is Awarded, Make Check Payable to: My Sister's Keeper Success Institute, Inc.

Mailing Address: 41765 Rider Way
Temecula, CA 92590

ORGANIZATION AND GEOGRAPHIC AREA SERVED
Name of Applicant My Sister's Keeper Success
pp Institute, Inc. 2017
Organization: Year Founded:

Website: www.msksi.com Social Media: @msksiinc (FB, Twitter, IG) Number of Paid Staff: 0
Number of Volunteers: 15
Geographic Area(s) the Organization Serves: SW Riverside County Geographic Area(s) the Project/Program Serves: Temecula, CA NOTE: COMMUNITY SERVICE FUNDING GRANT PROGRAM FUNDING MUST BE EXCLUSIVELY USED TO SERVE TEMECULA.

Contact Name: Kristen Newsome Title/Position: Executive Director Contact Person's Direct Telephone: 760-613-1062 Contact Person's Email: kristennewsome@tusks

NONPROFIT STATUS
Is this organization incorporated as a nonprofit? Yes Date of Incorporation as a Nonprofit: 5-15-17 No ❑ IF NO, THEN INELIGIBLE TO RECEIVE CITY FUNDING
Federal Identification Number: 82-1665289
State Identification Number: C4025912
PRINT OUT AND ATTACH TO THIS APPLICATION VERIFICATION FROM FEDERAL (IRS) AND STATE (FTB) AS FOLLOWS:

1. ❑■ Attach IRS Deductibility Status using this link: http://apps.irs.gov/app/eos/

2. M Attach State Entity Status Letter using this link:
https://www.ftb.ca.govtonline/self serve entity status letter/index.as

3. N Attach first page only of most recent IRS Form 990 or attach print out of detailed info about your charity found on this State Registry's Search Tool: http:t/rat.doj.ca.govlVerificationfWeb/Sepreh.asox?facility=Y City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 5 of 13

APPLICATION AUTHORIZATION
Has the organization or any members of the Board of Directors of the organization been involved with any personal business transactions valued over $500 including any business transactions, negotiations, investments, or interests in real property with a Temecula City Council Member during the past 12 months? No C7 Yes ❑ IF YES, BRIEFLY DESCRIBE:
i
Is a Temecula City Council Member a member of the Board of Directors or an Officer of the organization? No I11 Yes ❑ IF YES, PROVIDE COUNCIL MEMBER'S NAME AND TITLE WITHIN THE ORGANIZATION:

This Application has been authorized by the organization's:

Executive Committee ■0 Board of Directors ❑ Members -at -Large ❑

MISSION STATEMENT OF ORGANIZATION

BRIEFLY DESCRIBE THE ORGANIZATION'S MISSION/GOALS AND OBJECTIVES, Mission: We inspire girls and young women and those who are historically the most underrepresented in STEM and business ownership to become confident, bold world changers through STEAM & Career Mentoring and Personal Development Programs.

Our programs support students to:

Develop leadership skills
Build their confidence
Practice problem solving
Build critical thinking skills
Build their communication skills
Gain an interest in pursuing STEM and/or entrepreneurship Increase their knowledge about STEM and/or entrepreneurship and how to pursue those careers

FINANCIAL STATEMENTS

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 6 of 13

I_ FUNDING SOURCES
CITY OF TEMECULA—SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

CONCURRENTLY REQUESTING) ANY OTHER SOURCES OF FUNDING FROM THE CITY FOR ANY PROGRAM? No Ir Yes ❑ IF YES, PROVIDE BELOW.
f NAME OF PROGRAM/PROJECT AMOUNT MONTH + YEAR NAME OF CITY GRANT !I FUNDED BY THE CITY GRANT OR SPONSORSHIP FUNDING RECEIVED OR SPONSORSHIP i
i
I
$
OTHER OUTSIDE SOURCES —SINCE MARCH OF 2020, HAS THIS ORGANIZATION RECEIVED (OR IS

AMOUNT Y MONTH + YEAR

NAME OF ENITY

RECEIVED FUNDING RECEIVED
$
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 7 of 13

GRANT PROJECT/PROGRAM DESCRIPTION

IMPORTANT -RECEIPTS/INVOICES IS REQUIRED TO BE SUBMITTED TO THE CITY TO VALIDATE THE ORGANIZATION SPENT GRANT

FUNDING AWARDED BY THE CITY TO SUPPORT THE PROJECT/PROGRAM AS DESCRIBED HERE 1 DESCRIBE THE PROJECT/PROGRAM THE TEMECULA GRANT FUNDING WILL SUPPORT.

The Math Genius Program is an Afterschool Expanded Learning Opportunity that will be instrumental in supporting Temecula's most vulnerable students whose 'CAASPP assessments are currently less than proficient in Math, to increase their proficiency. This is an expansion of the current online program that will be piloted to families in TVUSD and can include multiple children per household. The program combines mentoring and tutoring, as well as SEL coaching, extends instructional learning time, accelerates progress to close learning gaps, establishes community learning hubs, gives access to additional academic 12 DESCRIBE HOW THE ORGANIZATION WILL SPEND THE GRANT FUNDING, IF AWARDED.

