THE LEUKEMIA & LYMPHOMA SOCIETY APPLICATION - SRPM 2014.PDF

Admin Tribe Selection
Created Friday, October 17, 2014
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Please select to which tribe this Organization has applied to:
Salt River
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Created Wednesday, October 22, 2014
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General information
General information | Organization The Leukemia & Lymphoma Society
General information | Contact First name Jim
General information | Contact Last name Brewer
General information | Contact e-mail jim.brewer@lls.org
General information | Contact phone number 602-567-7620
Address
Address | Street 3877 N. 7th St., Suite 300
Address | City Phoenix
Address | State AZ
Address | ZIP Code 85014
What is the name of the program or project for which your organization is requesting grant
funds?
Reducing Cancer Health Disparities Through Education and Outreach, and Providing Financial Aid to Blood Cancer Patients in
Arizona
For what grant amount does the organization plan to request funding?
$100000
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IRS Department of the Treasury
Internal Revenue Service
P.O. Box 2508 In reply refer to: 0248145604
Cincinnati OH 45201 Mar. 07, 2014 LTR 4168C 0
13-5644916 000000 00
00026147
BODC: TE
LEUKEMIA & LYMPHOMA SOCIETY INC
1311 MAMARONECK AVENUE
WHITE PLAINS NY 10605
N
008559
Employer Identification Number: 13-5644916
Person to Contact: MR. CORDELL
Toll Free Telephone Number: 1-877-829-5500
Dear Taxpayer:
This is in response to your Feb. 27, 2014, 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.

SALT RIVER PIMA-MARICOPA
INDIAN COMMUNITY
10,005 E. Osborn Road, Scottsdale, Arizona 85256 / Phone 480-362-7520 / Fax 480-362-7593
12% Gaming Contributions Application
Date of Application: May 13, 2014
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
In 200 words or less, please provide a brief description of the project submitted to the
12% SRPMIC Grant program.
Funds will underwrite a select group of LLS Patient Services programs:
• Patient Financial Aid (direct financial support to blood cancer patients).
• 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, 2014 End Date of Project: October 30, 2015
Geographic Area to be served: State of Arizona
** Attach Detailed Budget**
Amount of Total Project: $119,500 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 and a list of other 12 % grants funding
you are seeking from other Tribal Governments for the 2012-2013 12% cycle.
SRPMIC Funding:
2013 - $50,000
2012 - $50,000
2011 - $100,000
2010 – $100,000

2009 – $100,000
2008 – $100,000
List any other funds you have received from the SRPMIC 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.) Patient Financial Aid
B.) Community Outreach to Patients/Health Care Providers
C.) Staying Connected – Facilitating the Learning Experience During and After Cancer
Treatment
D.) “Meet the Expert” Educational Program and Family Support Meetings
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.
May 13, 2014
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.