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
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome