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Agenda PacketCITY OF CUPERTINO DISTINGUISHED ARTIST AWARD JUDGING FORM Artist Name Judge Name Evaluate the piece on each of the four judging criteria indicated below, from 5 points (high) to 1 point (low). Suggested criteria guidelines are below. Total Points__________/20 Criteria Points Notes Design and Composition -Observe the totality of the artists portfolio. Consider if the following elements and principles are evident in their work. Note that not all principles will apply to every medium. o *Principles: Unity, Balance, Rhythm/Movement, Emphasis, Contrast o *Elements: Line, Shape, Space, Form, Color, Value, Texture o *For additional guidance on the principles and elements, see below the criteria table. Technique/Skill of Construction -Has the artist demonstrated a high level of skill and/or ability in the selected techniques that they have chosen for their artwork? Do the pieces display an effective use of tools, methods, and working materials? Has the artist used materials and skills to effectively portray what they are trying to convey? Creativity and Originality -Is the work executed in a manner that is unique to the idea expressed? Is there evidence of creative thought? Personal Statement -Does the personal statement include goals, education, training, volunteerism, community involvement, and/or achievements and awards? 19 Design and Composition Observe the totality of the artists portfolio. Consider if the following elements and principles are evident in their work. Note that not all the principles will apply to every medium. Principles Unity: Do the parts work as a whole? Consider the marks, shapes, colors, values, and textures. Balance: Is there an equal distribution of visual weight? Has symmetrical or asymmetrical balance been created in the shapes, colors, textures, and values? Rhythm/Movement: Is there fluidity of form in three-dimensional works? Are there shapes or directional lines to connect pieces within two-dimensional works? Does your eye travel around the entire picture plane? Emphasis: Is there a defined focal point or center of interest? Contrast: Is there a variety of values, shapes, colors, lines and textures? Elements Line: Is there variety of line? Have lines been used to create texture, perspective, or movement? Shape: Is there variety of shape? Are the shapes used been successfully created and used in the work? Space: Has the illusion of foreground, middle ground, and background shape been successfully created? Form: Has the illusion of depth been successfully created in two-dimensional works? Have appropriate figures been used to represent the ideas within three-dimensional works? Color: Is there a variety of color? Have colors been used to create space or emotion? Value: Is there a defined light source? Have highlights, shadows, and cast shadows been included in the art? Texture: Are there visual or tactile surface characteristics in the work? Does it have a variety of texture and interesting patterns? 20 CITY OF CUPERTINO EMERGING ARTIST AWARD JUDGING FORM Artist Name Judge Name Evaluate the piece on each of the four judging criteria indicated below, from 5 points (high) to 1 point (low). Suggested criteria guidelines are below. Total Points__________/25 Criteria Points Notes Media/Tools -Does the piece display an effective use of tools, methods, and working materials? Has the artist used materials and skills to make an effective piece for what they are trying to convey? Creativity and Originality -Is the work executed in a manner that is unique to the idea expressed? Is there evidence of creative thought? Imagination - Has the artist shown imagination in their artwork? Is there evidence of creative thought? Individuality -How well does the artist showcase their individuality in the piece? Personal Statement -Does the personal statement include goals, education, training, volunteerism, community involvement, and/or achievements and awards? 21 CITY OF CUPERTINO YOUNG ARTIST AWARD JUDGING FORM Artist Name Judge Name Evaluate the piece on each of the four judging criteria indicated below, from 5 points (high) to 1 point (low). Suggested criteria guidelines are below. Criteria Points Notes Media and Tools -Has the artist demonstrated a level of skill and ability in the selected techniques? Does the piece display an effective use of tools, methods, and working materials? Has the artist used materials and skills to make an effective piece for what they are trying to convey? Creativity of Contest Theme -How well has the artist conveyed the contest theme? Can it be understood by others? Imagination -Has the artist shown imagination in their artwork? Is there evidence of creative thought? Individuality -How well does the artist showcase their individuality n the piece? Total Points__________/20 22 ARTIST AWARD PROGRAM TIMELINE ARTS AND CULTURE COMMISSION This is an estimated annual timeline of events for the Arts and Culture Commission Artist Award Program. MONTH JULY AUGUST SEPTEMBER OCTOBER NOVEMBER JANUARY NOTES Commissioners Discuss and Finalize: - Outreach Plan - Young Artist Award Theme Commissioners start outreach and inform their respective networks that the Artist Award Applications will open in September. Artist Award Applications Open on September 1 - Artist Awards announced on City website and social media platforms - Commissioners continue marketing Artist Award Applications Close on October 1 Commissioners select award winners at the November Arts and Culture Commission meeting and staff notifies winners. Commission recognizes and presents awards to selected winners at the January Arts and Culture Commission meeting. 23 Are You an Artist, Musician, Writer, Actor, Photographer, or Dancer? Every year the City of Cupertino and the Cupertino Arts and Culture Commission chooses a Distinguished Artist and an Emerging Artist who lives, works, or attends school in the City. You are invited to submit your portfolio. If selected, you will receive public recognition and a cash award. It's easy to apply. Online application and a detailed description of the contests are available at cupertino.org/artawards. Submit your entry by Sunday, October 1. Questions? Email to artsandculture@cupertino.org 24 ARE YOU A YOUNG ARTIST? The City of Cupertino's Arts and Culture Commission is looking for outstanding young Cupertino artists to submit their artwork for the Young Artist Awards. Winners receive public recognition and a cash award. It’s easy to apply! Get the award rules and apply online at cupertino.org/artawards and submit your entry digitally by Sunday, October 1. There will be three awards for each of two categories: Group A: 6-10 years old Group B: 11-14 years old Your artwork will be judged on how effectively and creatively you’ve communicated this year's theme of: “[INSERT THEME]" Questions? Email to artsandculture@cupertino.org 25 Chair Stanek requested a follow-up on signage and maintenance for the labyrinth. Recreation Manager Koverman noted that staff are looking into the signage policy for the Corridor and can discuss with Public Works for the maintenance. APPROVAL OF MINUTES 2. Subject: June 1, 2023 Parks and Recreation Commission Meeting Minutes Recommended Action: Review and approve the June 1, 2023 Parks and Recreation Commission meeting minutes. Vice Chair Shearin motioned to approve the June 1, 2023 Parks and Recreation Commission meeting minutes as submitted. Commissioner Begur seconded. Motion carried with 4 yes and 1 abstain. POSTPONEMENTS None ORAL COMMUNICATIONS Deepali Pathak, Dhruv Yadati, Sumedha Kumar (ElderAid Team) presented on the ElderAid App, showed a Youtube Video for an in-app demonstration, and requested to be added to the September Parks and Recreation Commission agenda. WRITTEN COMMUNICATIONS None OLD BUSINESS None NEW BUSINESS 3. Subject: Cupertino Historical Society Annual Report Recommended Action: Receive a presentation on the Cupertino Historical Society annual report. Neeraj Mathur, Cupertino Historical Society and Museum (CHSM) President introduced Bill Kerr, CHSM Treasurer, and Manuel Valerio, CHSM Interim Executive Director. CHSM President Mathur presented on the CHSM Annual Report as part of their contractual agreement with the City including an annual report summary for use of City funds, fundraising activities and achievements, and future projects and programs. 8 Chair Stanek requested clarification on the Commission’s role and City Council’s role regarding the CHSM funding. Recreation Manager Koverman clarified that Council determines the funding received, and the current contract is set for three years. Commissioner Begur requested clarification on the funding for the new projects and programs. CHSM President Mathur clarified that on the Projects & Programs – Estimated Funds presentation slide, the one-year projects and programs are those which can be completed if the funds are available within the year, and the three-year projects and programs are long-term which can continue if the funds are available. Clarified that the Annual Report Summary presentation slide represents only the City funding, not the entire budget. Commissioner Begur requested that the CHSM detailed report be shared with the Commission. Commissioner Swamy requested a prioritization list and impact section for the projects and programs. CHSM President Mathur clarified that they are currently sorting through the prioritization, and additional information on the projects and programs can be found on their website. Clarified that they are also capturing headcount numbers to help with measuring impact. Commissioner Swamy requested clarification on the Traveling Trunk Program. Donna Austin, CHSM Board Member, clarified that the trunk program volunteers visit CUSD third-grade classes and share the history of Cupertino with students. Vice Chair Shearin requested that the CHSM detailed report be shared with the Commission to see the impact of the $40,000 City funding on the total budget. CHSM Treasurer Kerr added that the total CHSM budget is an estimated $140,000. Vice Chair Shearin asked if there was anything that CHSM wanted the Commission to share with residents. CHSM President Mathur noted that sharing the mission, vision, and resources available through CHSM with parents is the most important (and their kids). Chair Stanek clarified that CHSM used to be apart of the Community Funding Grant Program application process, however, the Commission recommended that CHSM be removed and added as a line item in the budget. Chair Stanek requested that the CHSM detailed report be shared with the Commission. Commissioner Buch requested clarification on how CHSM manages and recruits volunteers for their programs. CHSM President Mathur clarified that they recently added five new board members and are actively trying to recruit more parents and kids in the community. Commissioner Buch requested to see the Museum membership budget line item, and requested clarification on whether it was a source of revenue. 9 CHSM President Mathur clarified that it is fee-based membership that is part of Community Outreach. STAFF AND COMMISSION REPORTS Vice Chair Shearin reported on the Wilson Park Ribbon Cutting Ceremony for the community garden and full-sized basketball court, Disco at Dusk intergenerational event, and the Wilson Park baseball fields. Commissioner Begur reported on the July Mayor’s Commissioners meeting led by Vice Mayor Mohan, and an inappropriate graffiti incident at the Wilson Park restrooms. Commissioner Buch reported on the Asian American Parents Association Multicultural Festival, and the Linda Vista Dog Off-Leash Area (DOLA). Chair Stanek reported on the June Mayor’s Commissioners meeting, and the Summer Concert Series. Commissioner Swamy reported on the March Mayor’s Commissioners meeting. Recreation Manager Koverman, provided the Liaison’s update on the following: - On June 21, the Memorial Park Specific Plan Design Concept went to City Council and Council approved proceeding with the Memorial Park Specific Plan design process into Schematic Design with the following revisions to the Conceptual Plan: o Retain the existing softball field; o Prioritize finding a revised location for pickleball and the basketball court; o Consider options to reduce the size of the extra parking area on Anton Avenue; and o Include native plants and gardens where feasible, especially in the nature walk area, as presented by the Audubon Society - On July 6, the Creekside Park School Age Play Area (part of the Annual Playground Equipment Replacement Project) went to City Council and was approved, including the three inclusive elements selected by the Commission. - Summer Concert Series – Thursday, August 10, 17, 24, and September 7 from 6:30 to 8 p.m. at the Memorial Park Amphitheatre - Shakespeare in the Park – Friday through Sunday, August 4, 5, and 6 at 6 p.m. at the Memorial Park Amphitheatre - Movies in the Park – Friday, August 11, 18, 25, and September 8 at 8 p.m. at Creekside Park 10 COMMISSIONER ATTENDANCE AT UPCOMING MEETINGS AND EVENTS Jessica Javier, Administrative Assistant, informed the Commission of the following for the Mayor’s Commissioners Meetings – - The August meeting was canceled due to City Council’s August recess. - Starting in September, the Mayor’s Commissioners Meetings will resume in- person only format at the Quinlan Community Center Social Room. - For September’s meeting, the City Manager’s Office has requested that all Chairs attend the first in-person meeting. Commissioners to attend the upcoming Mayor’s meetings as follows: September 13 – Chair Stanek October 11 – Commissioner Swamy November 8 – Commissioner Buch December 13 – Commissioner Buch FUTURE AGENDA SETTING Commissioner Begur requested ElderAid App Team presentation. Commissioner Buch seconded. Commissioner Begur requested FY22-23 Community Funding Grant Program Summary Report. Vice Chair Shearin seconded. Commissioner Begur requested an overview of procedures for Commission meetings in-person at the Quinlan Social Room. Vice Chair Shearin seconded. ADJOURNMENT Chair Stanek adjourned the meeting at 8:57 p.m. to the September 7, 2023 meeting at 7:00 p.m. Respectfully Submitted by, Jessica Javier, Administrative Assistant Parks and Recreation Department Minutes approved at the _____ regular meeting 11 CITY OF CUPERTINO Agenda Item 23-12539 Agenda Date: 9/7/2023 Agenda #: 4. Subject: Fiscal Year 2022-2023 Community Funding Grant Program Written Reports Receive an update on the Fiscal Year 2022-23 Community Funding Grant Program Written Reports. CITY OF CUPERTINO Printed on 8/30/2023Page 1 of 1 powered by Legistar™12 PARKS AND RECREATION COMMISSION STAFF REPORT Meeting: September 7, 2023 Subject Fiscal Year 2022-2023 Community Funding Grant Program Written Reports Recommended Action Receive an update on the Fiscal Year 2022-23 Community Funding Grant Program Written Reports. Reasons for Recommendation On June 9, 2022, City Council approved $69,460.46 for the Fiscal Year 2022-2023 Community Funding Grant Program. The following funding amounts for the Community Funding Program was approved: • West Valley Community Services - $10,000 • Women SV - $20,000 • Senior Services – Heart of the Valley - $6,160.46 • American Cancer Society – Relay for Life - $6,000 • Omniware Networks - $2,000 • Buddhist Tzu Chi Medical Foundation - $8,300 • Breathe California of the Bay Area - $4,000 • Chinese American Coalition For Compassionate Care - $13,000 Per the Community Funding Grant Policy (Attachment A), grant recipients are required to submit a written report to show proof that the grant funds have been spent in the manner and for the purposes stated on the application, including information about the number of persons served and other results that benefit Cupertino. All organizations successfully submitted a written annual report (Attachment B) within the deadline and provided proof of allowable expenses actually incurred. Any funding awarded and not used for the applicant’s program/project/event/ was reimbursed back to the City. The Cupertino Historical Society provided an annual report presentation at the 13 August 3 Parks and Recreation Commission meeting. Attachment C includes