Fillable Agua Caliente Band of Cahuilla Indians &KDULWDEOH Application

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Agua Caliente Band of Cahuilla Indians &KDULWDEOH Application

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Requests require a
30 day or more
advance notice
For Office Use Only:
Application No. _________________
Date of Application: _________________
Please submit application to:
Agua Caliente Band of Cahuilla Indians
ATTN: Charitable Donations Department
5401 Dinah Shore Drive
Palm Springs, CA 92264
Agua Caliente Band of Cahuilla Indians – &KDULWDEOH Application
__________________________________________________________________________
Organization Information
Legal Name of Organization Applying: __________________________________________________________________________
(Should be same as on IRS determination letter and as supplied on IRS Form 990)
Principal Address: __________________________________________________________________________________________________
City: ______________________________________________ State/Prov: ______________________ Postal Code: ____________________
Mailing Address: ______________________________ City: ____________________ State/Prov:__________ Postal Code: _______________
(If different from Principal Address)
Phone Number: _________________________ Fax Number: _______________________ E-Mail: ___________________________________
Website:_________________________________________________ Executive Director/CEO: ______________________________________
Contact Person/Title
(if different from Executive Director): ________________________________________________________________________
□ Organization is tax-exempt under IRS Code 501 (c) ___ (please fill in section number and attach copy of determination letter)
Federal Tax ID# ________________________________________ Year Organization Founded: _______________________
□ Organization is a non-governmental organization (NGO); if outside the U.S. please attach copy of certification letter
Date of Organization’s Fiscal Year: __________ to ____________. Total operating budget for current year: $ __________________________
Program Area Served (check only one box)
□ Education □ Civic & Community □ Arts & Culture □ Health & Human Services
Geographical Areas Served (check all that apply):
□ Palm Springs □ Rancho Mirage □ Cathedral City □ Desert Hot Springs
□ Palm Desert □ Thousand Palms □ Indio □ Indian Wells □ Other (Please specify): _____________________________________
Estimate number of people actively involved in organization as board/executive members_______; volunteers ______; employees ________.
Are you a United Way Agency? Yes
□ No□ If yes, current allocation: ______________________________________________________
Have you submitted any requests to ACBCI in the last 12 months? Yes
□ No□
Has the ACBCI previously donated to your organization? Yes
□ No□ If yes, please provide history including year, amount, purpose/project:
Date: ______________ Amount: $________________ Purpose/Project: ____________________________________
Date: ______________ Amount: $________________ Purpose/Project: ____________________________________
Page 1 of 2
Donation Request Instructions
Please answer all questions with complete information.
Project/Program/Event Title: __________________________________________________________________________________________
Type of Project: ● Event/Sponsorship
□ ● Program □ ● General Financial Support □ ● Special Need □ Ɣ2WKHU
Date of Event: ____________________________ Location of Event: _____________________________________________________
Total Project/Program/Event Cost: $___________________ Request Amount: $_______________ Amount Raised to Date: $______________
Deadline by which the ACBCI must commit in order to be listed as a sponsor in all printed materials: __________________________________
Please state how the funds will be directed, should the ACBCI fulfill your request: _________________________________________________
__________________________________________________________________________________________________________________
If the ACBCI fulfills your request, will you be able to provide data of results, and how the money was spent? Yes
□ No□
Please attach the following information:
One page event/project budget
Source of other funds to support this project
Objectives of project to be funded
Signatory Information
It is fully understood that this donation and / sponsorship is not an admission of any liability, and that ______________
___________________________________ is fully responsible for, and shall indemnify and hold Agua Caliente Band of Cahuilla
Indians harmless for and against any liability or claim arising from the above described event. I have read and understood the
foregoing.
Authorized Signature: _______________________________________________________________________
Type/print name and title: ___________________________________________________________________
www.aguacaliente-nsn.gov
Page 2 of 2
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Agua Caliente Band of Cahuilla Indians &KDULWDEOH Application

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Completed 3 September 2020

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