Fillable Special Assistance Funding Application (Triadex Services)

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Special Assistance Funding Application (Triadex Services)

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69-825 HIGHWAY 111 / RANCHO MIRAGE, CA 92270 / (760) 324-4511
Special Assistance Funding Application
NOTE: Please read the City of Rancho Mirage Special Assistance Funding Guidelines prior to completing this application.
Organization:
Address:
Contact Person:
Title: Phone:
Address of Contact Person (If different):
Number of Years Organization has served the Coachella Valley:
Attach a cover letter identifying the project/activity, funding request amount and how funds will
be used.
Name of Project and/or Activity to be considered for Funding:
1. What is the amount of funding request from the City of Rancho Mirage? ____________
2. What is the location of proposed project/activity and any specific benefit of the project/activity to
Rancho Mirage? (
Indicate if location is confidential for protection of your clients.)
___________________________________________________________________________.
1. Provide specific client information based on last year’s client participation.
(N/A if no information available from last year.)
Total number of clients served in 2020/2021 that lived in Rancho Mirage.
Total number of clients to be served by proposed project in 2021/2022.
Complete this section only if the funding request is over $5,000.
Section I - Project Summary:
Section II - Participation Statistics:
Section III - Financial Information:
69-825 HIGHWAY 111 / RANCHO MIRAGE, CA 92270 / (760) 324-4511
1. What is the total 2021/2022 Budget for your Organization? ________________________
2. Provide a listing of other sources of funding (i.e. private, community or individual contributions)
for this project. Also provide a percentage of each contribution toward the total cost of the
project.
(N/A if no other funding sources)
Funding Source How Much
Requested
($)
How Much
Committed
($)
If the applicant is awarded the funding, applicant agrees that it shall, at its sole cost, defend,
indemnify and hold harmless the City, its agents, officers, and employees, against any and all
actions, suits, proceedings, claims, demands, losses, injuries (including wrongful death), judgments
and costs and expenses, including settlement costs, legal costs and attorneys’ fees, resulting from
any legal action or proceeding initiated by any individual or entity arising out of or resulting from, or
otherwise in connection with, any act or omission of applicant, its employees, agents, volunteers or
independent contractors, in carrying out the purposes for which applicant was given the
funding. Without limiting the generality of the foregoing, the protections afforded to the City
hereunder shall also extend to any damages, loss or liability arising from any failure to pay federal
or state prevailing wages. The City shall notify applicant of any claim, action or proceeding as soon
as practicable after receiving notice of any of such claim, action or proceeding, and the City shall
cooperate in any defense. Moreover, although applicant would be considered the real party in
interest in any claim, action or proceeding, the City may, at its sole discretion, participate in the
defense of such claim, action or proceeding, but under no circumstances shall such participation
relieve applicant of any obligation herein.
______________________________ ________________
Signature/Title Date
Organizations which receive SAF funding are absolutely prohibited from directly or indirectly
participating in, or intervening in, any political campaign on behalf of (or in opposition to) any
Section IV – Indemnity:
Section V – No Participation in
Political Activities:
69-825 HIGHWAY 111 / RANCHO MIRAGE, CA 92270 / (760) 324-4511
candidate for elective public office. Contributions to political campaign funds or public statements of
position (verbal or written) made on behalf of the organization in favor of or in opposition to any
candidate for public office clearly violate the prohibition against political campaign activity. Violating
this prohibition may result in denial or refund of SAF funds. In addition, voter education or registration
activities with evidence of bias that (a) would favor one candidate over another; (b) oppose a
candidate in some manner; or (c) have the effect of favoring a candidate or group of candidates,
constitute prohibited participation or intervention.
______________________________ ________________
Signature/Title Date
Each organization which applies for SAF funding represents that it is an equal opportunity employer
and shall not discriminate against any subcontractor, employee, or applicant (“Person”) for
employment because of race, color, ancestry, national origin, religion, creed, age (over 40), mental
or physical disability, sex, gender, sexual orientation, gender identity, gender expression, medical
condition, genetic information, marital status or military and veteran status. Unless otherwise
permitted under the law, such organization shall not refuse to hire or employ any such Person or
refuse to select any such Person for a training program leading to employment, or bar or discharge
any such Person from employment or from a training program leading to employment, or otherwise
discriminate against any such Person in compensation or in terms, conditions, or privileges of
employment.
______________________________ ________________
Signature/Title Date
The foregoing information is true and correct to the best of my knowledge. I understand that any
false or misleading information will disqualify this application for consideration of special assistance
funding.
Signature/Title Date
Return the completed application and cover letter to the City of Rancho Mirage for consideration of
funding for FY 2021/2022. Please do not reproduce application or a new application will have to be
completed. Extra copies of the application are not necessary. Special Assistance Funds (SAF)
information is available on the City’s website at www.ranchomirageca.gov, under the Quick Link,
Non Profit Funding page.
If you have any questions regarding the SAF Program or the SAF Application, please call Gloria Griego,
Sr. Management Analyst at (760) 324-4511 Ext. 265, mobile phone (760) 404-9872, or by email at
gloriag@ranchomirageca.gov.
Updated 08-02-21
Section VI – No Discrimination:
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Completed 9 August 2021

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