an expense breakdown of the annual sum of forty thousand dollars ($40,000) as stated in the Cupertino Historical Society Agreement. Sustainability Impact No sustainability impact. Fiscal Impact Reviewing the presentation does not incur any fiscal impact. Prepared by: Jacinta Liang, Management Analyst Reviewed by: Jenny Koverman, Recreation Manager Approved for Submission by: Rachelle Sander, Director of Parks and Recreation Attachments: A – Community Funding Grant Policy B – Community Funding Annual Reports & Checklist C – Cupertino Historical Society Annual Report 14 Revised due to November 15, 2022 City Council Meeting PURPOSE SCOPE POLICY Fiscal Policies – Community Funding Grant Policy The City of Cupertino currently provides funding to local non-profit organizations in the areas of social services, fine arts, and other programs for the general public. The policy provides a framework for the City's Community Funding Grant Program and guides the administration of the program and decision-making process. It also provides guidance on key aspects of the City's Community Funding Grant Program processes including Eligibility, Evaluation Criteria, Restrictions/Guidelines, and Procedure. All requests for funding must comply with this policy. The City has established the Community Funding Grant Program, subject to availability of funds, with a range of $70,000 to $90,000 in total funding available. Community Funding Grants shall not exceed $20,000 per applicant, per year. City Council will determine the organizations to be awarded funds through the Community Funding Grant Program. City Staff shall review applications for completeness and review the qualifications and accuracy based upon the eligibility criteria set forth below. In all cases, the City reserves the right to reject any and all applications in the event staff identifies a potential conflict of interest or the appearance of a conflict of interest. Submission of an application in no way obligates the City to award a grant and the City reserves the right to reject any or all applications, for any reason, at any time. Eligibility To receive consideration for a Community Funding Grant, grant requests must: • Be a 501(c)(3) non-profit organization with experienced members capable of implementing and managing the program/project/event. • Identify how the funds will be used to benefit the Cupertino community. • Be awarded only once per project • For specific needs, not ongoing, operational costs, or endowment funds. • Have more than 75% of the requested funds allocated for direct service costs versus administrative costs. • Be complete and submitted by the application deadline. Evaluation Criteria • Impact on and benefit to the Cupertino community o Number of Cupertino residents served vs. number of non-Cupertino residents served 15 Revised due to November 15, 2022 City Council Meeting o Availability of the program/project/event to the entire Cupertino community • Community need for the program/project/event • Alignment with Cupertino General Plan Principles • Uniqueness of the program/project/event o Lack of duplication in service in Cupertino o Level of collaboration if a duplicated service • Qualifications and experience of the organization and its members • Reasonable cost • Demonstrated effort to secure funding from other sources and/or establishing partnerships with other community or city organizations • Clarity, completeness, and accuracy of grant application • Past performance and compliance with requirements if a recurring applicant Applications will be sorted into two categories: • New applicants • Past recipients Applications in each category will be evaluated using a tiered structure based on the dollar amount requested for award as follows: • < $999.99 • $1,000.00 - $4,999.99 • $5,000.00 – $9,999.99 • $10,000.00 - $20,000.00 Restrictions/Guidelines • An organization that is applying for multiple grants shall only submit one application. • If requested, recipients must provide full financial statements for the organization. • Festivals currently receiving funding through Festival Fee waivers may not apply for funding through the Community Funding Grant Process for the same festival • Admission to or participation in the event must be "free of charge" • If an applicant makes a grant request directly to a member of the City Council, whether individually or as a group, the Council shall refer the applicant to the Parks and Recreation Department for a Grant application to be reviewed in accordance with this policy. • Grant recipients shall acknowledge the City contribution in formal promotional materials and efforts related to the funded activity. Any use of the City logo must be approved by the City’s Communications Officer. 16 Revised due to November 15, 2022 City Council Meeting Procedure 1. Applicants submit timely and complete grant applications by February 1. 2. City Staff reviews application for completeness and compliance eligibility. 3. Applications will then be forwarded to the Parks and Recreation Commission to be evaluated and sorted into the tiered funding structure. All applicants will be notified and invited to attend the Parks and Recreation Commission Meeting where their applications will be discussed. This meeting typically takes place in Spring. 4. City Council will make the final decision on grant amounts for each applicant as part of the budget adoption which typically happens in June. All applicants will be notified and invited to attend the City Council Meeting where their applications will be discussed. 5. Grant recipients shall submit a written report to the Parks and Recreation Department to show proof that the grant funds have been spent in the manner and for the purposes stated on the application, including information about the number of persons served and other results that benefit Cupertino. o Due by the 15th business day of July following the Fiscal Year in which grant funds are disbursed. o Failure to submit a written report by the July deadline could result in the loss of grant funding eligibility in the future. o Applicants will be expected to reimburse the City any funding awarded and not used for their program/project/event. 17 City of Cupertino Community Funding Grant Annual Project Report Program/Project/Event Name: Agency/Organization Project Contact Person Title Phone E-Mail Grant Received: A. Project Results: Was your program/project/event affected by COVID-19? Yes No Was the program/project/event successful? Please indicate how success was measured: B. Clients Served: Please report the number of clients served as a result of this grant: Proposed in Application Actual from Event Total Number of Individuals Cupertino Residents Particular community groups served: Was the program/project/event available to the entire community/public or were there any eligibility criteria? Was there a charge or fee for the program/project/event? Yes No Gift of Hope West Valley Community Services Gift of Hope Sujatha Venkatraman 408-956-6113 10,000 Executive Director sujathav@wvcommunityservices.org 900 300 1075 264 Low income The program was availble to all low income residents of Cupertino. The eligibility criteria was they had to certify to become a client of WVCS. 18 What outreach methods did your organization use to promote the program/project/ event? C. Budget: Please enter your proposed budget from your application, and your actual expenses accrued from this grant: Category Application Budget Actual Expenditures % of Total Admin Staff Materials/Equipment Entertainment Room/Venue Rental Professional Services (describe) Other: Other: Total 100% Remaining Balance Do you intend to apply for Community Funding next year? Yes No If yes, how much to you intend to apply for? Please list any additional funding received last year from other sources for this program: Person who Prepared Form Title Phone Number Date: D. Upload Documents: 1. Financial Statements 2. Supporting Receipts 0 0 0 0 0 62,000 0 62,000 0 0 0 0 0 10,000 0 10,000 0 0 0 0 0 0 0 15% 10,000 Sujatha Venkatraman Executive Director 408-255-8033 7/4/2023 0 Gift of Hope purchases 0 19 3. Other Signature Date Sujatha Venkatraman Jul 4, 2023 20 Organization Name West Valley Community Services Project Gift of Hope: Holiday Gift Program Project Budget Expense Type Cost Cupertino Grant Clothing (jackets, scarves, gloves, pants, shirts, etc)($13,000) ($5,000) Toys ($18,000) ($2,000) Household items, blankets ($12,000) ($3,000) Food (grocery gift cards for families)($10,000) Program supplies (tape, wrapping paper, AV, printing, etc)($3,000) Direct staff ($6,000) Total Expenses ($62,000) ($10,000) 21 22 23 Community Funding Report Final Audit Report 2023-07-04 Created:2023-07-04 By:PG (preetig@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAPoyQU-qSaqGwxgVSINrAV9qA5JWzuXkH "Community Funding Report" History Web Form created by PG (preetig@cupertino.org) 2022-06-09 - 6:26:57 PM GMT Sujatha Venkatraman (sujathav@wvcommunityservicces.org) uploaded the following supporting documents: File Attachment 1 File Attachment 2 2023-07-04 - 9:49:11 PM GMT Web Form filled in by Sujatha Venkatraman (sujathav@wvcommunityservicces.org) 2023-07-04 - 9:49:11 PM GMT- IP address: 73.92.160.28 User email address verification waived 2023-07-04 - 9:49:13 PM GMT- IP address: 73.92.160.28 Agreement completed. 2023-07-04 - 9:49:13 PM GMT 24 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application,X Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X West Valley Community Services Report Checklist (staff use only) 25 City of Cupertino Community Funding Grant Annual Project Report Program/Project/Event Name: Agency/Organization Project Contact Person Title Phone E-Mail Grant Received: A. Project Results: Was your program/project/event affected by COVID-19? Yes No Was the program/project/event successful? Please indicate how success was measured: B. Clients Served: Please report the number of clients served as a result of this grant: Proposed in Application Actual from Event Total Number of Individuals Cupertino Residents Particular community groups served: Was the program/project/event available to the entire community/public or were there any eligibility criteria? Was there a charge or fee for the program/project/event? Yes No Technical Support for Domestic Abuse Survivors WomenSV Support for Domestic Abuse Survivors Ruth Darlene 650-996-2200 $20,000 Founder & Executive Director ruth@womensv.org 216 10 170 4 Last year (2021-22), WomenSV served 210 women; 56% of the women we served were from Santa Clara County; 15% from San Mateo County; 16% from other Bay Area locations; 7% from other locations in California and 6% from other locations across the U.S. and Canada. WomenSV’s program is available to any woman who seeks our services. We offer long-term individual support of each survivor, establishing a lasting relationship that is maintained for as long as she chooses. 26 What outreach methods did your organization use to promote the program/project/ event? C. Budget: Please enter your proposed budget from your application, and your actual expenses accrued from this grant: Category Application Budget Actual Expenditures % of Total Admin Staff Materials/Equipment Entertainment Room/Venue Rental Professional Services (describe) Other: Other: Total 100% Remaining Balance Do you intend to apply for Community Funding next year? Yes No If yes, how much to you intend to apply for? Please list any additional funding received last year from other sources for this program: Person who Prepared Form Title Phone Number Date: D. Upload Documents: 1. Financial Statements 2. Supporting Receipts 0 $7,500 0 0 $10,000 $2,500 0 $20,000 0 $9,233.86 0 0 $6,645 $4,800 0 $20,678.86 -678.86 0 0 123% 0 0 66% 192% Rebecca Hull Grant Writer 831-331-3478 7/12/23 website development & tech support educational videos n/a 27 3. Other Signature Date Ruth Darlene Jul 12, 2023 28 WomenSV City Of Cupertino Grant Below is a summary of WomenSV's expenditures of the City of Cupertino grant in the amount of $20,000 Receipts/invoices for each vendor can be found in the corresponding tabs at bottom of spreadsheet. Budget Category Vendor(s)Amount(s) Materials/Equipments Amazon $1,815.08 Best Buy $5,364.45 Apple $2,054.33 Total Materials/Equipment $9,233.86 Professional Services New Moon Marketing $4,320.00 Skyline Computer $2,325.00 Total Professional Services $6,645.00 Other (educational videos)New Moon Marketing $4,800.00 Total Other TOTAL EXPENDITURES $20,678.86 29 30 31 32 33 Date Name Memo/Description Account Split 07/14/2022 Best Buy Georgi's monitor and mouse (split invoice)Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/15/2022 Best Buy Georgi's laptop, mouse, monitor, cord Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/15/2022 Best Buy Georgi's computer dock (split invoice)Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/25/2022 Best Buy Ruth's mouse Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's Laptop Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's Dock Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's Mouse and Cord Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's monitor Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 08/19/2022 Best Buy Survivor tech supplies Direct Client Support Chase Ink Card:Chase - Ruth 08/27/2022 Best Buy Survivor tech supplies Direct Client Support Chase Ink Card:Chase - Ruth 10/28/2022 Best Buy Buy phones Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 10/28/2022 Best Buy BESTBUYCOM806694636500 Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 10/29/2022 Best Buy buy phones Direct Client Support Chase Ink Card:Chase - Ruth 10/31/2022 Best Buy Buy phones Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 12/16/2022 Best Buy phone card Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 12/19/2022 Best Buy Phones Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 12/20/2022 Best Buy phone card Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 01/11/2023 Best Buy BESTBUYCOM806732626059 Direct Client Support Chase Ink Card:Chase - Ruth 01/12/2023 Best Buy BESTBUYCOM806732626059 Direct Client Support Chase Ink Card:Chase - Ruth 01/24/2023 Best Buy BESTBUYCOM806736059104 Direct Client Support Chase Ink Card:Chase - Ruth 01/25/2023 Best Buy BESTBUYCOM806736059104 Direct Client Support Chase Ink Card:Chase - Ruth 01/28/2023 Best Buy BESTBUYCOM806736792694 Direct Client Support Chase Ink Card:Chase - Ruth 02/04/2023 Best Buy BESTBUYCOM806738830712 Direct Client Support Chase Ink Card:Chase - Ruth TOTAL Transaction Report July 2022 - June 2023 Tuesday, Jul 11, 2023 10:47:01 AM GMT-7 - Cash Basis 34 Amount 149.99 1,725.92 245.27 87.29 1,848.49 282.09 56.40 113.49 -26.03 262.49 77.78 103.70 21.81 120.01 14.91 54.68 15.68 15.76 53.94 15.76 $ 54.63 15.76 54.63 $5,364.45 Transaction Report July 2022 - June 2023 Tuesday, Jul 11, 2023 10:47:01 AM GMT-7 - Cash Basis 35 Date Name Memo/Description Account 08/18/2022 Amazon Smile Ruth's Birdie personal safety alarm Operations:Equipment 09/02/2022 Amazon Smile Return item credit Operations:Office Expenses:Telephone & Internet 10/25/2022 Amazon Smile pens and notebooks Operations:Office Expenses:Supplies:Office Supplies 10/25/2022 Amazon Smile AMZN Mktp US*H04BN3340 Operations:Office Expenses:Supplies:Office Supplies 10/31/2022 Amazon Smile Amazon.com*H01946KF1 Operations:Office Expenses:Telephone & Internet 11/03/2022 Amazon Smile Survivor tech supplies Direct Client Support 11/05/2022 Amazon Smile Professional development textbook Coercive Control in Children's and motheres' Lives by Emma KatzOperations:Other Expenses:Professional Development:Professional Development 11/21/2022 Amazon Smile Credit Operations:Office Expenses:Telephone & Internet 12/09/2022 Amazon Smile Volunteer appreciation gift candle Operations:Other Expenses:Volunteer Recognition 12/19/2022 Amazon Smile AMZN Mktp US*887U64Q43 Operations:Other Expenses:Professional Development:Professional Development 01/04/2023 Amazon Smile AMZN Mktp US*AB2UG6LQ3 Operations:Office Expenses:Supplies:Office Supplies 01/09/2023 Amazon Smile AMZN Mktp US*JB6BW0HH3 Operations:Office Expenses:Supplies:Office Supplies 01/13/2023 Amazon Smile AMZN Mktp