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Mayor Grant- Alpert Jewish Family ServiceR15-055 EXHIBIT "A" COMMUNITY SUPPORT FUNDS [� �rr►'r REQ UES T FORM Part I - Summary of Request (to be completed by City Clerk) Date of Request: 1/28/2020 Requested by Mayor/Commissioner: Mayor Steven B. Grant Amount Requested: $ 200.00 Recipient/Payee: Alpert Jewish Family Service Description of project, program, or activity to be funded: The Judith and Jack Rosenberg Mentoring 4 Kids Program provides children living in single-family homes with mentors. Mentors meet with their mentee twice a month. A mentor serves as a positive role model and friend to the child. Mentors provide support and they enjoy fun activities together. See the attached brochure for additional information. Part 11 - Availability of funds The annual appropriation of funds available to the requesting Member of the Commission listed above is $ 2,000.00 . The balance of funds available for the requesting Member of the Commission is $ 1000.00 Accordingly: There are funds available as requested There are insufficient funds available as requested Dated: By: Z_1."ZQ�g i City Clerk Part III -Eligibility Evaluation f/ Public funds will not be used to improve private property unless there is a clear public need, purpose and benefit C9/ The recipient/payee provides services within the City l/The public purpose is beneficial to the en' mmunity served by such donation Dated: 0 By: Requesting MembWof the City Commission ❑ MAIL CHECK TO VENDOR ❑ RETURN CHECK TO DEPU INCLUDE BACK-UP W/ CHECK CITY OF BOYNTON BEACH DIRECT PAYMENT REQUISITION Please issue a check in the amount of $200.00 TO: Alpert Jewish Family Service 5841 Corporate Way, Suite 200 West Palm Beach, FI 33407 FOR: Communitv Investment Funds Mayor Grant Community Investment Funds Requested By: Queenester Nieves Approvals: Div Head 'l Finance Dept. City Manager VENDOR # W-9 atached Date: February 12, 2020 FUND DEPT BASIC ELE OBJ AMOUNT 001 1110 511 95 47 200.00 200.00 Taxpayer Identffication Number M Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid t Social security number backup withholding. For individuals, this is generally your social security number . However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1,, later. For other entities. It is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. 77-7 Under penalties of perjury, I certify that: 1. The namber shown on this form is my correct taxpayer identification number (or 1 am waiting for a number to be issued to me); and 2. 1 am not subject to backup witnholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions, You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement ORA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Here Signature of U.S. person ► - General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), Individual taxpayer identification number (iTIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099 -INT (interest earned or paid) nate ► ) / % 120 2_C> • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not retum Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) .,9 Request for Taxpayer Give Form to the Form (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service ► Go to www.irs.gov/FormW9 for instructions and the latest information. I Name (as shown on your income tax return). Name is required on this line; do not leave this line blank Ferd & Gladys Alpert Jewish Family Service of Palm Beach County, Inc. 2 Business name/disregarded entity name, if different from above M m 3 Check appropriate box for federal tax classification of the person whose name igentered on line 1. Check only one of the pp P Y 4 Exemptions codes I only to P� ( apply Y a following seven boxes. certain entities, not individuals; see CL C: ❑ IndividuaVsole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑ Trust/estate instructions on page 3): 6 c single member LLC Exempt payee code [I any) 1 CL o ❑ Limited liability oompary. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) b- 0 c Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check Exemption from FATCA reporting N C LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is LLC that is disregarded from code (If any) a another not the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. y ✓ Other (see instructions) ► A.P"sroaccamomanraeo-9:a<dwU.si a � 5 number, streetand , , Address Add { apt. or suite no.) See instructions Requester's name and address (optional) 5841 Corporate Wat, Suite 200 C/) 6 City, state. and ZIP code West Palm Beach, FL 33407 7 List account number(s) here (optional) Taxpayer Identffication Number M Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid t Social security number backup withholding. For individuals, this is generally your social security number . However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part 1,, later. For other entities. It is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. 77-7 Under penalties of perjury, I certify that: 1. The namber shown on this form is my correct taxpayer identification number (or 1 am waiting for a number to be issued to me); and 2. 1 am not subject to backup witnholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Intemal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. 