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Boca Raton's Promise - Com. Fitzpatrick 0 FORWARD CHECK. CITY OF BOYNTON BEACH DIRECT PAYMENT REQUISITION Please issue a check in the amount of $ 200.00 . TO: BOCA RATON'S PROMISE-THE ALLIANCE FOR YOUTH, INC 6300 PARK OF COMMERCE BLVD BOCA RATON FL 33487 FOR: To assist with costs associated with the purchase of business cards& printed presentation folders for networking, conversations, workshops and events; printed letterhead and envelopes, copying and office supplies and two Mental Health First Aid Training sessions (Commissioner Fitzpatrick's Community Support Funds) Requested By: Janet M. Prainito Date: September 22, 2015 Approvals: FUND DEPT•BASIC ELE OBJ AMOUNT 001 1110 511 95 47 200.00 Div Head tin • net M. Prainito Finance Dept. Tim Howard I City Manager Lori LaVerriere 200.00 R15-055 EXHIBIT "A" COMMUNITY SUPPORT FUNDS REQUEST FORM Part I - Summary of Request (to be completed by City Clerk) Date of Request: 5 P,zio Requested by by Mayor/Commissioner: r a4-T4ick. Amount Requested: $ Recipient/Payee: I4g9iom!4 iateptivi he,jfah ODA Description of project, program, or activity to be funded: Part II - Availability of funds The annual appropriation of funds available to the requesting Member of the Commission listed above is $,206-p.` The balance of funds available for the requesting Member of the Commission is $/Socetl . Accordingly: EV-There are funds available as requested ID There are insufficient funds available as requested Dated: 4///0/S. By: City Clerk , beev/7 Part III-Eligibility Evaluation "Public funds will not be used to improve private property unless there is a clear public need, purpose and benefit VjThe recipient/payee provides services within the City 'ion Dated: public purpose is beneficial to the entire comm lity served by such d• dr Dated: II 2©i By: ' 4 Requesting Member of the City Commission S:\CC\WP\COMMUNITY INVESTMENT FUNDS\Community_Support_Funs_Policy.2015.doc I • 4064,, :4) .'--wnr • _-•� Boynton Beach Mental Health Committee (BBMHC) ' Budget Narrative . On July 1, 2015, the BBMHC completed its first full year of existence and accomplishments. The primary focus has been to build capacity for an Education and Awareness campaign. This involved ' creating a marketing brand, building relationships with Boynton Beach Community High School and community organizations, meeting with community leaders, creating and copying special handouts,conducting community conversations,working on a website,etc. The cost of copying material and buying notebooks, folders and other supplies has been modest , during this period. We have appreciated the support of the Boynton Beach Mental Health Initiative (BBMHI) in covering the cost of copying and supplies, as well as support from other organizations who have provided generous in-kind services. Boca Raton's Promise has supported BBMHI as one of the early mental health community grass rood efforts. A major focus for year 2 is to expand Education and Awareness outreach to existing and new partners,conduct community conversations and promote Mental Health First Aid (MHFA)training in the community. It is essential for BBMHC to have professional marketing materials and the resources to copy sizeable quantities of educational information to support this effort and purchase basic office supplies. Other funding needs will include hosting MHFA trainings and small groups of community leaders at breakfast or lunch to engage them in our mission and in providing support for events and trainings. • Se Z,0°o 14dgat • BBMHC is requesting sqpport from the City's Community Support Funds in the amount of$4itnik We have read and agree to abide by Policy R15-055. As we educate the community about the importance of our vision and mission,we will look to service clubs,individuals and businesses for additional funding and in-kind support •500 business cards and 500 printed presentation folders for networking, conversations,workshops and events.................................................................$800.00 •500 printed letterhead and envelopes.......................................................... 300.00 •Copying and office supplies(cartridges,notebooks,name badges,paper, markers,flip chart and stand,postage etc.) 1,000.00 •Food for special gatherings.................................................................... 400.00 •2 Mental Health First Aid training sessions:25-30 people,8 hours each • @$750................................................................................................................... 1,500.00 TOTAL $4,000 . 