US*MX42D4A53 Direct Client Support 05/04/2023 Amazon Smile Amazon.com*8F42K09A3 Operations:Office Expenses:Supplies:Office Supplies 05/20/2023 Amazon Smile AMZN Mktp US*PHXX837F3 Operations:Office Expenses:Supplies:Office Supplies 06/05/2023 Amazon Smile Amazon.com*EXXX59Z03 Operations:Office Expenses:Supplies:Office Supplies 06/06/2023 Amazon Smile AMZN Mktp US*XKX730JK3 Operations:Office Expenses:Supplies:Office Supplies 06/09/2023 Amazon Smile Amazon.com*HR90L8HZ3 Operations:Office Expenses:Supplies:Office Supplies 06/09/2023 Amazon Smile AMZN Mktp US*DIX6J0I93 Operations:Office Expenses:Supplies:Office Supplies 06/12/2023 Amazon Smile AMZN Mktp US*T08MV1SR0 Operations:Office Expenses:Supplies:Office Supplies 06/13/2023 Amazon Smile AMZN Mktp US*XX09D2ZT3 Operations:Office Expenses:Supplies:Office Supplies 06/17/2023 Amazon Smile Amazon.com*XEXKX4623 Operations:Office Expenses:Supplies:Office Supplies 06/21/2023 Amazon Smile Amazon.com*XI45A5KS3 Operations:Office Expenses:Supplies:Office Supplies 06/25/2023 Amazon Smile AMZN Mktp US*DV22X6EW3 Operations:Office Expenses:Supplies:Office Supplies 06/27/2023 Amazon Smile AMZN Mktp US*RX6ES17K3 Operations:Office Expenses:Supplies:Office Supplies TOTAL Transaction Report July 2022 - June 2023 36 Tuesday, Jul 11, 2023 10:48:00 AM GMT-7 - Cash Basis 37 Split Amount Chase Ink Card:Chase - Ruth 32.68 WomenSV Main -69.97 Chase Ink Card:Chase - Ruth 55.40 Chase Ink Card:Chase - Ruth 11.36 Chase Ink Card:Chase - Ruth 217.72 Chase Ink Card:Chase - Ruth 29.76 Chase Ink Card:Chase - Ruth 60.02 WomenSV Main -73.76 Chase Ink Card:Chase - Ruth 18.53 Chase Ink Card:Chase - Ruth 47.79 Chase Ink Card:Chase - Ruth 46.87 Chase Ink Card:Chase - Ruth 38.18 Chase Ink Card:Chase - Ruth 7.53 Chase Ink Card:Chase - Ruth 145.85 Chase Ink Card:Chase - Ruth 155.52 Chase Ink Card:Chase - Ruth 6.15 Chase Ink Card:Chase - Ruth 9.77 Chase Ink Card:Chase - Ruth 54.49 Chase Ink Card:Chase - Ruth 15.00 Chase Ink Card:Chase - Ruth 231.06 Chase Ink Card:Chase - Ruth 39.87 Chase Ink Card:Chase - Ruth 134.36 Chase Ink Card:Chase - Ruth 208.32 Chase Ink Card:Chase - Ruth 148.60 Chase Ink Card:Chase - Ruth 243.98 $1,815.08 Transaction Report July 2022 - June 2023 38 Tuesday, Jul 11, 2023 10:48:00 AM GMT-7 - Cash Basis 39 40 41 42 Date Name Memo/Description Account Split Amount 03/26/2023 Apple APPLE.COM/US Operations:Equipment Chase Ink Card:Chase - Ruth 1,635.78 03/26/2023 Apple APPLE STORE #R099 Operations:Equipment Chase Ink Card:Chase - Ruth 96.08 03/26/2023 Apple APPLE STORE R099 Operations:Equipment Chase Ink Card:Chase - Ruth 322.47 TOTAL $2,054.33 WomenSV Transaction Report July 2022 - June 2023 Tuesday, Jul 11, 2023 10:45:54 AM GMT-7 - Cash Basis 43 WomenSV City Of Cupertino Grant Below is a summary of WomenSV's expenditures of the City of Cupertino grant in the amount of $20,000 Receipts/invoices for each vendor can be found in the corresponding tabs at bottom of spreadsheet. Budget Category Vendor(s)Amount(s) Materials/Equipments Amazon $1,815.08 Best Buy $5,364.45 Apple $2,054.33 Total Materials/Equipment $9,233.86 Professional Services New Moon Marketing $4,320.00 Skyline Computer $2,325.00 Total Professional Services $6,645.00 Other (educational videos)New Moon Marketing $4,800.00 Total Other TOTAL EXPENDITURES $20,678.86 44 45 46 47 48 Date Name Memo/Description Account Split 07/14/2022 Best Buy Georgi's monitor and mouse (split invoice)Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/15/2022 Best Buy Georgi's laptop, mouse, monitor, cord Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/15/2022 Best Buy Georgi's computer dock (split invoice)Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/25/2022 Best Buy Ruth's mouse Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's Laptop Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's Dock Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's Mouse and Cord Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 07/27/2022 Best Buy Valerie's monitor Operations:Information Technology:Hardware/Equipment Chase Ink Card:Chase - Ruth 08/19/2022 Best Buy Survivor tech supplies Direct Client Support Chase Ink Card:Chase - Ruth 08/27/2022 Best Buy Survivor tech supplies Direct Client Support Chase Ink Card:Chase - Ruth 10/28/2022 Best Buy Buy phones Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 10/28/2022 Best Buy BESTBUYCOM806694636500 Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 10/29/2022 Best Buy buy phones Direct Client Support Chase Ink Card:Chase - Ruth 10/31/2022 Best Buy Buy phones Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 12/16/2022 Best Buy phone card Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 12/19/2022 Best Buy Phones Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 12/20/2022 Best Buy phone card Operations:Office Expenses:Telephone & Internet Chase Ink Card:Chase - Ruth 01/11/2023 Best Buy BESTBUYCOM806732626059 Direct Client Support Chase Ink Card:Chase - Ruth 01/12/2023 Best Buy BESTBUYCOM806732626059 Direct Client Support Chase Ink Card:Chase - Ruth 01/24/2023 Best Buy BESTBUYCOM806736059104 Direct Client Support Chase Ink Card:Chase - Ruth 01/25/2023 Best Buy BESTBUYCOM806736059104 Direct Client Support Chase Ink Card:Chase - Ruth 01/28/2023 Best Buy BESTBUYCOM806736792694 Direct Client Support Chase Ink Card:Chase - Ruth 02/04/2023 Best Buy BESTBUYCOM806738830712 Direct Client Support Chase Ink Card:Chase - Ruth TOTAL Transaction Report July 2022 - June 2023 Tuesday, Jul 11, 2023 10:47:01 AM GMT-7 - Cash Basis 49 Amount 149.99 1,725.92 245.27 87.29 1,848.49 282.09 56.40 113.49 -26.03 262.49 77.78 103.70 21.81 120.01 14.91 54.68 15.68 15.76 53.94 15.76 $ 54.63 15.76 54.63 $5,364.45 Transaction Report July 2022 - June 2023 Tuesday, Jul 11, 2023 10:47:01 AM GMT-7 - Cash Basis 50 Date Name Memo/Description Account 08/18/2022 Amazon Smile Ruth's Birdie personal safety alarm Operations:Equipment 09/02/2022 Amazon Smile Return item credit Operations:Office Expenses:Telephone & Internet 10/25/2022 Amazon Smile pens and notebooks Operations:Office Expenses:Supplies:Office Supplies 10/25/2022 Amazon Smile AMZN Mktp US*H04BN3340 Operations:Office Expenses:Supplies:Office Supplies 10/31/2022 Amazon Smile Amazon.com*H01946KF1 Operations:Office Expenses:Telephone & Internet 11/03/2022 Amazon Smile Survivor tech supplies Direct Client Support 11/05/2022 Amazon Smile Professional development textbook Coercive Control in Children's and motheres' Lives by Emma KatzOperations:Other Expenses:Professional Development:Professional Development 11/21/2022 Amazon Smile Credit Operations:Office Expenses:Telephone & Internet 12/09/2022 Amazon Smile Volunteer appreciation gift candle Operations:Other Expenses:Volunteer Recognition 12/19/2022 Amazon Smile AMZN Mktp US*887U64Q43 Operations:Other Expenses:Professional Development:Professional Development 01/04/2023 Amazon Smile AMZN Mktp US*AB2UG6LQ3 Operations:Office Expenses:Supplies:Office Supplies 01/09/2023 Amazon Smile AMZN Mktp US*JB6BW0HH3 Operations:Office Expenses:Supplies:Office Supplies 01/13/2023 Amazon Smile AMZN Mktp US*MX42D4A53 Direct Client Support 05/04/2023 Amazon Smile Amazon.com*8F42K09A3 Operations:Office Expenses:Supplies:Office Supplies 05/20/2023 Amazon Smile AMZN Mktp US*PHXX837F3 Operations:Office Expenses:Supplies:Office Supplies 06/05/2023 Amazon Smile Amazon.com*EXXX59Z03 Operations:Office Expenses:Supplies:Office Supplies 06/06/2023 Amazon Smile AMZN Mktp US*XKX730JK3 Operations:Office Expenses:Supplies:Office Supplies 06/09/2023 Amazon Smile Amazon.com*HR90L8HZ3 Operations:Office Expenses:Supplies:Office Supplies 06/09/2023 Amazon Smile AMZN Mktp US*DIX6J0I93 Operations:Office Expenses:Supplies:Office Supplies 06/12/2023 Amazon Smile AMZN Mktp US*T08MV1SR0 Operations:Office Expenses:Supplies:Office Supplies 06/13/2023 Amazon Smile AMZN Mktp US*XX09D2ZT3 Operations:Office Expenses:Supplies:Office Supplies 06/17/2023 Amazon Smile Amazon.com*XEXKX4623 Operations:Office Expenses:Supplies:Office Supplies 06/21/2023 Amazon Smile Amazon.com*XI45A5KS3 Operations:Office Expenses:Supplies:Office Supplies 06/25/2023 Amazon Smile AMZN Mktp US*DV22X6EW3 Operations:Office Expenses:Supplies:Office Supplies 06/27/2023 Amazon Smile AMZN Mktp US*RX6ES17K3 Operations:Office Expenses:Supplies:Office Supplies TOTAL Transaction Report July 2022 - June 2023 51 Tuesday, Jul 11, 2023 10:48:00 AM GMT-7 - Cash Basis 52 Split Amount Chase Ink Card:Chase - Ruth 32.68 WomenSV Main -69.97 Chase Ink Card:Chase - Ruth 55.40 Chase Ink Card:Chase - Ruth 11.36 Chase Ink Card:Chase - Ruth 217.72 Chase Ink Card:Chase - Ruth 29.76 Chase Ink Card:Chase - Ruth 60.02 WomenSV Main -73.76 Chase Ink Card:Chase - Ruth 18.53 Chase Ink Card:Chase - Ruth 47.79 Chase Ink Card:Chase - Ruth 46.87 Chase Ink Card:Chase - Ruth 38.18 Chase Ink Card:Chase - Ruth 7.53 Chase Ink Card:Chase - Ruth 145.85 Chase Ink Card:Chase - Ruth 155.52 Chase Ink Card:Chase - Ruth 6.15 Chase Ink Card:Chase - Ruth 9.77 Chase Ink Card:Chase - Ruth 54.49 Chase Ink Card:Chase - Ruth 15.00 Chase Ink Card:Chase - Ruth 231.06 Chase Ink Card:Chase - Ruth 39.87 Chase Ink Card:Chase - Ruth 134.36 Chase Ink Card:Chase - Ruth 208.32 Chase Ink Card:Chase - Ruth 148.60 Chase Ink Card:Chase - Ruth 243.98 $1,815.08 Transaction Report July 2022 - June 2023 53 Tuesday, Jul 11, 2023 10:48:00 AM GMT-7 - Cash Basis 54 55 56 57 Date Name Memo/Description Account Split Amount 03/26/2023 Apple APPLE.COM/US Operations:Equipment Chase Ink Card:Chase - Ruth 1,635.78 03/26/2023 Apple APPLE STORE #R099 Operations:Equipment Chase Ink Card:Chase - Ruth 96.08 03/26/2023 Apple APPLE STORE R099 Operations:Equipment Chase Ink Card:Chase - Ruth 322.47 TOTAL $2,054.33 WomenSV Transaction Report July 2022 - June 2023 Tuesday, Jul 11, 2023 10:45:54 AM GMT-7 - Cash Basis 58 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application,X Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X WomenSV Report Checklist (staff use only) 59 City of Cupertino Community Funding Grant Annual Project Report Program/Project/Event Name: Agency/Organization Project Contact Person Title Phone E-Mail Grant Received: A. Project Results: Was your program/project/event affected by COVID-19? Yes No Was the program/project/event successful? Please indicate how success was measured: B. Clients Served: Please report the number of clients served as a result of this grant: Proposed in Application Actual from Event Total Number of Individuals Cupertino Residents Particular community groups served: Was the program/project/event available to the entire community/public or were there any eligibility criteria? Was there a charge or fee for the program/project/event? Yes No COVID Car Kit Heart of the Valley, SERVICES FOR SENIORS, Inc. COVID Car Kit Sylvia Abboud 408-417-7867 6120 Executive Director sylvia@servicesforseniors.org 252 50 100 22 SeniorsSeniors 65+ living independently in their homes in the City of Cupertino Eligibility criteria is for Seniors 65+ living independently in their homes in the City of Cupertino 60 What outreach methods did your organization use to promote the program/project/ event? C. Budget: Please enter your proposed budget from your application, and your actual expenses accrued from this grant: Category Application Budget Actual Expenditures % of Total Admin Staff Materials/Equipment Entertainment Room/Venue Rental Professional Services (describe) Other: Other: Total 100% Remaining Balance Do you intend to apply for Community Funding next year? Yes No If yes, how much to you intend to apply for? Please list any additional funding received last year from other sources for this program: Person who Prepared Form Title Phone Number Date: D. Upload Documents: 1. Financial Statements 2. Supporting Receipts 0 6120 0 0 0 0 0 0 0 $6,877.96 0 0 0 0 0 0 0 0 0 100 0 0 0 0 0 Syvlia Abboud Executive Director 408-417-7867 7/18/23 0 0 0 61 3. Other Signature Date Sylvia Abboud Jul 18, 2023 62 Submitter Sylvia Abboud Invoice # Need COVID Car Kit - Grant from City of Cupertino Individuals Involved How many of each in office?Items to be Purchased Ship Status Delivered? Number Boxes Ordered Price of Item Total Cost Minus Tax & Shipping FOR THE BAGGIES = 2,000 of them KN95 MASKS Done KN95 Masks - 20/box = 2,000 100.00 $8.95 $895.00 Done KN95 Masks = 20/box = 1,360 = 2,000 baggies+68.00 $8.95 $608.60 TOTAL KN95 MASKS 168.00 $1,503.60 Done Blue Masks - 50 / box = 1,200 / 2 = 600 baggies 9/9/2022 Yes 24.00 $17.49 $419.76 Done Blue Masks - 50 / box = 1,400 / 2 = 700baggies 9/9/2022 Yes 28.00 $17.49 $489.72 Done Blue Masks - 50 / box = 1,400 / 2 = 700 baggies = 2 ,000 baggies 9/9/2022 Yes 28.00 $17.49 $489.72 TOTAL BLUE MASKS 80.00 $1,399.20 Done Medium Gloves - 2,000 / pack * 3 = 6,000 / 6 = 1,000 baggies 8/3 - 5, 2022 4000 - need 2000 more3.00 $94.88 $284.64 Done Large Gloves - 2,000 / pack * 3 = 6,000 / 6 = 1,000 baggies 8/3 - 5, 2022 Yes 3.00 $94.88 $284.64 Done X - Large Gloves - 2,000 / pack * 2 = 4,000 / 6 = 700 baggies 8/3 - 5, 2022 Yes 2.00 $94.88 $189.76 Done X - Large Gloves - 1,000 / pack * 2 = 2,000 /6 = 333 baggies = 2,000 baggies 8/8 - 12, 2022 Yes 2.00 $58.88 $117.76 Mix of gloves per baggie for different sized hands TOTAL GLOVES 10.00 343.52 876.80 HAND SANITIZING WIPES Done Purell Hand Sanitizing Wipes - 300 / box * 34 boxes /5 = 2,040 baggies 9/9/2022 Yes 34.00 $23.29 791,86 TOTAL HAND SANITIZING WIPES 34.00 $23.29 791,86 SHOE COVERS Done NonDisposable shoe covers - XL Blue - 10 / box * 10 boxes = 100 pairs 7/31/2022 Yes 10.00 $28.99 $289.90 For in-home services on rainy days TOTAL SHOE COVERS 10.00 $28.99 $289.90 FUNDER COURTESY CARDS Done Biz Cards - 500 - Courtesy of the City of Cupertino - order more as needed 8/11/2022 No 1.00 $25.95 $25.95 TOTAL FUNDER COURTESY CARDS $25.95 $25.95 FOR THE SATCHELS = 200 each LYSOL DISINFECTANT Done Lysol Fabric Disinfectant - Transportation - 100 Satchels - order more as needed 7/31/2022 Yes 100.00 $5.97 $597.00 Done Lysol Disinfectant - 12/ case * 3 = 36 - for indoor handyman - 36 satchels 8/4/2022 Yes 3.00 $71.88 $215.64 For bathroom areas only 63 TOTAL LYSOL DISINFECTANT 103.00 77.85 812.64 PAPER TOWELS Done Paper Towels - 16 packs / case * 3 = 48 9/9/2022 Yes 3.00 $33.99 $101.97 Done Paper Towels - 16 packs / case * 10 = 160 + 48 = 208 sachels 9/9/2022 Yes 10.00 $33.99 $339.90 TOTAL PAPER TOWELS 13.00 67.98 441.87 KLEENEX Done Kleenex - 36 boxes / case * 3 = 108 sachels - order more as needed 9/9/2022 Yes 3.00 $54.91 $164.73 TOTAL KLEENEX 3.00 54.91 164.73 ZIPLOCK BAGGIES Done Gallon Ziplock baggies - 250 / box = 250 baggies 8/3 - 5, 2022 Yes 1.00 $39.05 $39.05 Done Gallon Ziplock baggies - 250 / box * 3 = 750 baggies = 1,000 baggies 8/3 - 5, 2022 Yes 3.00 $39.05 $117.15 Order more as needed TOTAL ZIPLOCK BAGGIES 4.00 78.10 156.20 TOTE BAGS Done Tote bag w/ HOV logo - 100 / package * 2 = 200 Tote bags 8/9 - 10, 2022 Yes 2.00 $113.29 $226.58 TOTAL TOT BAGS TOTAL COST OF PURCHASES GRANT AMOUNT TOTAL OVER 64 Tax Shipping Total Cost Where Purchased On-line In Store HOV / Personal Credit Card Date Reimbursed Billing Code Receipt(s) Attached (Y/N) Sent to Lidia (Date) Free Free $895.00 Chicago Medical Supply X HOV 9/9/2022 Free Free $608.60 Chicago Medical Supply X HOV 9/9/2022 $1,503.60 Free Free $419.76 Smile.Amazon.com X HOV Emailed 9/9/2022 Free Free $489.72 Smile.Amazon.com X HOV Emailed 9/9/2022 Free Free $489.72 Smile.Amazon.com X HOV Emailed 9/9/2022 $1,399.20 Free Free $284.64 Smile.Amazon.com X HOV Emailed 9/9/2022 Free Free $284.64 Smile.Amazon.com X HOV Emailed 9/9/2022 Free Free $189.76 Smile.Amazon.com X HOV Emailed 9/9/2022 $11.04 Free $128.80 Smile.Amazon.com X HOV Emailed 9/9/2022 11.04 $887.84 Free Free $791.86 Smile.Amazon.com X HOV Emailed 9/9/2022 $791.86 $27.20 Free $317.10 Smile.Amazon.com X HOV Emailed 9/9/2022 $27.20 $317.10 Free Free $52.63 OverNightPrints X HOV Emailed 9/9/2022 $0.00 $0.00 $52.63 $55.97 Free $651.94 Walmart X Personal Emailed 9/9/2022 $20.22 Free $235.86 Smile.Amazon.com X HOV Emailed 9/9/2022 65 76.19 0.00 887.80 Free Free $104.97 Smile.Amazon.com X HOV Emailed 9/9/2022 Free Free $349.90 Smile.Amazon.com X HOV Emailed 9/9/2022 0.00 0.00 454.87 Free Free $164.73 Smile.Amazon.com X HOV Emailed 9/9/2022 0.00 0.00 164.73 Free Free $42.71 Smile.Amazon.com X HOV Emailed 9/9/2022 Free Free $127.80 Smile.Amazon.com X HOV Emailed 9/9/2022 0.00 0.00 170.51 Free $247.82 Smile.Amazon.com X HOV Emailed 9/9/2022 $247.82 $6,877.96 $6,120.00 $757.96 66 7/18/23 Hi Jacinta, Thank goodness the form is short – I had to restart quite a few times. I did put the text to the questions into a word doc, so I could copy paste them– but I still had to fill out all the other sections again and again. There are a lot of receipts for this project and when I tried to upload them – only 1 was accepted – so I attached an Excel that lists everything out. I have all the receipts, please let me know who I should email them to – and it took me some time to realize that I needed to make my documents PDFs – so while the Excel is in landscape – the data is in 4 quadrants (pages) – I can email that to you or the point of contact also, for easier reading. Best, Sylvia Abboud Executive Director Heart of the Valley, SERVICES FOR SENIORS, Inc. ~Thank you for helping us keep seniors living independently in their homes~ 67 Community Funding Report Final Audit Report 2023-07-18 Created:2023-07-18 By:PG (preetig@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAA_bY0syLFcQpPl1uL-UXTucqvFoY1Dh3l "Community Funding Report" History Web Form created by PG (preetig@cupertino.org) 2022-06-09 - 6:26:57 PM GMT Sylvia Abboud (sylvia@servicesforseniors.org) uploaded the following supporting documents: File Attachment 1 File Attachment 2 2023-07-18 - 9:36:12 PM GMT Web Form filled in by Sylvia Abboud (sylvia@servicesforseniors.org) 2023-07-18 - 9:36:12 PM GMT- IP address: 69.181.246.133 User email address verification waived 2023-07-18 - 9:36:15 PM GMT- IP address: 69.181.246.133 Agreement completed. 