ALSO, INCLUDE A LIST OF GOODS, EQUIPMEMENT, AND/OR SERVICES THIS ORGANIZATION HAS PURCHASED OR PLANS TO PURCHASE WITH AWARDED FUNDS TO SUPPORT THIS PROGRAM/PROJECT.

Grant funding will be spent to establish a pilot math tutoring hub at participating TVUSD middle and high schools.

Purchases will include the following for each tutoring hub:

1. Training for tutors/participating teachers
�2, Family coaching and curriculum materials

3. Insurance

4. Online curriculum (at home)

5. Meals/Snacks

6. LPriatina
3 TEMECULA RESIDENTS MUST BENEFIT FROM THIS PROGRAM/PROJECT IF AWARDED CITY FUNDING.

EXPLAIN HOW THIS GRANT FUNDING SPECIFICALLY BENEFITS TEMECULA RESIDENTS.

Mathematics is a foundation of STEM learning and includes content and thinking that can be used as tools for tackling integrative STEM problems. Expanding this program in Temecula schools will create a consistent hub of support in the community and provide necessary tutoring, mentoring, and support to improve student outcomes and interest, so that performance gaps are addressed and an increased population of students can widen their opportunities to participate in STEM related careers and higher education, which will ultimately create a stronger, more highly skilled and prepared workforce in Temecula. 3b ESTIMATED NUMBER OF PEOPLE FROM TEMECULA EXPECTED TO BENEFIT 500+ I FROM THIS PROJECT/PROGRAM:
3c ESTIMATED NUMBER OF VOLUNTEERS INVOLVED IN THIS PROJECT/PROGRAM: 1�0 City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 8 of 13

PROJECT/PROGRAM DESCRIPTION

CONTINUED
14 SUMMARY STATEMENT - SUMMARIZE ANSWERS 1 - 3 ABOVE IN 50 WORDS OR LESS.

MGP will support Temecula's most vulnerable students to gain proficiency in math. Grant funding will be spent to establish two math tutoring hubs and provide online curriculum and training accessible to households. This creates a consistent hub of support in the community and improves the workforce readiness of Temecula residents.
5 IF APPLYING FOR MORE THAN $5,000, PLEASE EXPLAIN HOW THE COVID-19 PANDEMIC

AFFECTED THIS NONPROFIT ORGANIZATION'S ABILITY TO SERVE THE TEMECULA COMMUNITY. YOU MAY ALSO INCLUDE INFLATIONARY CONCERNS.

COVID-19 impacted our ability to serve the Temecula community because of the reduction in our volunteer staff, strained operating budgets and extreme competition for charitable funding for nonprofits, which directly impacts our ability to expand services. Many families have also experienced economic and personal hardships that impacted their ability to afford extracurricular programs. 'Inflationary concerns further exacerbate the issue and our nonprofit organization has to do more to address growing needs of students emerging from a pandemic, with less revenue to cover costs to perform services, and decreased staff. Space rental prices are increasing, gas costs are prohibitive for some parents to continue with in person programminq not hosted at their child's school. 6 IF APPLYING FOR MORE THAN $5,000, EXPLAIN HOW FUNDS HAVE OR WILL:
(1) CREATE NEW PROJECT/PROGRAM, (2) EXPAND EXISTING PROJECT/PROGRAM, AND/OR (3) CONTINUE EXISTING PROJECT/PROGRAM.

With receipt of grant funding, we will expand our program beyond 100% virtual participation to a hybrid program with 2 community hubs at a participating Temecula schools that will include both online instruction, in -person mentoring and tutoring, and family support services and coaching to ensure parents are partnering in their child's success. Funds will support duplicating the program at two locations with virtual programs and parent coaching support.

City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 9 of 13

PROJECT/PROGRAM BUDGET ado not fill In shaded areas)

LINE ITEMS FOR PROJECT/PROGRAM REVENUES I EXPENSES

LIST REVENUES/INCOME FOR PROJECT/PROGRAM
Amount of money requested from this City of Temecula $ 35,000 Community Services Grant (Not to exceed $50,000)
Amount contributed to the Project/Program by the Applicant $ 25,000 Organization I
� Other grants or funding already awarded for Project/Program, if any $ 0 In -Kind match amount or volunteer credit hours estimated amount $ 42,400 TOTAL REVENUE $ 102,400

LIST OF EXPENSES FOR PROJECT/PROGRAM
Online family curriculum, ipads, hotspots, f
Tools/Equipment portable speakers, Zoom upgrade
Facilities/Rent/Insurance
Supplies Printing, mini whiteboards, markers, paper, etc.

Marketing Peachjar Marketing to TVUSD
Services Tutor/Teacher Training & Parent Coaching
Food
Other
Staffing Expense THIS IS INELIGIBLE TO BE FUNDED BY CITY'S GRANT; ' HOWEVER PLEASE INCLUDE.