1 am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions, You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement ORA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Here Signature of U.S. person ► - General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), Individual taxpayer identification number (iTIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099 -INT (interest earned or paid) nate ► ) / % 120 2_C> • Form 1099 -DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not retum Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 10-2018) Judith & JackRosenberg Mentoring 4 IGds is a program of Alpert Jewish Family Service. Since 1998' our Rrogram hays been working to achieve Ter hea th fu##ure or the children in Palm Eseach County. Cont;*-* Jennifer DiSilvestro MSW Director, M4V 561-238-0285 Jennifer.DiSilvestro@AlpertJFS.org Lyndora Frazier, MA Outreach Coordinator, M41K 561.238.0244 Lyndora.Frazier@AlpertJFS.org 5841 Corporate Way Suite 200 West Palm Beach f`L 33407 www. Al ertJrS.org 561-M-1991 Childm's OiAsIhM BhE-NdCcH rC..nUIIuloll wSCMMI TV i �/ MMWMPAV BEK FS IF" 'ISH FAMILY SERFICF Judith & Jack Rosenberg V MENTORING FOR KIDS EhL, I , I / 01 n Program for :,t Families Mentoring 4 Kids A non-sectarian program for single -parent families Program Overview The Judith & Jack Rosenberg Mentoring 4 Kids program at Alpert Jewish Family Service has helped many families since it was established in 1998. • M4K is a no -cost, non-sectarian mentoring program. • We serve children ages 6-14 who are being raised in a single parent family due to the loss or absence of a parent/guardian. The program also provides mentors for children being raised by grandparents. • We match children with volunteer mentors who provide unconditional friendship and support to help fill the void of the absent caregiver. • Potential mentors are carefully screened. • Children are assessed for eligibility. • Throughout the match, supervision and ongoing support are provided to mentors and families. Together, the child and mentor share in a wide range of community-based activities (2-3 times per month for at least 1 year) while building a long-lasting friendship. Parent Responsibilities • Encourage child to be a great friend to his/ her mentor. • Communicate with child's mentor to help coordinate outings. • Provide activity report to M4K after each outing your child has with his/her mentor. • Participate in supervision with M4K program clinical social worker. PI What our parents love about M4K "I love that my child .ren ha ve another' "The support of adult as their support but above all a having another role model to look up to. " adult in my child's life. 0 "Th egra ceful heartfelt approach they take toward the service theygive. " What our mentees like best about having a mentor "To ha ve a friend 'Ilike that I ha ve someone else to that I can trust." talk to and ha ve fun with . " "My mentor teat hes "Having someone to me new things. " talk to. " Mentoring 4 Kids No -cost program for single -parent famil Criteria for Mentee Participants • Children ages 6-14 being raised in a single -parent home due to the loss or absence of a parent/guardian. The program also provides mentors for children being raised by grandparents. • Child is in need of a same gender role model to help fill the void of absent parent. • Child's home must be stable; no conflict with non-custodial parent; Proof of custody needed. L • Child must be motivated to have a mentor and be able to establish a relationship with a caring adult. • Extenuating circumstances will be reviewed on a case-by-case basis. • AJFS is an accredited social service agency and has specific criteria that a family must meet prior to being accepted into the M4K program. "It is a pleasure being a part of M4K. Da vid is a joy to be with. His charisma and passion for life makes me a better person. " Andy (Pictured on front corer ►i ith his mentee Da vid) * Children in foster care are not eligible as there must be a consistent primary custodial parent/guardian residing with the child. * Children with serious mental health or behavioral issues are not appropriate for the program. Benefits of Mentorship As evidenced by MO program outcomes, mentoring helps mitigate potential at -risk behaviors in children. �'ii��+I�!llf��iiL���3��f�'• • ra • Raises children's self-esteem • Increases academic performance • Strengthens communication skills and family values r—M "The encouragement, planned group activities and support truly enhance the program. " WKMen tor Keys to M4K Success Rate • Annual surveys are used to measure program goals and satisfaction. • Ongoing supervision, support and training to volunteer mentors and families ensures longevity of the match. • Group outings help to connect all the program participants leading to greater satisfaction with the program. Mentoring 4 Kids Make a difference. Be a Mentor! A volunteer mentor is a caring person who shares a one-to-one friendship with a child of the same gender. A mentor is a positive role model who offers guidance, support and encouragement. Mentors gain an increased sense of personal satisfaction. "My mentoring relationship is very fulfilling; I love knowing that I'm making a positive difference in my mentee's life" - M4KMentor Criteria for Volunteer Mentors • Mentors must be at least 25 years of age with a valid FL driver's license and car. • Mentors must be year-round FL residents. • Mentors commit to seeing the child a minimum of twice a month for at least one year. Screening Process for Mentors • Interview at AJFCS with our Director of Volunteer Services and Clinical Director. • Background check; Driver's record (7 years); Fingerprinting; Drug test; TB Screening; 1 3 Reference checks. 0 2 -hour assessment at mentor's home. Be A Mentor ... Inspire Bright Futures Mentor Responsibilities • Successfully complete orientation. • Provide activity report after each visit with the mentee. • Participate in ongoing supervision with M4K program coordinator. • Attend trainings and mentor network meetings. • Provide fun, community-based activities. • Attend group outings hosted by the M4K program. • Optional CPR and First Aid training provided. "Steve's a real"tgreat guy.ind he'll always he by my side. "- Sam (pictured with his mentor Steve) What our mentors like best about M4K: "Watching the men tee ha ve a good time and continuing to grow. " "The ability to connect to a young person who might need help in navigatinglife. "