2023-07-18 - 9:36:15 PM GMT 68 INVOICE TO: Sylvia Abboud Heart of the Valley, SERVICES POBox 418 Santa Clara, CA, 95052 United States PAID BY: Visa 1204 SHIPPING TO Sylvia Abboud Heart of the Valley, SERVICES United States ORDER SUMMARY Double Sided Business Cards 500 $69.62 Product $69.62 15 PT Card Stock Paper Complimentary SUBTOTAL $69.62 FILE REVIEW $1.00 DISCOUNT -$52.63 SHIPPING $7.96 TAX $0.00 TOTAL $25.95 Do you have questions concerning your order? Simply login to My Account to view the order items associated with this invoice. Overnight Prints 7582 Las Vegas Blvd. S. Suite #487, Las Vegas, NV, 89123 Customer Service: 714.838.8888 (Available M-F 8am-5pm PST) ORDER NUMBER 201394210 ORDER DATE July 31, 2022 PAYMENT DETAILS SHIPPING DETAILS ORDER DATE:July 31, 2022 EST. DELIVERY DATE:August 11, 2022 SHIPPING COST:$7.96 CONTACT PHONE:+1 408-417-7867 CONTACT EMAIL:sylvia@servicesforseniors.org ITEM QUANTITY PRICE 69 Item(s) Subtotal: $39.05 Shipping & Handling: $0.00 ----- Total before tax: $39.05 Estimated tax to be collected: $3.66 ----- Grand Total:$42.71 Final Details for Order #113-8949915-6594628 Print this page for your records. Order Placed: July 29, 2022 Amazon.com order number: 113-8949915-6594628 Seller's order number: -ID Order Total: $42.71 Shipped on August 2, 2022 Items Ordered Price 1 of: Ziploc 682257 1 Gal. Ziploc Double Zipper Storage Bags (250/Box) Sold by: flipcost (seller profile) Co ndition: New $39.05 Shipping Address: Sylvia Abboud United States Shipping Speed: Standard Shipping Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud United States Credit Card transactions Visa ending in 1204: August 2, 2022:$42.71 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-8949915-6594628 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 1 of 1 9/9/2022, 11:41 AM 70 Item(s) Subtotal: $226.58 Shipping & Handling: $0.00 ----- Total before tax: $226.58 Estimated tax to be collected: $21.24 ----- Grand Total:$247.82 Final Details for Order #113-8132119-9571466 Print this page for your records. Order Placed: July 29, 2022 Amazon.com order number: 113-8132119-9571466 Order Total: $247.82 Shipped on August 1, 2022 Items Ordered Price 2 of: Custom Southern Style Grocery Tote Bags Set of 50, Personalized Bulk Pack - Reusable, Great for Grocery, Shopping, Travel, Carry on Bag - Red Sold by: Discount Promos (seller profile) Co ndition: New $113.29 Shipping Address: Sylvia Abboud United States Shipping Speed: Standard Shipping Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud United States Credit Card transactions Visa ending in 1204: August 1, 2022:$247.82 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-8132119-9571466 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 1 of 1 9/9/2022, 11:42 AM 71 Item(s) Subtotal: $215.64 Shipping & Handling: $0.00 ----- Total before tax: $215.64 Estimated tax to be collected: $20.22 ----- Final Details for Order #113-4007014-2398627 Print this page for your records. Order Placed: July 29, 2022 Amazon.com order number: 113-4007014-2398627 Order Total: $235.86 Shipped on July 30, 2022 Items Ordered Price 1 of: Lysol Disinfectant Spray, Sanitizing and Antibacterial Spray, For Disinfecting and Deodorizing, Crisp Linen, 12 Count, 19 fl oz each Sold by: Amazon.com Services LLC Condition: New $71.88 Shipping Address: Sylvia Abboud United States Shipping Speed: Two-Day Shipping Shipped on July 31, 2022 Items Ordered Price 2 of: Lysol Disinfectant Spray, Sanitizing and Antibacterial Spray, For Disinfecting and Deodorizing, Crisp Linen, 12 Count, 19 fl oz each Sold by: Amazon.com Services LLC Condition: New $71.88 Shipping Address: Sylvia Abboud United States Shipping Speed: Two-Day Shipping Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud Amazon.com - Order 113-4007014-2398627 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 1 of 2 9/9/2022, 11:47 AM 72 Grand Total:$235.86United States Credit Card transactions Visa ending in 1204: July 31, 2022:$235.86 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-4007014-2398627 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 2 of 2 9/9/2022, 11:47 AM 73 Order details - Walmart.com https://www.walmart.com/orders/200010074836444 1 of 3 9/9/2022, 12:33 PM 74 Order details - Walmart.com https://www.walmart.com/orders/200010074836444 2 of 3 9/9/2022, 12:33 PM 75 Order details - Walmart.com https://www.walmart.com/orders/200010074836444 3 of 3 9/9/2022, 12:33 PM 76 Final Details for Order #113-5472379-6760255 Print this page for your records. Order Placed: July 31, 2022 Amazon.com order number: 113-5472379-6760255 Order Total: $317.10 Shipped on July 31, 2022 Items Ordered Price 4 of: Anmerl Shoe & Boot Covers, Durable Cotton Breathable Reusable Shoe Covers, Non-Slip Washable Dust Foot & Shoe Covers for Indoors Contractors Workers Shoeless Home, 10 Pairs (ExtraLarge - Navy Blue) Sold by: Anmerl (seller profile) Co ndition: New $28.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 31, 2022 Items Ordered Price 4 of: Anmerl Shoe & Boot Covers, Durable Cotton Breathable Reusable Shoe Covers, Non-Slip Washable Dust Foot & Shoe Covers for Indoors Contractors Workers Shoeless Home, 10 Pairs (ExtraLarge - Navy Blue) Sold by: Anmerl (seller profile) Co ndition: New $28.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 31, 2022 Items Ordered Price Amazon.com - Order 113-5472379-6760255 https://www.amazon.com/gp/css/summary/print.html?orderID=113-54... 1 of 2 9/9/2022, 11:25 AM 77 Item(s) Subtotal: $289.90 Shipping & Handling: $0.00 ----- Total before tax: $289.90 Estimated tax to be collected: $27.20 ----- Grand Total:$317.10 2 of: Anmerl Shoe & Boot Covers, Durable Cotton Breathable Reusable Shoe Covers, Non-Slip Washable Dust Foot & Shoe Covers for Indoors Contractors Workers Shoeless Home, 10 Pairs (ExtraLarge - Navy Blue) Sold by: Anmerl (seller profile) Co ndition: New $28.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud United States Credit Card transactions Visa ending in 1204: July 31, 2022:$317.10 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-5472379-6760255 https://www.amazon.com/gp/css/summary/print.html?orderID=113-54... 2 of 2 9/9/2022, 11:25 AM 78 Final Details for Order #113-9491312-7079465 Print this page for your records. Order Placed: July 29, 2022 Amazon.com order number: 113-9491312-7079465 Order Total: $3,074.07 Shipped on July 30, 2022 Items Ordered Price 2 of: Scott Essential Multifold Paper Towels (01840) with Fast-Drying Absorbency Pockets, White, 16 Packs / Case, 250 Sheets / Pack, 4,000 Towels / Case Sold by: Amazon.com Services LLC Condition: New $34.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 2 of: Scott Essential Multifold Paper Towels (01840) with Fast-Drying Absorbency Pockets, White, 16 Packs / Case, 250 Sheets / Pack, 4,000 Towels / Case Sold by: Amazon.com Services LLC Condition: New $34.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 2 of: Scott Essential Multifold Paper Towels (01840) with Fast-Drying Absorbency Pockets, White, 16 Packs / Case, 250 Sheets / Pack, 4,000 Towels / Case Sold by: Amazon.com Services LLC Condition: New $34.99 Amazon.com - Order 113-9491312-7079465 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 1 of 7 9/9/2022, 11:35 AM 79 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 2 of: Scott Essential Multifold Paper Towels (01840) with Fast-Drying Absorbency Pockets, White, 16 Packs / Case, 250 Sheets / Pack, 4,000 Towels / Case Sold by: Amazon.com Services LLC Condition: New $34.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 1 of: Scott Essential Multifold Paper Towels (01840) with Fast-Drying Absorbency Pockets, White, 16 Packs / Case, 250 Sheets / Pack, 4,000 Towels / Case Sold by: Amazon.com Services LLC Condition: New $34.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price Amazon.com - Order 113-9491312-7079465 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 2 of 7 9/9/2022, 11:35 AM 80 2 of: Scott Essential Multifold Paper Towels (01840) with Fast-Drying Absorbency Pockets, White, 16 Packs / Case, 250 Sheets / Pack, 4,000 Towels / Case Sold by: Amazon.com Services LLC Condition: New $34.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 2 of: Scott Essential Multifold Paper Towels (01840) with Fast-Drying Absorbency Pockets, White, 16 Packs / Case, 250 Sheets / Pack, 4,000 Towels / Case Sold by: Amazon.com Services LLC Condition: New $34.99 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 28 of: DemeTECH ASTM Level 3 Highly Protective 3 Layer Face Mask with Ear Loops - Made in the USA - 50 Qty Sold by: DemeTech Corporation (seller profile) Condition: New $17.49 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on August 2, 2022 Amazon.com - Order 113-9491312-7079465 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 3 of 7 9/9/2022, 11:35 AM 81 Items Ordered Price 24 of: DemeTECH ASTM Level 3 Highly Protective 3 Layer Face Mask with Ear Loops - Made in the USA - 50 Qty Sold by: DemeTech Corporation (seller profile) Condition: New $17.49 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 1 of: Kleenex Professional Facial Tissue Cube for Business (21270), Upright Face Tissue Box, 36 Boxes/Case, 95 Tissues/Box, 3,420 Tissues/Case Sold by: Amazon.com Services LLC Condition: New $54.91 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 1 of: Kleenex Professional Facial Tissue Cube for Business (21270), Upright Face Tissue Box, 36 Boxes/Case, 95 Tissues/Box, 3,420 Tissues/Case Sold by: Amazon.com Services LLC Condition: New $54.91 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Amazon.com - Order 113-9491312-7079465 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 4 of 7 9/9/2022, 11:35 AM 82 Shipped on July 30, 2022 Items Ordered Price 1 of: Kleenex Professional Facial Tissue Cube for Business (21270), Upright Face Tissue Box, 36 Boxes/Case, 95 Tissues/Box, 3,420 Tissues/Case Sold by: Amazon.com Services LLC Condition: New $54.91 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 28 of: DemeTECH ASTM Level 3 Highly Protective 3 Layer Face Mask with Ear Loops - Made in the USA - 50 Qty Sold by: DemeTech Corporation (seller profile) Co ndition: New $17.49 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 10 of: Purell Hand Sanitizing Wipes, Alcohol Formula, Fragrance Free, 300 Count Individually Wrapped Hand Wipes - 9020-06-EC Sold by: Amazon.com Services LLC Condition: New $23.29 Amazon.com - Order 113-9491312-7079465 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 5 of 7 9/9/2022, 11:35 AM 83 Item(s) Subtotal: $2,810.66 Shipping & Handling: $0.00 ----- Total before tax: $2,810.66 Estimated tax to be collected: $263.41 ----- Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 12 of: Purell Hand Sanitizing Wipes, Alcohol Formula, Fragrance Free, 300 Count Individually Wrapped Hand Wipes - 9020-06-EC Sold by: Amazon.com Services LLC Condition: New $23.29 Shipping Address: Sylvia Abboud United States Shipping Speed: FREE Prime Delivery Shipped on July 30, 2022 Items Ordered Price 12 of: Purell Hand Sanitizing Wipes, Alcohol Formula, Fragrance Free, 300 Count Individually Wrapped Hand Wipes - 9020-06-EC Sold by: Amazon.com Services LLC Condition: New $23.29 Shipping Address: Sylvia Abboud San Jose, CA 95136 United States Shipping Speed: FREE Prime Delivery Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud Amazon.com - Order 113-9491312-7079465 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 6 of 7 9/9/2022, 11:35 AM 84 Grand Total:$3,074.07San Jose, CA 95136 United States Credit Card transactions Visa ending in 1204: July 30, 2022: $535.64 Visa ending in 1204: August 2, 2022:$2,538.43 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-9491312-7079465 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 7 of 7 9/9/2022, 11:35 AM 85 Item(s) Subtotal: $759.04 Shipping & Handling: $0.00 ----- Total before tax: $759.04 Estimated tax to be collected: $71.20 ----- Grand Total:$830.24 Final Details for Order #113-9052842-7080207 Print this page for your records. Order Placed: July 29, 2022 Amazon.com order number: 113-9052842-7080207 Order Total: $830.24 Shipped on July 30, 2022 Items Ordered Price 2 of: Vinyl Disposable Powder-Free Gloves, 5 Mil Thick, Size X-Large Pack of 2000 Sold by: PackagingSuppliesByMail (seller profile) Co ndition: New $94.88 3 of: Vinyl Disposable Powder Free Gloves, 5 Mil Thick, Size-Medium, Pack of 2000 Sold by: PackagingSuppliesByMail (seller profile) Co ndition: New $94.88 3 of: Vinyl Disposable Powder Free Gloves, 5 Mil Thick, Size-Large, Pack of 2000 Sold by: PackagingSuppliesByMail (seller profile) Co ndition: New $94.88 Shipping Address: Sylvia Abboud San Jose, CA 95136 United States Shipping Speed: Standard Shipping Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud San Jose, CA 95136 United States Credit Card transactions Visa ending in 1204: July 30, 2022:$830.24 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-9052842-7080207 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 1 of 1 9/9/2022, 11:38 AM 86 Item(s) Subtotal: $117.76 Shipping & Handling: $0.00 ----- Total before tax: $117.76 Estimated tax to be collected: $11.04 ----- Grand Total:$128.80 Final Details for Order #113-4346999-2925848 Print this page for your records. Order Placed: July 29, 2022 Amazon.com order number: 113-4346999-2925848 Order Total: $128.80 Shipped on August 1, 2022 Items Ordered Price 2 of: Dr.GreenPanda (XL 1000pcs) Clear Vinyl Disposable Gloves Food Safe / Service / Prep Cleaning Multipurpose Latex&Powder Free Non-Sterile Sold by: Dr.GreenPanda (seller profile) Co ndition: New $58.88 Shipping Address: Sylvia Abboud San Jose, CA 95136 United States Shipping Speed: Standard Shipping Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud San Jose, CA 95136 United States Credit Card transactions Visa ending in 1204: August 1, 2022:$128.80 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-4346999-2925848 https://www.amazon.com/gp/css/summary/print.html/ref=ppx_yo_dt_b... 1 of 1 9/9/2022, 11:45 AM 87 Item(s) Subtotal: $116.85 Shipping & Handling: $0.00 ----- Total before tax: $116.85 Estimated tax to be collected: $10.95 ----- Grand Total:$127.80 Final Details for Order #113-8703139-2772245 Print this page for your records. Order Placed: July 31, 2022 Amazon.com order number: 113-8703139-2772245 Order Total: $127.80 Shipped on August 2, 2022 Items Ordered Price 3 of: Ziploc 682257 1 Gal. Ziploc Double Zipper Storage Bags (250/Box) Sold by: Shoplet (seller profile) Co ndition: New $38.95 Shipping Address: Sylvia Abboud San Jose, CA 95136 United States Shipping Speed: Standard Shipping Payment information Payment Method: Visa | Last digits: 1204 Billing address Sylvia Abboud San Jose, CA 95136 United States Credit Card transactions Visa ending in 1204: August 2, 2022:$127.80 To view the status of your order, return to Order Summary. Conditions of Use | Privacy Notice © 1996-2022, Amazon.com, Inc. or its affiliates Amazon.com - Order 113-8703139-2772245 https://www.amazon.com/gp/css/summary/print.html?orderID=113-87... 