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Admin Tribe Selection Last updated: 09/15/2015 This is my Form. Page 1 Please select to which tribe this Organization has applied to: Salt River 1 of 1 Last updated: 09/17/2015 Page 1 General information Organization Arizona Town Hall Contact First name Laura Contact Last name Parsons Contact e-mail lparsons@aztownhall.org Contact phone number 602-252-9600 Address Street 2400 W. Dunlap Ave., Ste. 200 City Phoenix State AZ ZIP Code 85021 What is the name of the program or project for which your organization is requesting grant funds? Community Outreach Programs For what grant amount has the organization requested from the tribe? 20,000 1 of 1 W.9 Form Request for Taxpayer Give Form to tie (Rev. August 2013) requester. Do lot Identification Number and Certification Department of the Treasury send to the IRS. Internal Revenue Service Name (as shown on your income tax return ARIZONA TOWN HALL 2. Business name/disregarded entity name, if different from above page Check appropriate box for federal tax classification: Exemptions (see instructions): on • Individual/sole proprietor • C Corporation illi S Corporation M Partnership • Trust/estate type Exempt payee code (if any) Instructions III Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Is. Exemption from FATCA reporting or code Of any) Print Bil Other (see instructions) l• 501 C-3 Corporation Address (number, street, and apt. or suite no.) Requester's name and address (optional) Specific ONE E. CAMELBACK ROAD, Suite 530 City, state, and ZIP code See PHOENIX, AZ 85012 I List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line I Social security number to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other — entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number number to enter. 8 6 - 0 1 7 7 8 7 6 Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal 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. I 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 abov if you have been notified by the IRS that you are currently subject to backup withholcing because you have failed to report all interest and dividend - on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured pro erty, cancellation of debt, contributions to an individual retirement arrangement (IRA), an d generally, payments other than interest and dividends, .0 are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3. Sign Signature of if Here U.S. person • Date • f 9 ,.. e,7, General Instructions withholding tax on foreign partner share of e ectively connected income, ar d 4. Certify that FATCA code(s) entered on this form (if any) indicating that yo,1 are Section references are to the Internal Revenue Code unless otherwise noted, exempt from the FATCA reporting, is correct. Future developments. The IRS has created a page on IRS.gov for information Note. If you are a U.S. person and a requester gives you a form other than Farm about Form W-9, at www.irs.gov/w9 . Information about any future developments W-9 to request your TIN, you must use the requester's form if it is substantial") , affecting Form W-9 (such as legislation enacted after we release it) will be posted similar to this Form W-9. on that page. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. Purpose of Form person if you are: A person who is required to file an information return with the IRS must obtain your • An individual who is a U.S. citizen or U.S. resident alien, correct taxpayer identification number (TIN) to report, for example, income paid to • A partnership, corporation, company, or association created or organized in the you, payments made to you in settlement of payment card and third party network United States or under the laws of the United States, transactions, real estate transactions, mortgage interest you paid, acquisition or • An estate (other than a foreign estate), or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. • A domestic trust (as defined in Regulations section 301.7701-7). Use Form W-9 only if you are a U.S. person (including a resident alien), to Special rules for partnerships. Partnerships that conduct a trade or business in provide your correct TIN to the person requesting it (the requester) and, when the United States are generally required to pay a withholding tax under sectio1 applicable, to: 1446 on any foreign partners' share of effectively connected taxable income ffom such business. Further, in certain cases where a Form W-9 has not been race ved, 1. Certify that the TIN you are giving is correct (or you are waiting for a number the rules under section 1446 require a partnership to presume that a partner is a to be issued), foreign person, and pay the section 1446 withholding tax. Therefore, if you are a 2. Certify that you are not subject to backup withholding, or U.S. person that is a partner in a partnership conducting a trade or business in the 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If United States, provide Form W-9 to the partnership to establish your U.S. stal us applicable, you are also certifying that as a U.S. person, your allocable share of and avoid section 1446 withholding on your share of partnership income. any partnership income from a U.S. trade or business is not subject to the Cat. No. 10231X Form W-9 (Rev. 8+:113) SALT RIVERPIMA-MARICOPA INDIAN COMMUNITY 10005 E. Osborn Road, Scottsdale, Arizona 85256 / Phone 480-362-7520 / Fax 480-362-7593 12% Gaming Contributions Application Date of Application: July 23, 2015 Organization Name: Arizona Town Hall Organization/Municipal Government Street & Mailing Address: One E. Camelback Rd., Ste. 530, Phoenix, AZ 85012 Contact Person and Project Manager if different from Contact Person: Laura Parsons Title: Executive Assistant Address: 2400 W. Dunlap Ave., Ste. 200, Phoenix, AZ 85012 Phone: 602-252-9600 Fax: 602-252-6189 Email Address: lparsons@aztownhall.org Project Name: Community Outreach Programs Please provide a brief description of the project submitted to the 12% SRPMIC Grant program. Community