LEUKEMIA & LYMPHOMA SOCIETY APPLICATION.PDF

Admin Tribe Selection
Last updated: 09/14/2015
This is my Form.
Page 1
Please select to which tribe this Organization has applied to:
Salt River
1 of 1

Created: 09/14/2015
Last updated: 09/16/2015
Page 1
General information
Organization Leukemia & Lymphoma Society
Contact First name Naomi
Contact Last name Martinez
Contact e-mail naomi.martinez@lls.org
Contact phone number 6025677612
Address
Street 3877 N 7th St Ste 300
City phoenix
State Arizona
ZIP Code 85014
What is the name of the program or project for which your organization is requesting grant funds?
Travel Assistance Program
For what grant amount has the organization requested from the tribe?
100,000
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IRS Department of the Treasury
Internal Revenue Service
In reply refer to: 0248121964
CINCINNATI OH 45999-0038 Feb. 10, 2015 LTR 4168C 0
13-5644916 000000 00
00020385
BODC: TE
LEUKEMIA & LYMPHOMA SOCIETY INC
1311 MAMARONECK AVE STE 310
WHITE PLAINS NY 10605-5223
009717
Employer Identification Number: 13-5644916
Person to Contact: Ms.Mitchell
Toll Free Telephone Number: 1-877-829-5500
Dear Taxpayer:
This is in response to your Jan. 30, 2015, request for information
regarding your tax-exempt status.
Our records indicate that you were recognized as exempt under
section 501(c)(3) of the Internal Revenue Code in a determination
letter issued in January 2001.
Our records also indicate that you are not a private foundation within
the meaning of section 509(a) of the Code because you are described in
section(s) 509(a)(1) and 170(b)(1)(A)(vi).
Donors may deduct contributions to you as provided in section 170 of
the Code. Bequests, legacies, devises, transfers, or gifts to you or
for your use are deductible for Federal estate and gift tax purposes
if they meet the applicable provisions of sections 2055, 2106, and
2522 of the Code.
Please refer to our website www.irs.gov/eo for information regarding
filing requirements. Specifically, section 6033(j) of the Code
provides that failure to file an annual information return for three
consecutive years results in revocation of tax-exempt status as of
the filing due date of the third return for organizations required to
file. We will publish a list of organizations whose tax-exempt
status was revoked under section 6033(j) of the Code on our website
beginning in early 2011.

0248121964
Feb. 10, 2015 LTR 4168C 0
13-5644916 000000 00
00020386
LEUKEMIA & LYMPHOMA SOCIETY INC
1311 MAMARONECK AVE STE 310
WHITE PLAINS NY 10605-5223
If you have any questions, please call us at the telephone number
shown in the heading of this letter.
Sincerely yours,
/96, "1 4-itz-44t
Doris Kenwright, Operation Mgr.
Accounts Management Operations 1

SALT RIVER PIMA-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 22, 2015
Organization Name: The Leukemia & Lymphoma Society – Arizona Chapter
Organization/Municipal Government Street & Mailing Address:
3877 N. 7th Street, Suite 300
Phoenix, AZ 85014
Contact Person and Project Manager if different from Contact Person:
Jim Brewer
Title: Executive Director
Address: 3877 N. 7th Street, Suite 300
Phoenix, AZ 85014
Phone: 602-567-7600
Fax: 602-567-7601
Email Address: jim.brewer@lls.org
Project Name: Reducing Cancer Health Disparities Through Education and Outreach, and
Providing Financial Aid to Blood Cancer Patients in Arizona
Please provide a brief description of the project submitted to the 12% SRPMIC Grant program.
LLS Patient Travel Assistance Program- a program that will aid blood cancer patients with
financial need within the state of Arizona by helping cover therapy and treatment-related travel
and lodging expenses.
Outreach to underserved communities and health educators across Arizona including
collaborative relationships with other community-based organizations, as well as participation in
several community partnerships such as the Arizona Cancer Control Plan, Latino Cancer
Coalition, Tohono O’odham Nation Cancer Partnership, Navajo Nation Cancer Conference and
Health Through Action Alliance.

Staying Connected – a program designed to increase communication among educators,
healthcare professionals, parents and childhood leukemia patients to ensure a smooth transition
from active treatment back to school and daily life.
Efforts to reduce cancer health disparities among the state’s varied underserved populations,
including participation in the Arizona Cancer Quality of Life Committee.
Support for LLS-sponsored Family Support Groups, “Meet the Expert” Educational Meetings
and First Connection early diagnosis peer-to-peer counseling.
Educational programs for health care providers to enhance their knowledge of the latest
treatment methods and advances in research related to therapies and cures for blood cancers.
Beginning Date of Project: November 1, 2015 End Date of Project: October 30, 2016
Geographic Area to be served: State of Arizona
** Attach Detailed Budget**
Amount of Total Project: $109,500 Amount of 12% Request: $100,000
(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):
LLS will seek additional funding to underwrite these efforts. Sources may be internal (grants
and/or allocations from the Society’s Home Office) or external (support from corporate donors,
pharmaceutical partners, foundations, and individual contributors). Historically LLS has been
successful securing the level of funding necessary to complete these projects.
If you receive SRPMIC 12 % funding, will it be spent (Check One):
ð Monthly
ð Quarterly
ð Lump Sum
List of SRPMIC 12% funds you have received in the past.
SRPMIC Funding:
2014- $50,000 2010 – $100,000
2013 - $50,000 2009 – $100,000
2012 - $50,000 2008 – $100,000
2011 - $100,000
List any other 12% grant funds your organization may be seeking from other Tribal Governments
in 2015-2016
Tohono O’odham Nation $25,000
Gila River Indian Community $25,000

Ft. McDowell Yavapai Nation $25,000
List any other funds you have received from the SRPMIC (Enterprises included) and identify the
source:
$20,000 – Sponsorship of 2009 Hope Ball
$2,500 – Sponsorship of 2009 Links for Leukemia golf tournament
$25,000 – Sponsorship of 2010 Hope Ball
$25,000 – Sponsorship of 2011 Hope Ball
$25,000 – In-kind Sponsorship of 2012 Hope Ball
$25,000 – In-kind Sponsorship of 2013 Man & Woman of the Year
$25,000 – In-kind Sponsorship of 2014 Man & Woman of the Year
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.) Travel Assistance Program
B.) Patient Financial Aid
C.) Community Outreach to Patients/Health Care Providers
D.) Staying Connected – Facilitating the Learning Experience During and After Cancer
Treatment
Which municipal governmental entity will serve as your pass through or accept 12% funds on your
behalf?
Maricopa County
By execution of the 12% Gaming Contribution Grant Application the undersigned agrees that the
information contained in the Application is true to the best of the Applicants knowledge. The
Applicant shall notify the SRPMIC if any information in this Application changes.
July 22, 2015
Signature for the Applicant Date
Jim Brewer, Executive Director
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.

SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY
12% GAMING CONTRIBUTIONS
APPLICATION
Reducing Cancer Health Disparities Through Education and Outreach, and Providing
Financial Aid to Blood Cancer Patients in Arizona
THE LEUKEMIA & LYMPHOMA SOCIETY – ARIZONA CHAPTER
PROJECT BUDGET
2015-2016
Travel Assistance Program & Patient Financial Aid $80,000
Community Outreach to Patients/Health Care Providers 15,500
Staying Connected – Facilitating the Learning Experience 3,000
During and After Cancer Treatment
Family Support Group Meetings 6,000
Production/Distribution of Resource Materials 3,000
First Connection Volunteer Support 2,000
________
Project Total $ 109,500