1 of 1 9/9/2022, 11:28 AM 88 INVOICE TO: Sylvia Abboud Heart of the Valley, SERVICES POBox 418 Santa Clara, CA, 95052 United States PAID BY: Visa 1204 SHIPPING TO Sylvia Abboud Heart of the Valley, SERVICES SAN JOSE, CA, 95136 United States ORDER SUMMARY Additional Payments 1 $64.95 SUBTOTAL $64.95 DISCOUNT $0.00 SHIPPING Complimentary TAX $0.00 TOTAL $64.95 Do you have questions concerning your order? Simply login to My Account to view the order items associated with this invoice. Overnight Prints 7582 Las Vegas Blvd. S. Suite #487, Las Vegas, NV, 89123 Customer Service: 714.838.8888 (Available M-F 8am-5pm PST) ORDER NUMBER 747771713 ORDER DATE August 11, 2022 PAYMENT DETAILS SHIPPING DETAILS ORDER DATE:August 11, 2022 EST. DELIVERY DATE:Additional Payment SHIPPING COST:Free CONTACT PHONE:+1 408-417-7867 CONTACT EMAIL:sylvia@servicesforseniors.org ITEM QUANTITY PRICE 89 From:Sylvia Abboud To:Community Funding Subject:Fwd: Chicago Medical Supply LLC: Cash Sale #CS524791 Date:Tuesday, August 8, 2023 9:11:39 PM CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Best, Sylvia Abboud Executive Director Heart of the Valley, SERVICES FOR SENIORS, Inc. ~Thank you for helping us keep seniors living independently in their homes~ ---------- Forwarded message --------- From: Sylvia Abboud <sylvia@servicesforseniors.org> Date: Fri, Sep 9, 2022 at 11:12 AM Subject: Fwd: Chicago Medical Supply LLC: Cash Sale #CS524791 To: Lidia Donez <ldonez@sbcglobal.net> Best, Sylvia Abboud Executive Director Heart of the Valley, SERVICES FOR SENIORS, Inc. ~Thank you for helping us keep seniors living independently in their homes~ ---------- Forwarded message --------- From: Derik Vogelsang (dvogelsang@chimedsupply.com) <system@sent-via.netsuite.com> Date: Fri, Aug 5, 2022 at 1:33 PM Subject: Chicago Medical Supply LLC: Cash Sale #CS524791 To: <sylvia@servicesforseniors.org> 2900 MacArthur Blvd Northbrook, IL 60062 (866) 554-3734 http://www.chimedsupply.com - SAVE$$$ Bill To : Heart of the Valley Services For Seniors Inc. PO Box 418 Ship To : Sylvia Abboud Cash Sale Date : 8/5/2022 Sale # : CS524791 Acct # : 564879 Payment : VISA PO # : Sylvia 8/5/22 Src : P Ship Via : UPS® Ground Tracking 1Z2Y315V0392032110 90 Santa Clara, CA 95052 San Jose, CA 95136 # : Credit Card # : ************1204 CMS Item Description Qty B/O Units Price Amount 11658 ARUN KN95 Face Masks Earloop White LF FDA EUA Approved -20- 68 132 BX 8.95 608.60 Subtotal :608.60 Shipping & Handling : (UPS® Ground)0.00 Total :$608.60 Thank you for your business, please come back soon! 91 From:Sylvia Abboud To:Community Funding Subject:Fwd: Chicago Medical Supply LLC: Sales Order Confirmation #SO537023 Date:Tuesday, August 8, 2023 9:12:50 PM CAUTION: This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Best, Sylvia Abboud Executive Director Heart of the Valley, SERVICES FOR SENIORS, Inc. ~Thank you for helping us keep seniors living independently in their homes~ ---------- Forwarded message --------- From: Sylvia Abboud <sylvia@servicesforseniors.org> Date: Fri, Sep 9, 2022 at 11:13 AM Subject: Fwd: Chicago Medical Supply LLC: Sales Order Confirmation #SO537023 To: Lidia Donez <ldonez@sbcglobal.net> Best, Sylvia Abboud Executive Director Heart of the Valley, SERVICES FOR SENIORS, Inc. ~Thank you for helping us keep seniors living independently in their homes~ ---------- Forwarded message --------- From: Daniel Yufa (dyufa@chimedsupply.com) <system@sent-via.netsuite.com> Date: Fri, Aug 5, 2022 at 8:08 AM Subject: Chicago Medical Supply LLC: Sales Order Confirmation #SO537023 To: <sylvia@servicesforseniors.org> 2900 MacArthur Blvd Northbrook, IL 60062 Bill To : Heart of the Valley Services For Seniors Inc. PO Box 418 Santa Clara, CA 95052 Ship To : Sylvia Abboud Ct San Jose, CA 95136 Sales Order Confirmation Date : 8/5/2022 Order # : SO537023 Acct # : 564879 Payment Method : VISA PO # : Sylvia 8/5/22 Ship Via : UPS® Ground Ship Date : 8/5/2022 92 Credit Card # : ************1204 CMS #Description Uom Qty B/O Price Amt 11658 ARUN KN95 Face Masks Earloop White LF FDA EUA Approved -20- BX 200 8.95 1,790.00 Subtotal 1,790.00 Shipping Cost (UPS® Ground)0.00 Total :$1,790.00 Thank you for your business, please come back soon! 93 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application,X Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X Services for Seniors Report Checklist (staff use only) 94 City of Cupertino Community Funding Grant Annual Project Report Program/Project/Event Name: Agency/Organization Project Contact Person Title Phone E-Mail Grant Received: A. Project Results: Was your program/project/event affected by COVID-19? Yes No Was the program/project/event successful? Please indicate how success was measured: B. Clients Served: Please report the number of clients served as a result of this grant: Proposed in Application Actual from Event Total Number of Individuals Cupertino Residents Particular community groups served: Was the program/project/event available to the entire community/public or were there any eligibility criteria? Was there a charge or fee for the program/project/event? Yes No Relay For Life of Silicon Valley North American Cancer Society Relay For Life Olivia Catanio 510-956-5173 6000 Associate Director, Development olivia.catanio@cancer.org 60257 180 60257 100 Cupertino residents, all community groups including local students and adults There is no eligibility criteria to participate in the Relay For Life 95 What outreach methods did your organization use to promote the program/project/ event? C. Budget: Please enter your proposed budget from your application, and your actual expenses accrued from this grant: Category Application Budget Actual Expenditures % of Total Admin Staff Materials/Equipment Entertainment Room/Venue Rental Professional Services (describe) Other: Other: Total 100% Remaining Balance Do you intend to apply for Community Funding next year? Yes No If yes, how much to you intend to apply for? Please list any additional funding received last year from other sources for this program: Person who Prepared Form Title Phone Number Date: D. Upload Documents: 1. Financial Statements 2. Supporting Receipts 0 2500 1500 1200 0 800 0 6000 0 0 500 1000 0 926.51 0 2426.51 3573.49 0 0 0 21 41 0 38 Olivia Catanio Associate Director, Development 510-956-5173 7/11/2023 None permits, luminaria supplies, survivor recognition None 96 3. Other Signature Date Olivia Catanio Jul 11, 2023 97 Date Type Amount (Signed)Supplier Memo Society Key Product Restriction Association Event Year 6/6/2023 Journal 1,000.00 City of Cupertino ACT CTYCUPERTINOP&R MCATUT Resource : Events : Walk Events : WALK RFL Silicon Valley North CAUnrestrictedRelay For Life 2023 6/30/2023 Supplier Invoice 500.00 MDM Entertainment DJ Services MCATUT Resource : Events : Walk Events : WALK RFL Silicon Valley North CAUnrestrictedRelay For Life 2023 5/22/2023 Supplier Invoice 47.82 Peter E Kleine CompanySurvivor Lapel Pins- 15PK MCATUT Resource : Events : Walk Events : WALK RFL Silicon Valley North CAUnrestrictedRelay For Life 2023 5/22/2023 Supplier Invoice 26.27 Peter E Kleine CompanyCaregiver Lapel Pins 15PK MCATUT Resource : Events : Walk Events : WALK RFL Silicon Valley North CAUnrestrictedRelay For Life 2023 1/26 to 6/28/2023 Supplier Invoice 852.00 Silkscreening By Will Survivor/ELT/Hope/Gear MCATUT Resource : Events : Walk Events : WALK RFL Silicon Valley North CAUnrestrictedRelay For Life 2023 98 Quinlan Community Center 10185 N Stelling Rd. Cupertino, CA 95014 Phone: (408) 777-3120 FAX: (408) 777-1305 Email: recreation@cupertino.org AMERICAN CANCER SOCIETY JULIE STANLEY 747 CAMDEN AVE #B CAMPBELL, CA 95008 Receipt #1009794.030 May 18, 2023 12:21 PM Prepared By:Ruben Rodriguez Company ID:333 Main phone: (510) 464-8100, Work phone: -- Payment Summary Credit Card:$1,000.00 Visa xxx8621, Auth# 085177 Total Received:$1,000.00 Total Payments:$1,000.00 Transactions Customer Description Item Unit Qty Fee Charge Julie Stanley 747 Camden Ave #B Campbell, CA 95008 Main phone: (510) 464-8100 Email: julie.stanley@cancer.org ID: 81884 For: American Cancer Society American Cancer Society//Relay For Life SV North Action: Paid on Account Balance 1 Location: MP - Half Field - Festival at Memorial Park Permit #R143303 Security Deposit GL#100 Each $1,000.00 Total Charges $1,000.00 Total Payments $1,000.00 Balance $0 Federal Tax ID # 94.6027368 1 Payment Schedule for Original Balance of $1,000.00 Due Date Amount Due Amount Paid Withdrawal Adjustment Balance May 18, 2023 $1,000.00 $1,000.00 $0 $0 Current Balance $0 Due Now $0 99 MDM Entertainment 5875 Charlotte Dr. ⚫ Apt. #134 ⚫ San Jose, CA 95123 ⚫ (408) 597-5286 ⚫ mdmentdj79@gmail.com CONTRACTUAL AGREEMENT Contract Date: 03/07/2023 Invoice No: 06172023 CLIENT INFORMATION Client Name: JULIE STANLEY Primary Contact: Address: AMERICAN CANCER SOCIETY INC, P.O.BOX 111417 CAMPBELL, CA 95011 Phone No: 916-749-0672 E-mail: julie.stanley@cancer.org EVENT INFORMATION Event Date: 06/17/2023 Venue: RELAFY FOR LIFE EVENT Performance Time: 3-9PM Set-Up Time: 1PM Location: MEMORIAL PARK CUPERTINO CA Event Package: DJ MIKE & DJ ALEX WITH SOUND SYSTEM, 3 wired mics, 2 wireless mics Directions: N/A COMPENSATION The Client agrees to pay the sum of $_500__________, for the scheduled performance as described above. In the event the Client requests to extend the length of the performance, the Client agrees to pay an additional rate of $125.00 per hour, and to be paid prior to the performance. (NOTE: It is agreed upon that if any guest, employee or any other persons involved in this event shall damage, destroy and or misuse the DJ’s equipment, the Client shall be held fully responsible for any damage that may occur). DEPOSIT/REFUND The Client agrees to a retainer of 50% deposit within 24 hours on the day of the contract agreement, to secure the schedule performance. If the deposit has not been submitted with in 24 hours, the client must pay the Full Balance the day of the event. The balance of ___$__500________, is due on the day of the performance, and be paid by CASH , CHECK, OR CREDIT CARD. (NOTE: All deposits, and the balances of the amounts of the schedule performance are non-refundable and final). CANCELLATION The Client must notify the Contractor at least (24 HOURS) after the contract has been issued, for any cancellations and or any changes to the scheduled performances times. TERMS OF PAYMENT We accept the following: cash, money order, company check and credit cards. For money order and or company check, please make it payable to: Mike Westerman ADDITIONAL REQUIREMENTS FROM CLIENT ⚫ 1 six foot table ⚫ Set-up space (6 x 8 feet) ⚫ Covered area for any outside events ⚫ Within less than 25 feet for electricity outlet. CONTRACTOR CLIENT Print Name: MIKE W. Print Name: 100 MDM Entertainment 5875 Charlotte Dr. ⚫ Apt. #134 ⚫ San Jose, CA 95123 ⚫ (408) 597-5286 ⚫ mdmentdj79@gmail.com CONTRACTUAL AGREEMENT Signature: MIKE W. Signature: Date Signed: 03/07/2023 Date Signed: 101 Community Funding Report Final Audit Report 2023-07-11 Created:2023-07-11 By:PG (preetig@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAALxpQJU8z8Au-gSGjKuKkn0Mf0DDIji14 "Community Funding Report" History Web Form created by PG (preetig@cupertino.org) 2022-06-09 - 6:26:57 PM GMT Olivia Catanio (olivia.catanio@cancer.org) uploaded the following supporting documents: File Attachment 1 File Attachment 2 2023-07-11 - 11:32:13 PM GMT Web Form filled in by Olivia Catanio (olivia.catanio@cancer.org) 2023-07-11 - 11:32:13 PM GMT- IP address: 73.222.55.99 User email address verification waived 2023-07-11 - 11:32:16 PM GMT- IP address: 73.222.55.99 Agreement completed. 2023-07-11 - 11:32:16 PM GMT 102 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application, X Significant changes to the event allowed organization to reduce expenses, and unspent funds were reimbursed to the City Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X American Cancer Society Report Checklist (staff use only) 103 Cupertino Grant Report -Fiscal Year 2022-22023 By Omniware Networks Description of the project completed by 6/30/2023: We held two exhibitions of the ‘Peace Love Unity’youth artwork and a community art sharing reception,with a purpose to increase the awareness of and fight against hate and biased acts, between July 2022 and March 2023 in Cupertino. -We held the first exhibition at Cupertino Library,free to the public,in July and August 2022,which attracted about 3000 visitors. -We held the second exhibition at Cupertino Senior Center,free to the public,in Feb and March,2023,which attracted 600 visitors. -We organized a community art sharing reception during the Youth Art Month of March, open and free to the public,on March 6,2023.About 50 people attended the reception. Community Impacts: Our activities/programs served more than 3600 Cupertino residents across different ages, races,and cultural backgrounds,more than tripling the target presented to the City of Cupertino when we applied for the grant in Q1 2022. We have been serving Cupertino residents and generating positive impacts in multiple ways -virtual art sharing,face to face community engagement,promoting the awareness and improvement of good value of peace love unity to the community,and fostering social justice and equity.The depth and breadth of our program’s impacts to the community exceeded our target presented to the City of Cupertino when we applied for the grant in Q1 2022. We have received very positive community feedback.A few examples are below: “'We are very thankful that Santa Clara county,and Omniware Network gave us the great opportunity to stay on the theme “peace love unity”.We wish our people,our world,especially our children to live in peace,love and unity." "We put our hardwork and hearts in this art contest because we want to give our children a community and world full of peace love unity,and keep away from hate and bias acts.' "Peace Love Unity is not just an art contest theme.We shall all take actions in our daily lives to enable and foster peace love and unity in our communities.We have many volunteers who worked hard for this art contest and exhibitions because we all have the same faith in peace love and unity .” Cupertino students,whose artworks were displayed in our exhibitions,find profound meaning by participating in our programs and used their art skills to influence the community. Representative comments from Cupertino students are below: 104 ‘This artwork tells and shows you to do the right thing and go against hate crimes.This art also encourages you to be yourself and to not be afraid of who you are.’by Sara Mirza,student of DJ Sedgwick Elementary School ‘When it comes to love,there's no difference of their colors.’by Isabella Tsai,student of Lincoln Elementary School ‘Children from different places in the world all love peace.They unify together by contributing a piece of peace dove puzzle.’by Minerva Gao,student of Lincoln Elementary School Grant expenditure We spent all of the $2000 grant on the program’s direct service/expenditures per the project plan documented in the grant contract.Please see breakdown below: Key category Amount Materials &Supplies (banner,frames,hardware, handouts etc) $1565.22 Tool /equipment rental $230 Services (technology,etc)$224.88 Total $2020.10 Detailed expenditure with receipts type date description amount materials 7/3/2022 retractable banner with stand $94.92 105 materials 7/3/2022 peace paper cranes,goodies $41.01 materials 7/5/2022 Peace Love Unity tote bags $446.63 materials 7/5/2022 balloons /decos $54.55 106 materials 7/5/2022 frames $103.68 materials 7/5/2022 printing $417.18 materials 7/10/2022 frames $36.92 107 materials 7/11/2022 exhibition supplies $30.29 materials 7/13/2022 printing $109.11 