HomeMy WebLinkAboutPD15-163 - Original - State Farm Insurance - Contribution to Stop Illegal Street Racing in Kent - 03/30/2015 N��E , r
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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office. All portions are to be completed.
If you have questions, please contact City Clerk's Office.
Vendor Name: State Farm Insurance
Vendor Number: N/A
JD Edwards Number
Contract Number: 1!'Ms I )
This is assigned by City Clerk's Office
Project Name: 2015 Illegal Street Racing Prevention
Description: Interlocal Agreement ❑ Change Order ❑ Amendment Contract
x Other: Acknowledgement of Contribution
Contract Effective Date: 4/22/15 Termination Date: N/A
Contract Renewal Notice (Days): N/A
Number of days required notice for termination or renewal or amendment
Contract Manager: Sara Wood Department: Police
Detail: (i.e. address, location, parcel number, tax id, etc.):
State Farm Insurance has given the Kent Police Department $14,000 to fund community
outreach and education to prevent illegal street racing.
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S:Public\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08
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ACKNOWLEDGMENT OF CONTRIBUTION
Internal Use Only By
Enterprise Philanthropy
Please complete ALL sections, \ y,
PART A. l
The / _ i �fl 4'1C VWW AV 1 lv\&yl —
(name of L organization as filed, no abbreviations) (city) (state)
acknowledges the receipt of State Farm Mutual Automobile Insurance Company's charitable contribution of
$14,000.00 which was received on I I I n I I (date)
PART B.
(Our records indicate that$14.000.00 is a charitable gift to your non-profit organization. Was any portion of this
contribution a direct, tangible benefit back to State Farm? For example: booth, table, or advertising. Please verify below.)
Were any goods or services provided to State Farm in consideration of this contribution?
No
Yes (if yes, on the line below, give a description and the value of the goods or services)
PART C,
Please indicate whether your organization is qualified or non-qualified as described in IRC
Section 501(c)(3), 170(c)(1) or 115(1). See note below. "
Qualified Non-Qualified N/A or Other Specify ajOV Vb/Y`? i— e/"A� 1v'
Note: In general, an organization qualifies under section 501(c)(3) if it is a nonprofit group that meets the definition of a
charitable organization as prescribed in the Internal Revenue Code. An organization seeking recognition of exempt status
under section 501(c)(3) must file Form 1023 with the district director for the IRS district in which the organization is
located. Organizations may qualify under section 170(c)(1) if they are a governmental unit of the state or a political
subdivision of the state. Political subdivisions of a state are entities with one or more of the sovereign powers of the state
such as the power to tax. Typically they include counties or municipalities and their agencies or departments. An entity
that is not a political subdivision but that performs an essential government function may qualify under section 115(1).
PART D.
By signing below, I hereby agree that the above statements are correct regarding the amount and receipt of the
contribution, the value of goods or services provided, and the organization's status according to Section 501(c)(3),
170(c)(1) or 115(1).
51 [
Name (prin
tedy.? Title
/ p JJffj _
Signat0rer i Date !'
KeA ' lice Department
Kent, WA
Request ID 16647743
2015 DO
You may mail completed form OR fax to: (309) 766-2314
St teFarw
March 30, 2015
Kent Police Department
Attention: Sara Wood
220 Fourth Ave South
Kent, WA 98032
Dear Sara Wood:
On behalf of State Farm®, I am pleased to enclose a check for$14,000.00. State
Farm is proud to provide this contribution to support the Stop Illegal Street Racing in
Kent.
Please complete and return the enclosed Acknowledgment of Contribution form in
the envelope provided within 30 days.
Again, we are pleased to be associated with such a worthwhile organization.
Sincerely,
Ty Cordova
Public Affairs Specialist
StateFarm STATE FARM MUTUAL AUTgMOBILFXvSURANCE COWANY:, 1003936;650
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