TOTAL EXPENSES I
TOTAL BUDGET $102,400
$45, 800
$ 1,000
$ 3,200
$ 15000
$ 81000
$ 91000
$ 11000
$0
$69,000
$69,000
City of Temecula Community Service Funding - Reinvestment in Temecula GRANT APPLICATION Page 10 of 13

ACKNOWLEDGEMENT/SIGNATURE PAGE
The applicant acknowledges and agrees to the following:

Recipient is subject to all Community Service Funding Program requirements including submittal deadlines and payment disbursements.
• Every Community Service Funding application is considered individually and on its own merit. ■ Awards will be given to organizations and activities that directly benefit the residents of Temecula. • Funding is not immediately available to the recipient, and requires an award letter signature upon approval.

Please allow time for checks to be processed.

The awarding of Community Service Funding does not constitute an automatic annual allocation.

The recognition for Community Service Funding should accrue to the City of Temecula. ■ Community Service Funding must be spent as specified on the Application and records may be requested by the City of Temecula to ensure the funds were used appropriately, • Community Service Funding grants will not be awarded or announced within the 60 days before an election in which an awarding Council Member is on the ballot.
• The recipient shall provide a full accounting with documentation on the use of awarded funds. The recipient shall return to the City any funds not spent or documented per the signed agreement, • If awarded a Community Service Funding Grant by the City of Temecula last year, then compliance receipts must be submitted on or before this application's due date or this application may be rejected as incomplete.

I/we hereby certify the information contained in this Application is true to the best of our knowledge and belief.

ORGANIZATION NAME: My Sister's Keeper Success Institute, Inc.

MAILING ADDRESS: 41765 Rider Wy _ PHONE: (951 ) 290-8442 Temecula, CA 92590 EMAIL: [email protected]
PRESIDENT/AUTHORIZED OFFICER: Kristen Newsome Executive Director 'WNT NAME TITLE
SIGNATURE: DATE:
9/5/2022
P/10N I, H, DAY, YEAR

IF DIFFERENT THAN ABOVE,
APPICATION PREPARED BY:
iNl NAM,' TITLE
SUBMIT ORIGINAL APPLICATION BY MONDAY, SEPTEMBER 12, 2022, TO:

STATE OF CALIFORNIA

FRANCHISE TAX BOARD
F T B y' PO BOX 942857
`111� SACRAMENTO CA 94257-0540
Entity Status Letter
Date: 9/7/2022
ESL ID:2683468917
Why You Received This Letter
According to our records, the following entity information is true and accurate as of the date of this letter.

Entity ID: 4025912
Entity Name: MY SISTER'S KEEPER SUCCESS INSTITUTE, INC.

FZ1. The entity is in good standing with the Franchise Tax Board. ❑ 2. The entity is not in good standing with the Franchise Tax Board.

3. The entity is currently exempt from tax under Revenue and Taxation Code (R&TC) Section 23701 d,

4. We do not have current information about the entity.

5. The entity was administratively dissolved/cancelled on through the Franchise Tax Board Administrative Dissolution process.

Important Information
• This information does not necessarily reflect the entity's current legal or administrative status with any other agency of the state of California or other governmental agency or body. • If the entity's powers, rights, and privileges were suspended or forfeited at any time in the past, or if the entity did business in California at a time when it was not qualified or not registered to do business in California, this information does not reflect the status or voidability of contracts made by the entity in California during the period the entity was suspended or forfeited (R&TC Sections 23304.1, 23304.5, 23305a, 23305.1).
• The entity certificate of revivor may have a time limitation or may limit the functions the revived entity can perform, or both (R&TC Section 23305b).

INTERNAL REVENUE SERVICE
P. O. BOX 2508
CINCINNATI, OH 45201

DEPARTMENT OF THE TREASURY
Date. MAY o 1201E

MY SISTERS KEEPER SUCCESS INSTITUTE
INC
35130 GOLDTHREAD LANE
MURRIETA, CA 92563
Dear Applicant:

Employer Identification Number:
82-1665289
DLN:
17053363310037
Contact Person:

MRS. JOHNSON ID# 31287
Contact Telephone Number:
(877) 829-5500
Accounting Period Ending:

December 31
Public Charity Status:
170(b) (1) (A) (vi)
Form 990/990-EZ/990-N Required:

Yes
Effective Date of Exemption:

May 15, 2017
Contribution Deductibility:

Yes
Addendum Applies:

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 an addendum applies, the enclosed addendum is an integral part of this letter.

Letter 947

-1-

MY SISTERS KEEPER SUCCESS INSTITUTE
Sincerely,
Director, Exempt Organizations
Rulings and Agreements
Letter 947

Form 990-EZ
Short Form OMB No. 1545-0047
Return of Organization Exempt From Income Tax 2021
Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) ► Do not enter social security numbers on this form, as it may be made • ' ' ' Department of the Treasury
Intemal Revenue Service
public.
► uv
Go to ww.f►s gov/Form990EZ for instructions and the latest information.

Temecula City CouncilNovember 15, 2022

Temecula City Council
November 15, 2022