materials 8/6/2022 custom stickers with logo $14.72 108 materials 8/6/2022 certificate frame $21.81 materials 8/7/2022 custom stickers (rose gold)$17.63 materials 1/26/2023 hanging hooks and rail 26.12 109 materials 8/12/2022 embossed foil stickers $8.28 materials 8/15/2022 certificates $9.70 materials 8/17/2022 printer paper $12.53 materials 8/17/2022 paper clips $9.81 110 materials 8/18/2022 stationary $13.63 services 7/4/2022 Event insurance $105 services 7/4/2022 QR code generation $119.88 111 materials 3/3/2023 Appreciation token to volunteers $33.99 materials 3/1/2023 Certificate holders and trophies $62.61 112 Tool / equipmen t rental 7/9/2022 devices /tools rentals $230 113 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application,X Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X Omniware Networks Report Checklist (staff use only) 114 City of Cupertino Community Funding Grant Annual Project Report Program/Project/Event Name: Agency/Organization Project Contact Person Title Phone E-Mail Grant Received: A. Project Results: Was your program/project/event affected by COVID-19? Yes No Was the program/project/event successful? Please indicate how success was measured: B. Clients Served: Please report the number of clients served as a result of this grant: Proposed in Application Actual from Event Total Number of Individuals Cupertino Residents Particular community groups served: Was the program/project/event available to the entire community/public or were there any eligibility criteria? Was there a charge or fee for the program/project/event? Yes No Seniors Breathe Easy Breathe California of the Bay Area, Golden Gate, and Central Coast Seniors Breathe Easy Margo Sidener 316-689-2629 $4,000 Deputy Executive Director margo@lungsrus.org 2,500 2,500 5223 5,000 seniors Available to all residents 115 What outreach methods did your organization use to promote the program/project/ event? C. Budget: Please enter your proposed budget from your application, and your actual expenses accrued from this grant: Category Application Budget Actual Expenditures % of Total Admin Staff Materials/Equipment Entertainment Room/Venue Rental Professional Services (describe) Other: Other: Total 100% Remaining Balance Do you intend to apply for Community Funding next year? Yes No If yes, how much to you intend to apply for? Please list any additional funding received last year from other sources for this program: Person who Prepared Form Title Phone Number Date: D. Upload Documents: 1. Financial Statements 2. Supporting Receipts 250 1,600 0 300 1,800 50 0 4,000 250 1,670 0 175 1,856 49 0 4,000 0 0 6 42 0 4 47 1 $4,000 Margo Sidener Deputy Executive Director 316-689-2629 7/15/2023 health educators Travel 0 116 3. Other Signature Date Margo Sidener Jul 15, 2023 117 Cupertino Seniors Breathe Easy Financial Report With this small of a grant, it is not called out in a financial report, but we have transactions on QuickBooks and payroll records if the City of Cupertino wishes to retrieve those. Our bookkeeper is on vacation, but we can provide later if requested. (This has never been requested before.) The account that is part of the report includes all information pertinent to this small grant. 118 Cupertino Seniors Breathe Easy Receipts 95% of our grant is for educational materials and supplies, which are used from inventory with the charge figured per number of people served, and for payroll which comes from ADP & QuickBook records (for health education and administration personnel). There are no receipts for those. We have receipts for booth rental and travel, however. Our bookkeeper is on vacation, but he can supply those upon request after his return. I can be reached for further explanation at 316-689-2629.---Margo 119 Breathe California Expense Report to the City of Cuper�no Seniors Breathe Easy 2022-2023 Category Applica�on Budget Actual Expenditures % of Total Admin Staff Bookkeeping Clerical and Supervisory staff 250 250 6 Materials/Equipment Educa�onal brochures, booklets Office supplies Giveaways at health fairs 1,600 1,670 42 Entertainment 0 0 0 Room/Venue Rental 300 175 4 Professional Services (Health educators) 1,800 1,856 47 Other (Travel) 50 49 1 Total 100% 4,000 4,000 0 0 120 A-06 A-07 A-09 A-33 B-29 B-32 B-50 C-01 C-19 C-23 C-24 C-25 C-26 C-38 C-39 C-40 PG&E 0 % Breathe Southern CA %Clean Cities %CA State CTCP %BAAQMD % BACR API- CHAT % Penninsula Healthcare %SCCOE TUPE %CPAP % City of San Jose Seniors % El Camino Health Children's Asthma % El Camino Healthcare District Seniors % Santa Clara County TB % City of Cupertino Seniors %NHLBI COPD %Harden %Sierra Asthma %PG&E %Astra Seneca 0.00 ESTIMATED ESTIMATED 0.00 Grant Period Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Dec 31, 2023 Budget July 1 - April 30, 2023 Budget July 1,2022 - Jan 31, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget Oct 1,2022 - Sept 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Budget July 1,2022 - Jun 30, 2023 Project Director 48,472.00$ -$ -$ -$ Director of Programs 6,737.00$ 9,648.00$ 2,875.00$ -$ 1,500.00$ 1,000.00$ 24,500.00$ 4,000.00$ H. E. Project Coordinator 24,256.00$ 50,233.00$ -$ 14,312.50$ -$ 2,500.00$ 2,872.02$ 26,500.00$ 47,000.00$ 5,000.00$ Communications 11,222.00$ 530.99$ 1,542.00$ -$ 1,800.00$ 1,500.00$ 4,400.00$ 5,500.00$ H. Ed. Comm Outreach/Vol Coord 12,352.00$ -$ 534.80$ 2,000.00$ 2,000.00$ 3,300.00$ Principal Investigator -$ 4,000.00$ Health Educator -$ 11,906.00$ 94,700.00$ 10,562.50$ -$ 15,000.00$ 1,800.00$ 4,600.00$ -$ 40,000.00$ -$ Environmental Health Educator Community Programs Assistant Community Worker 1 23,291.00$ 7,462.50$ -$ 38,000.00$ Community Worker 2 18,708.00$ Trilingual Health Educ -$ Lung Health & Asthma Educ Trainer -$ -$ Total Salary/Wages 24,256.00$ 182,921.00$ 112,341.49$ 29,292.00$ 5,844.50$ 2,500.00$ 3,406.82$ 31,800.00$ 19,500.00$ 12,250.00$ 1,800.00$ 40,800.00$ 10,000.00$ 134,500.00$ -$ 5,000.00$ Hrs/Week Salary/Wages Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Balance Used Pro.Sal Salary July 2022 - June 2023 J. xxxxx hourly 35 x 137.50$ 487.50$ 16,075.00$ 12.5 -$ 10,562.50$ 5,150.00$ 1,000.00$ -$ 36,100.00$ J. xxxxx hourly 24 x 0 1,050.00$ 12,352.20$ 2,569.00$ 7.00$ 534.80$ 742.00$ 686.00$ 1,036.00$ 791.00$ 0 28,420.00$ K. xxxx bi-monthly 40 x -$ 31,058.10$ 31,341.90$ 62,400.00$ B. xxxxx 40 x -$ T. xxxxx bi-monthly 40 x 221.58$ 1,733.45$ 50,286.27$ 160.79$ -$ 15,784.47$ 657.93$ 68.18$ 269.30$ 235.22$ 1,159.59$ 136.36$ 490.89$ -$ 610.20$ 71,996.88$ S. xxxxx hourly 40 x 52,700.00$ 52,000.00$ D. xxxxx hourly 25 x -$ 19,580.00$ 1,650.00$ 21,617.50$ -$ 43,200.00$ B. xxxxx hourly 32 x 290.00$ 6,249.50$ 12,702.00$ 5,437.50$ 1,537.00$ 338.00$ 2,392.50$ 1,885.00$ -$ 7,061.50$ -$ 8,569.50$ 5,205.50$ -$ 232.00$ 48,024.00$ M. xxxxx hourly 40 x 512.00$ 21,344.00$ 6,976.00$ 5,008.00$ 1,402.88$ 144.00$ 48.00$ 32.00$ 1,680.00$ 1,328.00$ 96.00$ 4,208.00$ 224.00$ 4,864.00$ 3,392.00$ -$ 50,560.00$ Sharmin Sultana hourly 20 26.50$ 9,513.50$ 2,396.50$ 1,252.66$ 16,774.50$ 1,856.00$ 21,151.47$ 318.00$ 1,096.00$ 55,120.00$ V. xxxxx hourly 40 x -$ 16,695.00$ 18,179.00$ #VALUE!-$ -$ -$ 55,120.00$ P. xxxxx hourly 19 x -$ 20,612.50$ 2,350.00$ 24,700.00$ S. xxxxx 23 x - 4,600.00$ -$ P. xxxxx 18,958.35$ 1,161.08$ 66,517.80$ -$ 180,184.97$ 35,966.79$ 29,286.85$ 5,632.00$ 657.93$ 20,667.50$ #VALUE!37,394.56$ 20,908.72$ 3,605.59$ 1,856.00$ 33,593.33$ 1,874.00$ 68,992.79$ 9,693.50$ -$ 527,640.88$ -$ -$ R.Balance 23,094.92$ R.Balance (66,517.80)$ 2,736.03$ 0.00%76,374.70$ 5.15$ -$ 212.50$ -$ 1,842.07$ -$ (20,667.50)$ -$ #VALUE!-$ (5,594.56)$ -$ (1,408.72)$ -$ 8,644.41$ -$ (56.00)$ -$ 7,206.67$ -$ 8,126.00$ -$ 65,507.21$ -$ (9,693.50)$ R.Balance 68.18$ 0 26,346.97$ 54,040.63$ -$ 121 122 123 124 125 126 127 EMPLOYEE EXPENSE REIMBURSEMENT CLAIM 2023 Year 2023 TOTAL EXPENSES Grant/Dept FOR DAY Job # Miles 6/7/23 Cupertino Senior Center 30.00 $19.65 C26 4/11/23 Chateau Cupertino 30.00 $19.65 C26 5/19/2023 Cupertino Senior Center Live Well Age Well health Expo 14.81 $9.70 C26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 - - - - - - - 74.81 Purpose of trip, remarks and details (Attach receipts/vouchers when required) : Mileage rate claimed: $0.655/mile as of January 1, 2023 I HEREBY CERTIFY that the above is a true statement of the travel expenses incurred by me in accordance with Breathe California policies and guidelines. ACCOUNTING OFFICE USE ONLY PAID BY CHECK NUMBER: Signature of the Applicant Sharmin Sultana SIGNATURE OF OFFICER APPROVING TRAVEL AND PAYMENT DATE 8/16/2023 Breathe Team Site>BCBA Team Documents>Admin Forms>2022 Employee Expenses Reimbursement Form.xls SUBTOTALS 49.001 CLAIM TOTAL $49.00 - - - - - - - - - - - - - - Private Car Use 19.65 9.70 Amount 19.65 NAME: Sharmin Sultana DETAILS LODGING MEALS TRANSPORTATION: A = Air / T= Train / C = Car / R = Rental DATE MISC. EXPENSE Breakfast Lunch Dinner Cost of Transport Type used Carfare, Tolls, Parking 128 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application,X Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X Breathe CA Report Checklist (staff use only) 129 City of Cupertino Community Funding Grant Annual Project Report Program/Project/Event Name: Agency/Organization Project Contact Person Title Phone E-Mail Grant Received: A. Project Results: Was your program/project/event affected by COVID-19? Yes No Was the program/project/event successful? Please indicate how success was measured: B. Clients Served: Please report the number of clients served as a result of this grant: Proposed in Application Actual from Event Total Number of Individuals Cupertino Residents Particular community groups served: Was the program/project/event available to the entire community/public or were there any eligibility criteria? Was there a charge or fee for the program/project/event? Yes No Tzu Chi Healthy Cupertino Health Fair Tzu Chi Medical Foundation Tzu Chi Mobile Clinic Milpitas Yuaner Wu 650-208-3811 8300 Event Coordinator dryuanerwu@gamil.com 50 50 45 25 All the patients were recruited from West Valley Community Service network and low-income senior projects in the Cupertino areas. It was an event opened to public, we did not turn away any individual. However, individuals with low income status are welcomed to take part in the event. 130 What outreach methods did your organization use to promote the program/project/ event? C. Budget: Please enter your proposed budget from your application, and your actual expenses accrued from this grant: Category Application Budget Actual Expenditures % of Total Admin Staff Materials/Equipment Entertainment Room/Venue Rental Professional Services (describe) Other: Other: Total 100% Remaining Balance Do you intend to apply for Community Funding next year? Yes No If yes, how much to you intend to apply for? Please list any additional funding received last year from other sources for this program: Person who Prepared Form Title Phone Number Date: D. Upload Documents: 1. Financial Statements 2. Supporting Receipts 800 4000 0 2000 0 1500 0 8300 691.42 4658.62 0 2757.75 0 192.21 0 8300 0 0 8.33 56.13 0 33.22 0 2.32 0 Yuaner Wu Event Coordinator 650-208-3811 8/10/2023 0 malpractice and general liabilities insurance 0 131 3. Other Signature Date Yuaner Wu Aug 10, 2023 132 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572439680576110000000001048230524231 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 39680576 Invoice Date 05/24/23 Due Date 06/23/23 Invoice Total $1048.23 Purchase Order# 1397508 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM ** SPECIAL CONTRACT PRICE ** Quantity shipped from NV = 4 units and NV2 = 6 units ** SPECIAL CONTRACT PRICE ** ** SPECIAL CONTRACT PRICE ** ESTIMATED DELIVERY DATE: 05/29/23 * SPECIAL SCHEIN PRICE REDUCTION * ** SPECIAL CONTRACT PRICE ** * SPECIAL SCHEIN PRICE REDUCTION * ** SPECIAL CONTRACT PRICE ** ** SPECIAL CONTRACT PRICE ** YOUR ORDER 42042525 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. 1 107-1380 52/BX EMS Biological Monitor Mail In 1 1 T * 231.32 231.32 2 NV 2 112-4856 200/BX Self Seal Sterilization Pouch 2.75x9 10 10 T 6.95 69.50 2 NV 3 194-5141 100/BX Monoject Needles 30Ga Short Plastic Hub 2 2 T 11.00 22.00 2 NV 4 945-0488 20/BX Compoglass F Cartridge Refill 140/A2/22 2 2 T $ * 95.75 191.50 3 IN 5 777-0170 4GM/EA Filtek Supreme Ultra Syringe A2-B 1 1 T * 117.57 117.57 2 NV 6 643-7726 100/BX Cap Bouffant Blue Large 24"1 1 T $ 20.13 20.13 2 NV 7 900-7439 200/BX Criterion N200 PF Nitril Glove Medium 9 9 T 20.04 180.36 2 NV 8 112-6858 100/BX Criterion CR Chloroprene Glove SMALL 9 9 T 14.00 126.00 2 NV Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 39680576 Invoice Date 05/24/23 Invoice Total $1048.23 Order# 42042525 Order Date 05/23/23 # of Boxes 3 PO# 1397508 Distribution Names/Address Page 1 of 2Please remit payments to: Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 133 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $958.38 $89.85 $1,048.23 Ship To# 1397508 Bill To# 4035724 Invoice# 39680576 Invoice Date 05/24/23 Invoice Total $1048.23 Order# 42042525 Order Date: 05/23/23 # of Boxes 3 PO#: 1397508 Distribution Names/Address Page 2 of 2134 Address | City, St Zip Code July 12, 202 3 Rachelle Sander Assistant Director of Park and Recre a tion Park and Recreation RachelleS@cupertion.org (408)777 -3131 Dear Rachelle: I am reporting a very successful Tzu Chi Healthy Cupertino Health Fair that held on 5/28/2023 at Quinlan Community Center, 10185 Stelling Road, Cupertino. On this event, we provided free services including internal medicine consultation, acupuncture treatments, dental cleanings, cavities filling and teeth extractions, vision examinations, and chiropractic adjustments to 45 patients. We invite one internal medicine physician, one ophthalmologist, three dentists, two acupuncturists, one chiropractor, and five registered nurses to provide free services. Our services are comprehensive. For example, our dental team including 3 dentists, 6 dental assistants and 1 dental x-ray technologist developed 30 dental x- ray films, provided 20 dental cleanings, and 1 dental extraction. In other departments, we provided 45 physical assessments, 17 acupuncture treatments, 11 chiropractic adjustments, 8 full eye examinations, and 9 internal medicinal consultations. We also provided finger stick blood sugar tests that including 3 hemoglobin A1C finger stick tests. All the patients were recruited from West Valley Community Service network and low -income senior projects in the Cupertino areas. Two weeks prior to the event, Tzu Chi volunteers set up an information table in front of West Valley Community Service Center to promote the event. Five days in two weeks, two hours on each day we have designated volunteers to promote the event during the food pantry services. Two days prior to the event date, our volunteers made appointment reminder phone calls. Consequently, this recruitment effort brought us 50% more participants than last year. (30 participants on 3/27/2022). 