Outreach Programs are held throughout the state after each of the two annual Arizona Town Hall gatherings and reach thousands of community leaders and interested citizens. These programs educate and inspire local communities to take action to affect change within their community regarding a variety of topics relevant to Arizona. Our fall outreach programs will focus on Transportation and we will address Water in spring 2016 In 2014, 21 action-focused Community Outreach Programs were held in locations that included Flagstaff, Verde Valley, Show Low/Lakeside, Yuma, Tucson, Sierra Vista, Douglas, Prescott, Phoenix, Surprise, Verde Valley, Prescott, Flagstaff and Wickenburg. These programs allow for idea and discussion exchange with a broader and even more diverse group of community members to help not only inspire civic engagement, but to use their ideas and feedback to communicate the thoughts and needs of individual communities back to important state decision makers. We anticipate a similar number and breadth of outreach events in 2015- 2016 and are currently reaching out to several groups to help leverage our reach even further. The dollars invested through Salt River Pima-Maricopa Indian Community would be utilized to organize, promote and follow up on the Community Outreach Programs. Beginning Date of Project: August 2015 End Date of Project: August 2016 Geographic Area to be served: All of Arizona ** Attach Detailed Budget** Amount of Total Project: $50,000 Amount of 12% Request: $20,000 (No Multi-Year Request will be accepted) If the Amount of funding received is less than the amount needed for the project, do you have other funds to complete the project? (Please Explain): Yes, funds will be used from the general operating fund. General operating funds are generated through sponsorships, memberships, programs and donations. If you receive SRPMIC 12 % funding, will it be spent (Check One): X Monthly ð Quarterly ð Lump Sum List of SRPMIC 12% funds you have received in the past. 2014-2015: $20,000 2013-2014: $15,000 2012-2013: $15,000 2011-2012: $10,000 2010-2011: $10,000 List any other 12 % grant funds your organization may be seeking from other Tribal Governments in 2015-2016. N/A List any other funds you have received from the Salt River Pima-Maricopa Indian Community(Enterprises Included) and identify the amount and the source: N/A Funding for project/programs may be based on available funding. As such, if funding were not available for the full the amount of request how would you prioritize funding. A.) Programs in rural and underserved communities B.) Publications distributed to local communities C.) Staffing for programs D.) Marketing for programs Which municipal governmental entity will serve as your pass through or accept 12% funds on your behalf? City of Scottsdale By execution of the 12% Gaming Contribution Grant Application the undersigned agrees that the information contained in the Application is trueto the best of the Applicants knowledge. The Applicant shall notify the SRPMIC if any information in this Application changes. July 23, 2015 Signature for the Applicant Date Tara Jackson, President July, 23.2015 Name and Title The Application shall be signed by the senior elected official of the local government, or in the case of a non-profit entity, the Chief Executive Officer authorizes to commit the non-profit entity to apply for, accept, and implement an award from the SRPMIC utilizing 12% Gaming Contributions. Community Outreach Budget Fall 2015 to Spring 2016 BUDGET AMOUNTS 2015 Fall Community Outreach Programs On-Site Facilitation Publications Total Facility/ /Reports Event Planning Catering September, 2014 Yuma 1,800.00 500.00 200.00 2,500 September, 2014 Phoenix 1,800.00 200.00 200.00 2,300 (Soroptimist) September, 2014 Show Low/Lakeside 1,800.00 200.00 200.00 2,400 September, 2014 Phoenix (East 1,800.00 200.00 100.00 2,100 Valley) October, 2014 Phoenix (West 1,800.00 200.00 200.00 2.400 Valley) October, 2014 Sierra Vista 1,800.00 200.00 100.00 2,100 October, 2014 Douglas 1,800.00 200.00 100.00 2,100 October, 2014 Flagstaff 1,800.00 500.00 200.00 2.500 October, 2014 Verde Valley 1,800.00 200.00 100.00 2,100 October, 2014 Tucson 1,800.00 500.00 200.00 2,500 November, 2014 Prescott 1,800.00 500.00 200.00 2,500 TOTALS 19,800.00 3,400.00 1,800.00 25,000.00$ 2016 Spring Community Outreach Programs February 2015 Flagstaff 1,800.00 500.00 200.00 2,500 February 2015 Verde Valley 1,800.00 200.00 100.00 2,300 March 2015 Wickenburg 1,800.00 200.00 100.00 2,400 March 2015 Phoenix 1,800.00 200.00 200.00 2,100 (Soroptimist) March 2015 Show Low/Lakeside 1,800.00 200.00 200.00 2.400 March 2015 Yuma 1,800.00 500.00 200.00 2,100 March 2015 Tucson 1,800.00 500.00 200.00 2,100 March 2015 Sierra Vista 1,800.00 200.00 100.00 2.500 March 2015 Douglas 1,800.00 200.00 100.00 2,100 April 2015 Prescott 1,800.00 500.00 200.00 2,500 April 2015 Phoenix (West 1,800.00 200.00 200.00 2,500 Valley) TOTALS 19,800.00 3,400.00 1,800.00 25,000.00$ TOTAL BUDGET AMOUNT: 50,000.00$ September 17, 2015 Salt River PimaMaricopa Indian Community 12% Grant Application C/O Angela Willeford Office of Congressional and Legislative Affairs 10,005 E. Osborn Rd. Scottsdale, AZ 85256 Dear Ms. Willeford: Thank you for the opportunity to reapply for the Salt River PimaMaricopa Indian Community 12% Gaming Grant. The grant application and budget are enclosed. Arizona Town Hall would like to thank Salt River PimaMaricopa Indian Community for past support of our efforts to educate, engage and empower Arizonans regarding critical issues facing our State. Because of this partnership, the Town Hall Community Outreach Programs have continued to serve all areas of the state and to share the consensus recommendations from large Arizona Town Hall gatherings held twice each year. We look forward to continuing our partnership with Salt River PimaMaricopa Indian Community. Please feel free to contact me if you have any questions or need additional information. Sincerely, Tara Jackson President, Arizona Town Hall Encl.