AICCF 12% REVENUE SHARING APPLICATION.PDF

10,005 E. Osborn Road, 12% Scottsdale, SALT Gaming INDIAN RIVER Arizona Contributions 85256 COMMUNITY PIMA-MARICOPA / Phone Application 480-362-7520 / Fax 480-362-7593
July Date 22, of Application: 2013
Organization American Fiscal Sponsor Indian Name: is Children’s Technical Assistance Clinic Fund Partnership (AICCF) of Arizona (TAPAZ)
Organization/Municipal Technical American 2929 N. Central Assistance Indian Ave., Children’s Partnership Ste, Government 1550 Clinic of Fund Street Arizona & Mailing Address:
Phoenix, Contact Albion F. Person AZ Hargrave, 85012 and Project III, MD Manager if different from Contact Person:
Title: Executive Address: Director & Chair, American Indian Children’s Clinic Fund Advisory Board
7018 Phoenix, N. 13th AZ 85020-5433 St.
Phone: Ofc: Cell: 602.997.1328 602.361.6036
Fax: None
Email aiccf@hotmail.com Address:
Project American In 12% 200 SRPMIC words Name: Indian or Grant less, Children’s please program. provide Clinic a Fund brief –Capacity description Building of the project Funding submitted to the
• adolescent AICCF is clinic a $2.5M on the capital PIMC campaign campus. to It is create fiscally and sponsored equip a 10,000 by Technical sq. ft. pediatric Assistance and

Partnership fundraising. • provider The increased and of collocation Arizona clinic (TAPAZ). space for a will multi-disciplinary The provide volunteer at least AICCF care two team. Advisory exam This rooms Board will for efficiently is each implementing medical increase the
productivity old year medical adolescents. age home group. by is 30-40% Moreover In not the simply US, and it American a affords provide place but initial Indians the a capacity model space have of capacity to the highly service highest effective for an medical mortality additional patient-centered home rate 5,000 design. in the 16-18 15-18 The primary year
care. campaign completed $52,430 office and is needed TAPAZ and fund to approves complete the campaign the the actual $86,430 for capital the first of start-up campaign six months. funding major Once to fundraising create this funding a capital phase, is the
fundraising infrastructure begin. consultant/campaign will be put into place, executive and the director capital campaign will be hired, major the fundraising campaign phase will
Beginning 2013, last End 18-24 Date with of Date months. full Project: of cash Project: This flow aspect As requirements soon will as last startup by six September months. funding The can 15, whole be 2013. completed, capital campaign possibly August project 1, will
Geographic PIMC constituency pediatrics Area in the to serves be greater served: children Phoenix throughout community. the tribes of Arizona with its greatest
TAPAZ Contractors AICCF Expense Budget for the First Six Months
Campaign Capital Professional Expenses Campaign Fundraising Executive Counsel--Campaign Administrative Assistant Executive Director $48,000 $5,000
Audiovisual Case Brochure for Support (Professional Development DVD presentation) $16,000 $1,500 $2,500
General Donor Travel Postage Prospect Printing Briefings (3 to 5) $1,000 $5,000 $2,500 $500
TAPAZ TOTAL Contingency Administrative Fee (7% of contributions) $86,430 $1,000 $3,430
Amount Amount of of Total 12% Request: Project: $2,500,000; $45,000 Start-up $86,430

Adequate If funds the Amount to complete funding of funding the for project? the received first (Please six is months less Explain): than of the the amount AICCF (No Multi-Year needed $2,500,000 for the Request capital project, will campaign do be you accepted) have will other be
in requirement fundraising fundraising place before phase and by we our budgetary of would fiscal the capital accept sponsor, adjustments, campaign. the TAPAZ, 12% including revenue If before other they sharing contractor efforts grant such grants. approval negotiations, as ongoing This to is a begin concurrent minimum do not the result major in
adequate TAPAZ approve funding, phase the AICCF III of this will project, not be in which a position is the to launching accept this of this $45,000 capital grant, campaign. nor will
As costs SRPMIC you as will noted last notice, month. in this our budget potential in comparison contractor has to the considerably previous budget reduced AICCF the budgeted presented start-up to
If you receive Monthly SRPMIC 12 % funding, will it be spent (Check One): LUMP SUM
you List This are of is SRPMIC Quarterly Lump the seeking first Sum from SRPMIC 12% other funds 12% Tribal you funding have Governments received for AICCF. in for the the past 2013-2014 and a list 12% of other cycle. 12 % grants funding
AICCF this Dr. of such Pattea’s is 12% is a seeking grant revenue death may a and Ft. rise funding McDowell whatever to a level or from Yavapai changes of other other Nation that pressing tribal may sponsorship revenue entail, priorities AICCF sharing grant. for does FMYN sources. I am not at not believe this However sure time. whether approval with
Furthermore, List AICCF any has other not funds asking received you them have any anymore other received SRPMIC from about the funding. this SRPMIC seems and insensitive identify on the the source: part of AICCF.
Funding available for for project/programs the full the amount may of request be based how on available would you funding. prioritize As funding. such, if funding were not
As requires A.) noted adequate above, AICCF startup cannot funding. begin the capital campaign without TAPAZ approval. This
B.) C.)
D.)

Which municipal governmental entity will serve as your pass through or accept 12% funds on your
behalf?
TAPAZ is an Arizona nonprofit corporation with IRS 501(c)(3) exemption status. TAPAZ
will accept the funds. Therefore it will not be necessary for a municipal governmental
entity to serve as a pass through or accept 12% funds on behalf of AICCF.
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.
(y
Signature/or the Applicant Date
0 I( EK-e,e_AAVe
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.