135 2 On August 16, 2022, we received City of Cupertino Grant $8300. This grant was used to pay for event facility rental $720, dental supplies $2882.55, equipment transportation van rental $192.55, HA1C testing kits $657.59, portable dental unit compressor $1118.48, food and drinks for volunteers $691.42, and mobile van storage fee $2037.75. In total is $8300.54. In summary, we have used 100% of grant to provide 172 service encounters for 45 patients. I am proudly to report that Tzu Chi Milpitas Mobile Clinic has made the best use of the Cupertino Community Grant. Please feel free to contact me for any question and concerns. Best regards, Grantee Steven Voon COO/EVP Tzu Chi Medical Foundation Expenses, Invoices, and Receipts 136 3 U-Haul rental for equipment transportation---------------$192.55 Mobile Van gas expenses-------------------------------------$267.84 Food and Drinks for volunteers------------------------------$691.42 Quinlan community Center Cupertino Room Rental ---$720 HgA1C testing kits-----------------------------------------------$657.59 Air Compressors -------------------------------------------------$1118.48 Mobile van storage at Store Inside---------------------------$2037.75 SUM------------------------------------------------------------------$5685.63 Dental Supplies purchased from Henry Schein Invoice#24870449-------------------------------------------------$103.78 Invoice#35503357-------------------------------------------------$292.59 Invoice#25503358-------------------------------------------------$92.26 Invoice#26549687-------------------------------------------------$218.65 Invoice#28616545--------------------------------------------------$260.30 Invoice#35171593--------------------------------------------------$449.57 Invoice# 35171595-------------------------------------------------$48.10 Invoice#35196418--------------------------------------------------$100.57 Invoice#35510072--------------------------------------------------$83.98 Invoice#39680576--------------------------------------------------$1048.23 Invoice#39680579--------------------------------------------------$184.52 SUM--------------------------------------------------------------------$2882.55 TOTAL-----------------------------------------------------------------$8568.18 137 4 138 Invoice Date 5/17/2023 Invoice # 12/20/948 Bill To Tzu Chi Mobile Clinic 3898 N Ann Avenue Fresno, CA 93727 P.O. Number Due Date 6/1/2023 Account # 1575 Credit card on file will be charged. Note prepayments are non-refundable. Thank you from Store Inside 408-694-3492 info@storeinside.com www.storeinside.com Total Payment Instructions Balance Due Subtotal Sales Tax (8.75%) Payments/Credits Store Inside 930 Wrigley Way Milpitas, CA 95035 408-694-3492 DescriptionQuantity Price Each AmountStart Date Inside Storage 38'3 715.00 2,145.006/1/2023 Discount for prepayment of three months or more storage - Credit or Debit Card -5.00% -107.25 $2,037.75 $2,037.75 $2,037.75 $0.00 $0.00 139 Community Funding Report Final Audit Report 2023-08-10 Created:2023-08-10 By:PG (preetig@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAaJKlUnyRX4jkm59P4dJsTQN-QxFpFwgH "Community Funding Report" History Web Form created by PG (preetig@cupertino.org) 2022-06-09 - 6:26:57 PM GMT Yuaner Wu (dryuanerwu@gmail.com) uploaded the following supporting documents: File Attachment 1 File Attachment 2 File Attachment 3 2023-08-10 - 9:25:25 PM GMT Web Form filled in by Yuaner Wu (dryuanerwu@gmail.com) 2023-08-10 - 9:25:25 PM GMT- IP address: 24.6.105.130 User email address verification waived 2023-08-10 - 9:25:28 PM GMT- IP address: 24.6.105.130 Agreement completed. 2023-08-10 - 9:25:28 PM GMT 140 Address | City, St Zip Code July 12, 2023 Rachelle Sander Assistant Director of Park and Recrea tion Park and Recreation RachelleS@cupertion.org (408)777-3131 Dear Rachelle: I am reporting a very successful Tzu Chi Healthy Cupertino Health Fair that held on 5/28/2023 at Quinlan Community Center, 10185 Stelling Road, Cupertino. On this event, we provided free services including internal medicine consultation, acupuncture treatments, dental cleanings, cavities filling and teeth extractions, vision examinations, and chiropractic adjustments to 45 patients. We invite one internal medicine physician, one ophthalmologist, three dentists, two acupuncturists, one chiropractor, and five registered nurses to provide free services. Our services are comprehensive. For example, our dental team including 3 dentists, 6 dental assistants and 1 dental x-ray technologist developed 30 dental x- ray films, provided 20 dental cleanings, and 1 dental extraction. In other departments, we provided 45 physical assessments, 17 acupuncture treatments, 11 chiropractic adjustments, 8 full eye examinations, and 9 internal medicinal consultations. We also provided finger stick blood sugar tests that including 3 hemoglobin A1C finger stick tests. All the patients were recruited from West Valley Community Service network and low-income senior projects in the Cupertino areas. Two weeks prior to the event, Tzu Chi volunteers set up an information table in front of West Valley Community Service Center to promote the event. Five days in two weeks, two hours on each day we have designated volunteers to promote the event during the food pantry services. Two days prior to the event date, our volunteers made appointment reminder phone calls. Consequently, this recruitment effort brought us 50% more participants than last year. (30 participants on 3/27/2022). 141 2 On August 16, 2022, we received City of Cupertino Grant $8300. This grant was used to pay for event facility rental $720, dental supplies $2882.55, equipment transportation van rental $192.55, HA1C testing kits $657.59, portable dental unit compressor $1118.48, food and drinks for volunteers $691.42, and mobile van storage fee $2037.75. In total is $8300.54. In summary, we have used 100% of grant to provide 172 service encounters for 45 patients. I am proudly to report that Tzu Chi Milpitas Mobile Clinic has made the best use of the Cupertino Community Grant. Please feel free to contact me for any question and concerns. Best regards, Grantee Steven Voon COO/EVP Tzu Chi Medical Foundation Expenses, Invoices, and Receipts 142 3 U-Haul rental for equipment transportation---------------$192.55 Mobile Van gas expenses-------------------------------------$267.84 Food and Drinks for volunteers------------------------------$691.42 Quinlan community Center Cupertino Room Rental ---$720 HgA1C testing kits-----------------------------------------------$657.59 Air Compressors -------------------------------------------------$1118.48 Mobile van storage at Store Inside---------------------------$2037.75 SUM------------------------------------------------------------------$5685.63 Dental Supplies purchased from Henry Schein Invoice#24870449-------------------------------------------------$103.78 Invoice#35503357-------------------------------------------------$292.59 Invoice#25503358-------------------------------------------------$92.26 Invoice#26549687-------------------------------------------------$218.65 Invoice#28616545--------------------------------------------------$260.30 Invoice#35171593--------------------------------------------------$449.57 Invoice# 35171595-------------------------------------------------$48.10 Invoice#35196418--------------------------------------------------$100.57 Invoice#35510072--------------------------------------------------$83.98 Invoice#39680576--------------------------------------------------$1048.23 Invoice#39680579--------------------------------------------------$184.52 SUM--------------------------------------------------------------------$2882.55 TOTAL-----------------------------------------------------------------$8568.18 143 4 144 145 146 147 148 slmanchulin@gmail.com Order Confirmation Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 SHIP TO: Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose CA 951311404 BILL TO: Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno CA 937277447 Or d e r C o n f i r m a t i o n LINE NO ITEM CODE UNIT SIZE DRUG CLASS DESCRIPTION & STRENGTH QTY. ORD SHIPPED SHIPPING DETAILS CUSTOMER P.O.# UNIT PRICE EXTENSION ACCOUNT # 4035724 TOTAL AMOUNT 42042525 ORDER DATEORDER NUMBER SE 05/23/23 PAGE # 1 ... 1 1071380 52/Bx EMS Biological Monitor Mail In 1 SHIPPING 231.32 05/23/23 1.000 1 1397508 ** special contract price ** 2 1124856 200/Bx Self Seal Sterilization P 2.75x9 10 SHIPPING 6.95 05/23/23 2.000 10 1397508 ** special contract price ** 3 1945141 100/Bx Monoject Needles 30Ga Sho Plastic Hub 2 SHIPPING 11.00 05/23/23 3.000 2 1397508 ** special contract price ** 4 9450488 20/Bx Compoglass F Cartridge Re 140/A2/22 2 SHIPPING 95.75 PU 05/23/23 4.000 2 1397508 Item will be shipped from MIDWEST Distribution Center Estimated Delivery Date: 05/29/23 Estimated Delivery Date: 05/29/23 * special schein price reduction * 5 7770170 4gm/Ea Filtek Supreme Ultra Syri A2-B 1 SHIPPING 117.57 PU 05/23/23 5.000 1 1397508 ** special contract price ** 6 6437726 100/Bx Cap Bouffant Blue Large 24" 1 SHIPPING 20.13 05/23/23 6.000 1 1397508 * special schein price reduction * 7 5820237 500/Ca Bouffant CAP,21",White,LF White 1 BACKORDERED 56.99 05/23/23 7.000 1397508 231.32 69.50 22.00 191.50 117.57 20.13 ACCOUNT # 4035724 TOTAL AMOUNT ORDER NUMBER SE42042525 ORDER DATE 05/23/23 PAGE # 1 ... 149 Order Confirmation Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 SHIP TO: Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose CA 951311404 BILL TO: Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno CA 937277447 Or d e r C o n f i r m a t i o n LINE NO ITEM CODE UNIT SIZE DRUG CLASS DESCRIPTION & STRENGTH QTY. ORD SHIPPED SHIPPING DETAILS CUSTOMER P.O.# UNIT PRICE EXTENSION ACCOUNT # 4035724 TOTAL AMOUNT 42042525 ORDER DATEORDER NUMBER SE 1,232.75 05/23/23 PAGE # 2 ... * special schein price reduction * 8 9007439 200/Bx Criterion N200 PF Nitril Medium 9 SHIPPING 20.04 05/23/23 8.000 9 1397508 ** special contract price ** 9 1126858 100/Bx Criterion CR Chloroprene SMALL 9 SHIPPING 14.00 05/23/23 9.000 9 1397508 ** special contract price ** 10 1072671 50/Bx Isolation Gown Latex Free One Size 2 DROP SHIP 84.35 05/23/23 10.000 2 1397508 * special schein price reduction * 11 TAX 105.67 Your order 42042525 has been split into multiple shipments. You will be billed for these items when they are shipped. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 180.36 126.00 168.70 105.67 ACCOUNT # 4035724 TOTAL AMOUNT ORDER NUMBER 1,232.75 SE42042525 ORDER DATE 05/23/23 PAGE # 2 ... 150 Invoice Date 5/17/2023 Invoice # 12/20/948 Bill To Tzu Chi Mobile Clinic 3898 N Ann Avenue Fresno, CA 93727 P.O. Number Due Date 6/1/2023 Account # 1575 Credit card on file will be charged. Note prepayments are non-refundable. Thank you from Store Inside 408-694-3492 info@storeinside.com www.storeinside.com Total Payment Instructions Balance Due Subtotal Sales Tax (8.75%) Payments/Credits Store Inside 930 Wrigley Way Milpitas, CA 95035 408-694-3492 DescriptionQuantity Price Each AmountStart Date Inside Storage 38'3 715.00 2,145.006/1/2023 Discount for prepayment of three months or more storage - Credit or Debit Card -5.00% -107.25 $2,037.75 $2,037.75 $2,037.75 $0.00 $0.00 151 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572424870449110000000000103781004222 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 24870449 Invoice Date 10/04/22 Due Date 11/03/22 Invoice Total $103.78 Purchase Order# IC CARE Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM IC CARE DIRECT SHIPMENT FROM THE MANUFACTURER ** SPECIAL CONTRACT PRICE ** REQUEST# 340480 1 131-0115 EA instadose Annual Service Renewal 1 1 T M 94.88 94.88 MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $94.88 $8.90 $103.78 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 24870449 Invoice Date 10/04/22 Invoice Total $103.78 Order# 32012872 Order Date 08/29/22 # of Boxes PO# IC CARE Page 1 of 1Please remit payments to, Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 152 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572425503357110000000000292590915227 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 25503357 Invoice Date 09/15/22 Due Date 10/15/22 Invoice Total $292.59 Purchase Order# MILPITAS09142022 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM ** SPECIAL CONTRACT PRICE ** ** SPECIAL CONTRACT PRICE ** CASE GOOD ITEM, MAY BE SHIPPED SEPARATELY. ** SPECIAL CONTRACT PRICE ** ** SPECIAL CONTRACT PRICE ** . .GO TO YOUR ONLINE ACCOUNT TO RETRIEVE THIS SDS, 105BS09 - IF YOU CANNOT ACCESS ONLINE OPTIONS OR TO OPT OUT OF ELECTRONIC SDS CALL (800) 472-4346. ** SPECIAL CONTRACT PRICE ** YOUR ORDER 32550786 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1 492-0054 50/BX ICX Water Treatment Tablets 0.7 Ltr Btl 2 2 T * 31.76 63.52 2 NV 2 640-0024 160/CN CaviWipes1 6"x6.75"12 12 T C * 11.29 135.48 1 NV2 3 112-4856 200/BX Self Seal Sterilization Pouch 2.75x9 3 3 T 6.95 20.85 2 NV 4 712-0063 18X2/BX Proxabrush Refills Tight 2/Pk 2 2 T 15.47 30.94 2 NV 5 570-1998 12/BX Etch Gel Syringe Kit 40% Bulk Pk 1 1 T * 16.72 16.72 2 NV MERCHANDISE TOTAL $267.51 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 25503357 Invoice Date 09/15/22 Invoice Total $292.59 Order# 32550786 Order Date 09/14/22 # of Boxes 2 PO# MILPITAS09142022 Distribution Names/Address Page 1 of 2Please remit payments to, Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 153 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM SALES TAX INVOICE TOTAL $25.08 $292.59 Ship To# 1397508 Bill To# 4035724 Invoice# 25503357 Invoice Date 09/15/22 Invoice Total $292.59 Order# 32550786 Order Date: 09/14/22 # of Boxes 2 PO#: MILPITAS09142022 Distribution Names/Address Page 2 of 2154 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572425503358110000000000092260926226 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 25503358 Invoice Date 09/26/22 Due Date 10/26/22 Invoice Total $92.26 Purchase Order# MILPITAS09142022 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM DIRECT SHIPMENT FROM THE MANUFACTURER * SPECIAL SCHEIN PRICE REDUCTION * YOUR ORDER 32550786 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1 107-2671 50/BX Isolation Gown Latex Free Pink One Size 1 1 T M $ 84.35 84.35 MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $84.35 $7.91 $92.26 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 25503358 Invoice Date 09/26/22 Invoice Total $92.26 Order# 32550786 Order Date 09/14/22 # of Boxes PO# MILPITAS09142022 Page 1 of 1Please remit payments to, Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 155 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572426549687110000000000218651010221 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 26549687 Invoice Date 10/10/22 Due Date 11/09/22 Invoice Total $218.65 Purchase Order# 1397508 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# 51674 HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM NDC: 0362-0753-05/00362-0753-05 SEE TERMS OF SALE FOR (DSCSA) COMPLIANCE MESSAGE DETAILS ITEM UNDER LIMITED WARRANTY FROM INVOICE DATE. ** SPECIAL CONTRACT PRICE ** NDC: 0404-6512-05/00404-6512-05 SEE TERMS OF SALE FOR (DSCSA) COMPLIANCE MESSAGE DETAILS ** SPECIAL CONTRACT PRICE ** NDC: 0362-9049-02/00362-9049-02 SEE TERMS OF SALE FOR (DSCSA) COMPLIANCE MESSAGE DETAILS ** SPECIAL CONTRACT PRICE ** 1 131-8818 50/BX Carbocaine 3% Plain 1.7 mL INJ Plain Tan 1 1 P M2 W * 51.37 51.37 1 NV 2 543-6467 50/BX Peroxyl Packets Alcohol Free 10mL 3 3 * 14.29 42.87 1 NV 3 465-1205 50/BX Lidocaine 2% w/EPI 1.7 mL INJ 1:100 Red 3 3 P M2 * 26.00 78.00 1 NV 4 228-8210 50/BX Septocaine 4% w/EPI 1.7 mL INJ 1:100M Go 1 1 P M2 * 46.41 46.41 1 NV MERCHANDISE TOTAL INVOICE TOTAL $218.65 $218.65 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 26549687 Invoice Date 10/10/22 Invoice Total $218.65 Order# 34602974 Order Date 10/10/22 # of Boxes 1 PO# 1397508 Distribution Names/Address Page 1 of 1Please remit payments to, Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 156 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572428616545110000000000260301121229 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 28616545 Invoice Date 11/21/22 Due Date 12/21/22 Invoice Total $260.30 Purchase Order# 20221114 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM DIRECT SHIPMENT FROM THE MANUFACTURER ITEM UNDER 3 MONTHS WARRANTY FROM INVOICE DATE. 1 300-0428 EA Composi-Tight 3D Fusion Firm Mini Kit 1 1 T M W 237.99 237.99 MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $237.99 $22.31 $260.30 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 28616545 Invoice Date 11/21/22 Invoice Total $260.30 Order# 35822133 Order Date 11/14/22 # of Boxes PO# 20221114 Page 1 of 1Please remit payments to, Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 157 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572435171593110000000000449570303232 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 35171593 Invoice Date 03/03/23 Due Date 04/02/23 Invoice Total $449.57 Purchase Order# Milpitas-03022023 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM * SPECIAL SCHEIN PRICE REDUCTION * ** SPECIAL CONTRACT PRICE ** ESTIMATED DELIVERY DATE: 03/09/23 ** SPECIAL CONTRACT PRICE ** . .GO TO YOUR ONLINE ACCOUNT TO RETRIEVE THIS SDS, 1057386 - IF YOU CANNOT ACCESS ONLINE OPTIONS OR TO OPT OUT OF ELECTRONIC SDS CALL (800) 472-4346. ESTIMATED DELIVERY DATE: 03/09/23 ** SPECIAL CONTRACT PRICE ** ESTIMATED DELIVERY DATE: 03/09/23 * SPECIAL SCHEIN PRICE REDUCTION * YOUR ORDER 39403642 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1 840-9374 EA Capsule Dispenser 2 2 T $ 147.43 294.86 1 NV 2 102-6316 EA Or-Evac Evacuation Cleaner 32oz 1 1 T * 11.14 11.14 1 NV 3 772-0410 25/PK Midwest Once Diamond FG 368-016C 1 1 T 39.90 39.90 2 IN 4 195-8281 12/BX Dura-White Stones RA CN1 1 1 T * 25.40 25.40 2 IN 5 170-8601 2/BX Contact Matrix Contact Ring Refill 1 1 T $ 39.74 39.74 2 IN Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 35171593 Invoice Date 03/03/23 Invoice Total $449.57 Order# 39403642 Order Date 03/03/23 # of Boxes 2 PO# Milpitas-03022023 Distribution Names/Address Page 1 of 2Please remit payments to, Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 158 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $411.04 $38.53 $449.57 Ship To# 1397508 Bill To# 4035724 Invoice# 35171593 Invoice Date 03/03/23 Invoice Total $449.57 Order# 39403642 Order Date: 03/03/23 # of Boxes 2 PO#: Milpitas-03022023 Distribution Names/Address Page 2 of 2159 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572435171595110000000000048100303239 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 35171595 Invoice Date 03/03/23 Due Date 04/02/23 Invoice Total $48.10 Purchase Order# Milpitas-03022023 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM DIRECT SHIPMENT FROM THE MANUFACTURER * SPECIAL SCHEIN PRICE REDUCTION * DIRECT SHIPMENT FROM THE MANUFACTURER ITEM BACK ORDERED, WILL FOLLOW SHORTLY ** SPECIAL CONTRACT PRICE ** DIRECT SHIPMENT FROM THE MANUFACTURER ITEM BACK ORDERED, WILL FOLLOW SHORTLY * SPECIAL SCHEIN PRICE REDUCTION * YOUR ORDER 39403642 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1 553-0079 EA Water Bottle Heavy Duty 2 Liter 3 3 T M $ 14.66 43.98 2 189-0811 150/BX Full Chair Cover 44"x54"2 0 T M B 3 170-1415 EA Contact Matrix Ring Plier Plus 1 0 T M B $ MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $43.98 $4.12 $48.10 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 35171595 Invoice Date 03/03/23 Invoice Total $48.10 Order# 39403642 Order Date 03/03/23 # of Boxes PO# Milpitas-03022023 Page 1 of 1Please remit payments to, Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 160 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572435196418110000000000100570313230 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 35196418 Invoice Date 03/13/23 Due Date 04/12/23 Invoice Total $100.57 Purchase Order# Milpitas-03022023 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM This is a backordered shipment for order:39403642 original invoice:35171595 DIRECT SHIPMENT FROM THE MANUFACTURER ITEM BACK ORDERED, WILL FOLLOW SHORTLY ** SPECIAL CONTRACT PRICE ** DIRECT SHIPMENT FROM THE MANUFACTURER * SPECIAL SCHEIN PRICE REDUCTION * YOUR ORDER 39403642 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1 189-0811 150/BX Full Chair Cover 44"x54"2 0 T M B 2 170-1415 EA Contact Matrix Ring Plier Plus 1 1 T M $ 91.95 91.95 MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $91.95 $8.62 $100.57 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 35196418 Invoice Date 03/13/23 Invoice Total $100.57 Order# 39403642 Order Date 03/03/23 # of Boxes PO# Milpitas-03022023 Page 1 of 1Please remit payments to: Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 161 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572435510072110000000000083980314239 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 35510072 Invoice Date 03/14/23 Due Date 04/13/23 Invoice Total $83.98 Purchase Order# Milpitas-03022023 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM This is a backordered shipment for order:39403642 original invoice:35171595 DIRECT SHIPMENT FROM THE MANUFACTURER ** SPECIAL CONTRACT PRICE ** 1 189-0811 150/BX Full Chair Cover 44"x54"2 2 T M 38.39 76.78 MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $76.78 $7.20 $83.98 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 35510072 Invoice Date 03/14/23 Invoice Total $83.98 Order# 39403642 Order Date 03/03/23 # of Boxes PO# Milpitas-03022023 Page 1 of 1Please remit payments to: Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 162 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572439680576110000000001048230524231 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 39680576 Invoice Date 05/24/23 Due Date 06/23/23 Invoice Total $1048.23 Purchase Order# 1397508 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM ** SPECIAL CONTRACT PRICE ** Quantity shipped from NV = 4 units and NV2 = 6 units ** SPECIAL CONTRACT PRICE ** ** SPECIAL CONTRACT PRICE ** ESTIMATED DELIVERY DATE: 05/29/23 * SPECIAL SCHEIN PRICE REDUCTION * ** SPECIAL CONTRACT PRICE ** * SPECIAL SCHEIN PRICE REDUCTION * ** SPECIAL CONTRACT PRICE ** ** SPECIAL CONTRACT PRICE ** YOUR ORDER 42042525 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. 1 107-1380 52/BX EMS Biological Monitor Mail In 1 1 T * 231.32 231.32 2 NV 2 112-4856 200/BX Self Seal Sterilization Pouch 2.75x9 10 10 T 6.95 69.50 2 NV 3 194-5141 100/BX Monoject Needles 30Ga Short Plastic Hub 2 2 T 11.00 22.00 2 NV 4 945-0488 20/BX Compoglass F Cartridge Refill 140/A2/22 2 2 T $ * 95.75 191.50 3 IN 5 777-0170 4GM/EA Filtek Supreme Ultra Syringe A2-B 1 1 T * 117.57 117.57 2 NV 6 643-7726 100/BX Cap Bouffant Blue Large 24"1 1 T $ 20.13 20.13 2 NV 7 900-7439 200/BX Criterion N200 PF Nitril Glove Medium 9 9 T 20.04 180.36 2 NV 8 112-6858 100/BX Criterion CR Chloroprene Glove SMALL 9 9 T 14.00 126.00 2 NV Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 39680576 Invoice Date 05/24/23 Invoice Total $1048.23 Order# 42042525 Order Date 05/23/23 # of Boxes 3 PO# 1397508 Distribution Names/Address Page 1 of 2Please remit payments to: Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 163 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $958.38 $89.85 $1,048.23 Ship To# 1397508 Bill To# 4035724 Invoice# 39680576 Invoice Date 05/24/23 Invoice Total $1048.23 Order# 42042525 Order Date: 05/23/23 # of Boxes 3 PO#: 1397508 Distribution Names/Address Page 2 of 2164 INVOICE Ship/Sold-To: 1397508 Tzu Chi Foundation USA 2355 Oakland Rd NW Regional Ofc Ching Wong San Jose, CA 95131-1404 Bill-To: 4035724 Tzu Chi Mobile Clinic-USA 3898 N Ann Ave Steven Voon Fresno, CA 93727-7447 010000403572439680579110000000000184520524231 -------------------------------------------------------------------------------------------------Please detach here and mail above with your payment ------------------------------------------------------------------------------------------------------------------------------------- Tzu Chi Mobile Clinic-USA3898 N Ann AveSteven VoonFresno, CA 93727-7447 Invoice# 39680579 Invoice Date 05/24/23 Due Date 06/23/23 Invoice Total $184.52 Purchase Order# 1397508 Payment Terms Invoice Date + 30 days Customer DEA#Customer State Reg# HSI Federal ID# 11-3136595 HSI D&B# 01-243-0880 LINE NO. ITEM CODE UNIT SIZE DESCRIPTION QTY ORDERED QTY SHIPPED CODES UNIT PRICE EXT. PRICE BOX NO. SHIP FROM DIRECT SHIPMENT FROM THE MANUFACTURER * SPECIAL SCHEIN PRICE REDUCTION * YOUR ORDER 42042525 HAS BEEN SPLIT INTO MULTIPLE SHIPMENTS. YOU WILL BE BILLED FOR THESE ITEMS WHEN THEY ARE SHIPPED. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = 1 107-2671 50/BX Isolation Gown Latex Free Pink One Size 2 2 T M $ 84.35 168.70 MERCHANDISE TOTAL SALES TAX INVOICE TOTAL $168.70 $15.82 $184.52 Please refer to our standard Terms of Sale and disclosures at https://www.henryschein.com/us-en/specialmarkets/LegalTerms.aspx, including customer obligations regarding discounts/rebates.Such terms are incorporated herein by reference. Thank you for your order! Ship To# 1397508 Bill To# 4035724 Invoice# 39680579 Invoice Date 05/24/23 Invoice Total $184.52 Order# 42042525 Order Date 05/23/23 # of Boxes PO# 1397508 Page 1 of 1Please remit payments to: Henry Schein, Inc. PO Box 7156 Pasadena, CA 91109-7156 US 165 166 167 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application,X Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X Buddhist Tzu Chi Medical Foundation Report Checklist (staff use only) 168 City of Cupertino Community Funding Grant Annual Project Report Program/Project/Event Name: Agency/Organization Project Contact Person Title Phone E-Mail Grant Received: A. Project Results: Was your program/project/event affected by COVID-19? Yes No Was the program/project/event successful? Please indicate how success was measured: B. Clients Served: Please report the number of clients served as a result of this grant: Proposed in Application Actual from Event Total Number of Individuals Cupertino Residents Particular community groups served: Was the program/project/event available to the entire community/public or were there any eligibility criteria? Was there a charge or fee for the program/project/event? Yes No Mindfully Facing Grief and Loss and Starting the Conversation Chinese American Coalition for Compassionate Care (CACCC) Mindfully Facing Grief and Loss and Starting the Conversation Jeanne Wun 408-896-7366 $13,000 Past Board Chair jeanne@caccc-usa.org 5000 1000 9687 2509 Multigenerational Chinese, Chinese Americans All CACCC programs and events are free and open to the general public, specifically to the Chinese-speaking community. When applicable, CACCC provides simultaneous interpretation in English. 169 What outreach methods did your organization use to promote the program/project/ event? C. Budget: Please enter your proposed budget from your application, and your actual expenses accrued from this grant: Category Application Budget Actual Expenditures % of Total Admin Staff Materials/Equipment Entertainment Room/Venue Rental Professional Services (describe) Other: Other: Total 100% Remaining Balance Do you intend to apply for Community Funding next year? Yes No If yes, how much to you intend to apply for? Please list any additional funding received last year from other sources for this program: Person who Prepared Form Title Phone Number Date: D. Upload Documents: 1. Financial Statements 2. Supporting Receipts 3250.00 3500.00 0 850.00 4500.00 900.00 0 $13,000.00 3237.57 4030.72 0 989.80 4350.00 391.91 0 $13,000.00 0 0 25 31 0 8 33 3 Jeanne Wun Past Board Member 408-896-7366 July 6, 2023 Honorariums Shipping Not applicable 170 3. Other Signature Date Jeanne Wun Jul 6, 2023 171 172 CACCC City of Cupertino Fiscal Year 2022- 2023 Community Funding Report Category Applicational Budget Actual Expenditures % of Total a) Admin Staff $3,250.00 $ 3,237.57 25% b) Materials/Equipment $3,500.00 $ 4,030.72 31% c) Entertainment $0.00 0% d) Room/Venue Rental/Zoom $850.00 $ 989.80 8% e) Professional Services/Honorarium $4,500.00 $ 4,350.00 33% f) Other (Shipping)$900.00 $ 391.91 3% Total $13,000.00 $ 13,000.00 100% 173 Date Category Description Admin/Staff Total 9/22/22 Material/Equipment Printing program books 7/30/22 Material/Equipment Laptop 6/1/23 Material/Equipment Hard drive to store video 6/1/23 Material/Equipment Hard drive to store video Material/Equipment 200 AHCD form 9/55~9/22 Material/Equipment Beginner's Guide to The End Material/Equipment Decision Aid Material/Equipment 404 decks of Heart to Heart Cards Material/Equipment Total 1/24/23 Other (Shipping)Mail HTH cards to HTH Café participants 1/24/23 Other (Shipping)Bubble envelope (16pcs) 1/26/23 Other (Shipping)Bubble envelope (6pcs) 1/26/23 Other (Shipping)Mail HTH cards for HTH Café participants 1/31/23 Other (Shipping)Mail HTH cards for order 1/31/23 Other (Shipping)Mail 8 books to Cinny Feng 10/25/22 Other (Shipping)USPS, mailed 8 packages to donners. (program book, cards and books, with media rate) 10/13/22 Other (Shipping)USPS, mailed one package to requester (AHCD, program book, educational materials) 10/6/22 Other (Shipping)USPS, mailed 14 packages 9/30/22 Other (Shipping)USPS, mailed one flat rate package to Ling 10/8/22 Other (Shipping)USPS, mailed 8 decks of cards 10/7/22 Other (Shipping)USPS, mailed 9 packages ( cards, program books, books 10/18/22 Other (Shipping)Amazon, 25 padded envelope Other (Shipping)Total 6/30/23 Professional Services/Honorarium Honorarium to Redefining What Matters speakers: Dr. Cynthia Pan, Dr. Stephen Ma, Dr. BJ Miller 6/30/23 Professional Services/Honorarium Honorarium to What Ultimately Matters to End of Life Professional Services/Honorarium Total 11/17/22 Room/Venue Rental/Zoom Total 174 175 176 Amount 3,237.57$ 748.00$ 1,564.83$ 140.07$ 140.07$ 400.17$ 302.58$ 300.00$ 435.00$ 4,030.72$ 61.30$ 10.94$ 5.74$ 49.45$ 9.65$ 17.10$ 46.84$ 9.00$ 66.95$ 16.10$ 35.29$ 44.95$ 18.60$ 391.91$ 3,000.00$ 1,350.00$ 4,350.00$ 989.80$ 13,000.00$ 177 178 179 180 181 182 183 184 185 CACCC City of Cupertino Fiscal Year 2022- 2023 Community Funding Report Category Applicational Budget Actual Expenditures % of Total a) Admin Staff $3,250.00 $ 3,237.57 25% b) Materials/Equipment $3,500.00 $ 4,030.72 31% c) Entertainment $0.00 0% d) Room/Venue Rental/Zoom $850.00 $ 989.80 8% e) Professional Services/Honorarium $4,500.00 $ 4,350.00 33% f) Other (Shipping)$900.00 $ 391.91 3% Total $13,000.00 $ 13,000.00 100% 186 Date Category Description Admin/Staff Total 9/22/22 Material/Equipment Printing program books 7/30/22 Material/Equipment Laptop 6/1/23 Material/Equipment Hard drive to store video 6/1/23 Material/Equipment Hard drive to store video Material/Equipment 200 AHCD form 9/55~9/22 Material/Equipment Beginner's Guide to The End Material/Equipment Decision Aid Material/Equipment 404 decks of Heart to Heart Cards Material/Equipment Total 1/24/23 Other (Shipping)Mail HTH cards to HTH Café participants 1/24/23 Other (Shipping)Bubble envelope (16pcs) 1/26/23 Other (Shipping)Bubble envelope (6pcs) 1/26/23 Other (Shipping)Mail HTH cards for HTH Café participants 1/31/23 Other (Shipping)Mail HTH cards for order 1/31/23 Other (Shipping)Mail 8 books to Cinny Feng 10/25/22 Other (Shipping)USPS, mailed 8 packages to donners. (program book, cards and books, with media rate) 10/13/22 Other (Shipping)USPS, mailed one package to requester (AHCD, program book, educational materials) 10/6/22 Other (Shipping)USPS, mailed 14 packages 9/30/22 Other (Shipping)USPS, mailed one flat rate package to Ling 10/8/22 Other (Shipping)USPS, mailed 8 decks of cards 10/7/22 Other (Shipping)USPS, mailed 9 packages ( cards, program books, books 10/18/22 Other (Shipping)Amazon, 25 padded envelope Other (Shipping)Total 6/30/23 Professional Services/Honorarium Honorarium to Redefining What Matters speakers: Dr. Cynthia Pan, Dr. Stephen Ma, Dr. BJ Miller 6/30/23 Professional Services/Honorarium Honorarium to What Ultimately Matters to End of Life Professional Services/Honorarium Total 11/17/22 Room/Venue Rental/Zoom Total 187 188 189 Amount 3,237.57$ 748.00$ 1,564.83$ 140.07$ 140.07$ 400.17$ 302.58$ 300.00$ 435.00$ 4,030.72$ 61.30$ 10.94$ 5.74$ 49.45$ 9.65$ 17.10$ 46.84$ 9.00$ 66.95$ 16.10$ 35.29$ 44.95$ 18.60$ 391.91$ 3,000.00$ 1,350.00$ 4,350.00$ 989.80$ 13,000.00$ 190 191 192 193 194 195 196 197 198 Community Funding Report Final Audit Report 2023-07-06 Created:2023-07-06 By:PG (preetig@cupertino.org) Status:Signed Transaction ID:CBJCHBCAABAAKhRhWZFQ0eDHMxc4CjwLJ-l52rCwVPs8 "Community Funding Report" History Web Form created by PG (preetig@cupertino.org) 2022-06-09 - 6:26:57 PM GMT Jeanne Wun (jeanne@caccc-usa.org) uploaded the following supporting documents: File Attachment 1 File Attachment 2 File Attachment 3 2023-07-06 - 11:32:14 PM GMT Web Form filled in by Jeanne Wun (jeanne@caccc-usa.org) 2023-07-06 - 11:32:14 PM GMT- IP address: 76.217.55.147 User email address verification waived 2023-07-06 - 11:32:17 PM GMT- IP address: 76.217.55.147 Agreement completed. 2023-07-06 - 11:32:17 PM GMT 199 Criteria YES NO Notes: Grant funds have been spent in the manner and for the purposes stated on the application,X Have more than 75% of the requested funds allocated for direct service costs versus administrative costs.X Program/project/event benefitted the Cupertino community and served Cupertino residents X Admission to or participation in the program/project/event was "free of charge"X Report complete and submitted by the deadline.X Chinese American Coalition for Compassionate Cares Report Checklist (staff use only) 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214