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"demon amp 0 ams outlaws if .. ' . . C. 1 Form W•9 Request for Taxpayer Give sotto to the (Rev•Jamey 011) Identification Number and Certification requester.Do not Deirarrnmrofwe treasury cent to the IRS. Intend Revenue Service Name(ss shown on your income Ira rearm) • - Business,iruewaereperdad may names K different from above az Cheek&PAropnete box for tederai tax t tAmttotn(rewired): 0 Irma10111*otopnettar 0 o corporation ❑s Corporation 0 Partnership 0 Tnrevooudo 0 Wiles liehlity company.Encn sor e tax aaasiaeaston(C;c ernta pon,s=s otxpwanon,Pepartnersere► El Exam*payee c�• _ Q met impuctsms)► Addroaa(numbs.street,and apt.of supe noes Aeyuestera name end edam(optionf 02 Gly,state,and ZIP code List amount nurnix (•)iiaa(optim) . . • . . • • -.,,_... . .. . . Part I Taxpayer identification Number ON) Enter your TIN In the appropriate bac.The TIN provided must match the name given on me•Name line beetle asaiaty"w'bta to avoid backup withhold ng.For individuals,this Is your social security number(SSN).However,for a resident alien,sole patentor,or disregarded entity,dee the Pan I instructions on page 3.For other entitle&it is your employer identification number(SIN).if you do not have a number,see Now to gete TIN on page 3. Nabs.If the account Ia In more than ono name,see the chart on page 4 for guidelines on whom' Employer iden4boar on numbs I number to enter. gnu Certification Under penalties of pe4Nry,I unify that 1. The number shown on this form is my corsair taxpayer Identification number(or I am wafting for a number to be Issued to me),and 2. 1 am not subject to badtup withholding because(a)I ern exempt from backup wfthhaiding,or(b)I have not been notified by the lnnemaf Revamwe SeWee(IRS)that t am stb)ec t to backs.p withholding es a rester of a failure to report ell interest or dividends.or(c)the IRS has notified me that I am no longer subject to backup withholding,and 3. i ant a U.S.citizen or other U.S.person(defined befog+). Carlfication im.tsucimta.You must cross out item 2 above if you have been notified by the IRS that you are currently sub(oat to backup withholding because you have feted to report ell interest and dividends on your tax return For real estate transactions,Item 2 does not appfy.For mortgage intent paid,acquisition or abandonment of secured property,cancellation of debt,conttmutions to an individual retirement arrangement 9RA),and generally,payments other than Interest and dividends,you are not required to sign the unification.but you must provide your correct TIN.See the inetruerioha on page C.Sign Signature of ovy(1 .�/ p /o—/5Here uspersonl► Clam► senerai Instruction Note.if a requester gives you a form other than Form W-9 to request • Section references wet*the Internal Revenue Code unless otherwise your IN,W mtat tas9 regtrest�s form A It similar noted. Pervasion of a Y.S.person.For federal tax purposes.you are Purpose of Form considered a U.S.parson Ityor are: A person who is required to Cie an laureation return with the iRS must •An Individual who Is a U.S citizen or U.S resider*alien, obtain your correct taxpayer Identification number(11N)to report.for •A partnership,corporators,company,or essodatlon created or example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the Un ted States, you paid,acquisition or abandonment of secured property,cancellation •An estate(other than a foreign estate),or of debt,or cotarbutions you made to an IRA. •A domestic oust(ea defined In Regulations section 301.7701-7). Use Form W-9 only S you ire a U.S.person(including a resldtett Spee nd rules for pannweepe.Partnerships that conduct a trade or alien),to provide your correct 11N the person roquast+rag ff(tit' business In the United States are generally required to pay a withholding requester)and,when applicable,to: tax on any fordo partners'slam of income from such business. 1.Certify that the TUI you are giving is correct(or you are waiting far a Further in certain cases where a Form W-9 hes not been received,a number to be issued), partneiahfp Is regetred to presume that a partner is a foreign person, 2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you we a U.S.person that is a 3.Clain exemption from backup withholding It you area U.S..awmpt partner in a parnse ship conducting Astute or business In the United payee.It eppficebio,you are also certifying that as a U.S.person,your States,provide ram W-S to the peltrsesahlp to enamor,your U.S. allocable snare of any partnership Income from a U.S.trade or business eted ua and avoid wkh hskring on your share of bertnwahip Incarna- te not subject to the withholding tax on foreign partners'share of effectivelyy connected Income, Cat.No.10211X Form WA peg.14011)